A Soon To Be Common Endoscopic Finding?

Abstract

Purpose: Introduction: The long term complications of eosinophilic esophagitis(EoE) are still unknown. There have been reports of EoE with Barrett's esophagus (BE) but whether or not EoE is a pre-malignant condition is still unknown. Esophageal stricture formation can occur in both patients with GERD and EoE, but when stricture formation occurs in both settings it is difficult to discern which disease process caused the stricture. Case Presentation: A 62 year old Caucasian male with a past medical history of ankylosing spondylitis and hypertension presented to the emergency room with abrupt onset of midsternal pain and inability to control secretions after eating. An emergent esophagogastroduodenoscopy (EGD) was performed in which retained food debris was removed. Mucosal changes of concentric rings throughout the entire length of the visualized esophagus were noted, suspicious for EoE. Additionally, a significant stricture was found at endoscopic length 20-24 cm and a medium sized hiatal hernia. The gastroesophageal junction was difficult to visualize due to retained food debris. Pathology specimens of the mid-esophagus did confirm EoE. The patient was begun on fluticasone 220 mcg swallowed inhaler, 2 puffs bid. A repeat endoscopy was performed 4 weeks later in which the esophageal stricture underwent balloon dilatation. On repeat endoscopy, the patient was noted to have an irregular Z-line and the endoscopic appearance of BE near the gastroesophageal junction in addition to the mucosal changes of EoE. Biopsies of the distal esophagus did confirm BE. Discussion: This case illustrates two distinct disease processes occurring concomitantly. There are reports of both disease states occurring, but none with a stricture according to our literature search. Long term manifestations of gastroesophageal reflux disease (GERD) include esophageal stricture formation but it can not be said for certain if the stricture in the patient was from EoE or GERD. There have been no reports of an association with EoE and rheumatologic diseases such as ankylosing spondylitis. Conclusion: It is still unclear if aggressive surveillance in patients with EoE should be performed. Further insight is needed to discern if a patient's endoscopic findings such as a hiatal hernia or even esophageal strictures are risk factors for complications or malignancy from EoE. In light of the increased awareness for EoE, there will likely more cases reported of EoE and BE. There have been no reported cases of a patient with EoE, esophageal stricture and BE from our extensive literature search.