A Case of End-Stage Eosinophilic Esophagitis: 2658

Eosinophillic esophagitis (EoE) is an increasingly recognized cause of refractory heartburn and dysphagia. It is characterized by a chronic, immune/antigen-mediated esophageal dysfunction associated with eosinophil-predominant inflammation on histology. A diagnosis of EoE is often delayed because of symptomatic overlap with GERD and patients may present with severe complications such as strictures or esophageal fibrosis. An otherwise healthy 29-year-old Caucasian male with history of esophageal strictures requiring intermittent dilations presented with severe chest pain and food impaction sensation after eating a meal. Workup for cardiac cases of chest pain was negative. CT chest was concerning for possible esophageal micro-perforation. Empiric antibiotics were started for mediastinitis. Upper endoscopy revealed small caliber esophagus starting at 25 cm preventing the passage of an adult scope. A pediatric upper endoscope was passed with difficulty through the esophagus revealing a deep mucosal tear in the esophagus without any food bolus. Esophagus was noted to be narrow through the gastroesophageal junction. Distinct ring-furrow pattern suggestive of EoE was noted. Esophageal biopsies showed squamous mucosa with moderate to marked basal cell hyperplasia and increased numbers of intraepithelial eosinophils (> 45 per high power field). He was discharged home with plans for frequent serial dilations along with oral inhaled corticosteroids. Our patient had several prior endoscopies with dilations but was never diagnosed or treated for eosinophilic esophagitis. He has now progressed to end-stage eosinophilic esophagitis with a severely stenotic esophagus. He will likely have to be on a modified diet throughout his life.Figure 1Figure 2EoE is a relatively rare disease with an estimated prevalence of 25.9/100,000 patients affecting males more than females. Patients present with non-specific symptoms including heartburn, chest pain, dysphagia or epigastric pain, which often leads to a delay in diagnosis. Early identification and treatment of symptoms result in fewer complications. Prior studies have demonstrated a direct correlation with delay in diagnosis and prevalence of fibrotic features on endoscopy. A high degree of suspicion is required to diagnose this condition in patients who have persistent symptoms despite optimal PPI therapy and have concomitant allergies. Earlier diagnosis and treatment can prevent complications of esophageal fibrosis and stricture formation.