Diagnosis of Eosinophilic Esophagitis after Prior Nissen Fundoplication for Presumed “Refractory GERD”

Abstract

Purpose: Previous studies have shown that a small percentage of patients with symptoms of heartburn who carry the diagnosis of refractory gastroesophageal reflux disease (GERD) actually have eosinophilic esophagitis (EoE). The frequency of patients with presumed refractory GERD who undergo Nissen fundoplication but have EoE is unknown. The purpose of this study is to present a case series of patients with esophageal eosinophilia who underwent fundoplication and were subsequently found to have EoE. Methods: We performed a retrospective analysis of the University of North Carolina (UNC) EoE clinicopathologic database which contains information on patients with esophageal eosinophilia from any cause from 2000–2007. Patients diagnosed with EoE after a prior Nissen were identified, as were other patients with high levels of esophageal eosinophilia and a prior Nissen. Cases of EoE were defined as having ≥15 eosinophils per high-powered field (0.23 mm2; eos/hpf) with at least one typical symptom (eg dysphagia, heartburn, or feeding intolerance) and with other causes of esophageal eosinophilia excluded. The UNC electronic medical record was reviewed to extract pertinent data. Results: A total of 8 patients were identified who had a prior Nissen and high levels of esophageal eosinophilia. Of those, 4 patients (56 yo F, 38 yo M, 50 yo F, 8 yo M) met the diagnostic criteria for EoE for this study. All 4 had undergone Nissen prior to 2002. Their symptoms (dysphagia in 2/4, food impaction in 1/4, heartburn in 3/4, failure to thrive in 1/4) and esophageal eosinophilia (>50, 60, 50, and “innumerable” eos/hpf, respectively) persisted after the surgery. Time from Nissen to diagnosis of EoE ranged from 7–14 years. Despite their high eosinophil counts, the other 4 patients (77 yo M, 55 yo F, 69 yo F, 9 yo F) were felt to have GERD on a clinical basis (heartburn in 2/4, regurgitation in 1/4, and failure to thrive in 1/4) and due to their symptomatic response to surgery. Their esophageal eosinophilia (40, 30, 20, and 60 eos/hpf) also improved post-operatively. Conclusion: We have identified 4 patients with “refractory GERD” treated with Nissen fundoplication who were subsequently diagnosed with EoE. Therefore, a proportion of subjects undergoing this surgery for incomplete resolution of GERD symptoms appear to be undiagnosed cases of EoE. The proportion of PPI non-responsive subjects with EoE is unknown. However, given the rising prevalence of EoE, it may be prudent to obtain proximal and distal esophageal biopsies in such patients prior to performing anti-reflux surgery.