COMPLICATIONS OF EOSINOPHILIC ESOPHAGITIS

Abstract

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Idiopathic eosinophilic esophagitis is a chronic immune mediated eosinophilic infiltration of the esophageal mucosa. Clinical presentation is in the form of dysphagia and esophageal food impaction (1). Esophageal dissection is a complication which can occur spontaneously or secondary to a clinical complication of food impaction, Boerhaave syndrome or diagnostic and therapeutic interventions. Case reports have highlighted esophageal dissection including spontaneous dissection (2). Association between chronic inflammatory conditions and thromboembolism is well known, however there is only one case report of venous thromboembolism (VTE) occurring in eosinophilic esophagitis (3). CASE PRESENTATION: A 40-year-old male with no known past medical history presented to our emergency department with complaints of continuous chest pain, persistent emesis (occasionally blood tinged), dysphagia and odynophagia after eating ribs at a barbeque one day prior. The patient had no reported history of allergies, atopy, rhinitis, or asthma. Laboratory evaluation revealed leukocytosis of 11.0 k/uL with an eosinophil percentage of 1.8%. CT chest revealed food impaction in the esophagus with an incidental finding of right upper lobe acute pulmonary emboli (PE). The patient was admitted to the MICU for emergent endoscopy which revealed a large mucosal tear and food bolus impaction in the distal esophagus. Cold biopsies were taken. Patient was started on a heparin drip in MICU. Persistent chest pain led to an esophageal barium study which showed a double barrel sign suggestive of intramural esophageal dissection. Cardiothoracic surgery was consulted, patient was kept NPO for 72 hours and treated with a proton pump inhibitor for spontaneous resolution of esophageal dissection. Repeat esophageal barium study confirmed resolution and patient was restarted on enteral nutrition. The patient was discharged after being able to tolerate a soft diet and switched to an oral anticoagulation agent. Following up in two weeks, the patient remained asymptomatic and biopsy confirmed eosinophilic esophagitis. DISCUSSION: To our knowledge, this is the first reported case in which a patient presented with all of the above categories of complications, both local (food impaction and esophageal dissection) and systemic (VTE). This unique clinical presentation made the medical management increasingly challenging. In our case the patient was started on a heparin drip in the MICU for continuous monitoring in case the need for emergent repeat endoscopy or surgical intervention arose. Though conservative management with proton pump inhibitors and nil per mouth is the mainstay of management, surgery must be considered if esophageal perforation or mediastinal abscess occur. CONCLUSIONS: Surgery must be considered if esophageal perforation or mediastinal abscess occur. Reference #1: 1. Desai TK1, Stecevic V, Chang CH, Goldstein NS, Badizadegan K, Furuta GT. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointest Endosc. 2005 Jun;61(7):795-801. Reference #2: 2. Straumann A1, Bussmann C, Zuber M, Vannini S, Simon HU, Schoepfer A. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol. 2008 May;6(5):598-600. doi: 10.1016/j.cgh.2008.02.003. Epub 2008 Apr 14 Reference #3: 3. Patricia D. Jonesa, b Stephan Mollc Evan S. Dellona, b. Pulmonary Embolism in a Patient with Eosinophilic Esophagitis: Causal or Coincidental? Case Rep Gastroenterol 2013;7:82–88 DISCLOSURES: No relevant relationships by Michael Hoffman, source=Web Response No relevant relationships by Benjamin Mba, source=Web Response No relevant relationships by Heba Naseem, source=Web Response No relevant relationships by Rabab Nasim, source=Web Response No relevant relationships by Marcus Stammen, source=Web Response