Eosinophilic esophagitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Case history #1

A 23-year-old man with asthma and seasonal allergies presents to the emergency department with an acute food bolus impaction. He has had solid food dysphagia since elementary school, but had always been told to chew more carefully. He has not had any prior evaluation, and has never been to the emergency department before, but does have a sensation of food sticking with almost every meal. He minimizes symptoms by eating slowly, chewing thoroughly, and drinking a lot of water with each bite of food. He tends to avoid dry breads and steak, as these always stick. Most of the time when foods stick, if he relaxes himself they will eventually go down. However, sometimes he has to clear the foods with regurgitation. The endoscopic exam shows a food bolus impacted in the proximal esophagus, which is cleared. The esophagus is diffusely narrowed, with edema, rings, and furrows. Biopsies show 85 eosinophils per high-power microscopy field (eos/hpf) from the distal esophagus and 70 eos/hpf from the proximal esophagus. He is diagnosed with eosinophilic esophagitis (EoE) and started on the proton-pump inhibitor (PPI) omeprazole (20 mg orally twice daily).

Case history #2

A 4-year-old boy with food allergies and eczema presents to the gastroenterology clinic with poor growth and vomiting. His mother reports that he was a fussy baby who regurgitated feeds frequently and did not tolerate breast milk or most formulas. She reports using specialized formulas for the first year of his life. With introduction to solid foods, he had reactions to cow’s milk and peanuts, and these are now avoided. He is not interested in eating, and only eats small amounts of foods. He has fallen off the growth curve. If he eats what would be considered a regular-sized meal, he vomits. Meal times are very difficult and a source of stress for the family. He has been on a high-dose PPI since infancy for presumed reflux, but this has not helped the clinical symptoms. Esophagogastroduodenoscopy shows an edematous and congested esophagus with diffuse white plaques and mild linear furrows. Brushings exclude candidal esophagitis. Biopsies show 120 eos/hpf from the proximal esophagus and 65 eos/hpf from the distal esophagus and he is diagnosed with EoE.

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