This 24 year old man has experienced solid food and pill dysphagia for many years. There was no history of asthma, atopy, reflux symptoms, lye ingestion, or unexplained skin lesions. Barium swallow demonstrated these findings of concentric ring like contractions in the proximal half of the esophagus. Endoscopy confirmed the presence of these ringed contractions. This is the characteristic finding of feline esophagus of the disorder eosinophilic esophagitis. Typically, the mucosa is thin and fragile and shears easily on dilation This tearing occurred following the gentle passage a 14mm savory dilator resulting in the so called tissue paper sign. Biopsies demonstrate esophageal squamous mucosa with basal cell hyperplasia and numerous intraepithelial eosinophils. The pathologic diagnosis is eosinophilic esophagitis and the main differential includes reflux and allergy.
Note the whitish dots along the esophagus in this second patient. These are the sites of small abscess-like disruptions of the epithelium.
Eosinophilic esophagitis appears to be an allergic mediated chronic inflammatory condition of the esophagus. The majority of patients will have a history of asthma or atopy, and a peripheral eosinophilia. It is not yet clear whether there is a direct relationship with eosinophilic gastroenteritis.
The first line of therapy often involves food and exposure restriction following allergy testing. Proton pump inhibitor therapy is appropriate as there appears to be improvement in some patients with anti-reflux maneuvers. Careful esophageal dilation has been performed but this shearing mucosal injury is frequently observed. Patients with continued symptoms can receive corticosteroids. Excellent results have been reported with the use of oral prednisone as well as topical fluticasone therapy. Fluticasone use may be associated with fewer systemic side effects.
Peter B. Kelsey, M.D., Harvard Medical School, Massachusetts General Hospital
The esophageal biopsy demonstrates squamous mucosa with basal cell hyperplasia and numerous intraepithelial eosinophils. The findings here are very suggestive of eosinophilic esophagitis and the main differential includes reflux and allergy.
Barium swallow demonstrated these findings of concentric ring like contractions in the proximal half of the esophagus.