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Dysphagia in a 34-Year-Old Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 34-year-old woman presented with 2 years of progressively worsening intermittent dysphagia, primarily to solids, especially meats, localized retrosternally. She reported no heartburn, nausea, vomiting, abdominal pain, weight loss, or changes in bowel habits. She reported no medications or comorbidities. Physical examination was unremarkable. Results of a recent complete blood cell count were normal. Despite taking ranitidine (150 mg twice daily), she continued to have bothersome daily dysphagia, prompting her primary care clinician to order esophagogastroduodenoscopy (EGD). The EGD showed vertical furrows and circumferential rings in the esophagus (Figure 1A), while the stomach and duodenum appeared normal. Four biopsies each were taken from the proximal and distal esophagus (Figure 1B).

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Eosinophilic esophagitis (EoE)

C. Prescribe omeprazole (40 mg twice daily)

The key to the correct diagnosis is the esophageal mucosal biopsies demonstrating numerous intraepithelial eosinophils, in the setting of dysphagia symptoms and supportive endoscopic findings, and the absence of alternate etiologies for the eosinophilia.1 Other etiologies of esophageal eosinophilia, such as gastroesophageal reflux disease, eosinophilic gastroenteritis, hypereosinophilic syndrome, infections, drug hypersensitivity reaction, Crohn disease, or achalasia, should be carefully considered and excluded based on presenting history, physical examination findings, and diagnostic data.1 Once the diagnosis of EoE was made, the patient was prescribed twice-daily proton pump inhibitor (PPI) therapy, a well-tolerated first-line treatment option.

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Article Information

Corresponding Author: Amit Patel, MD, Division of Gastroenterology, Duke University School of Medicine, 10207 Cerny St, #210, Raleigh, NC 27617 (amit.patel@duke.edu).

Published Online: January 31, 2020. doi:10.1001/jama.2019.19121

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share her information. We thank Maureen Bauer, MD, and Kenneth Ellington, MD (Department of Pathology, Duke University School of Medicine), for providing pathology images of the case. Drs Bauer and Ellington received no compensation for their contributions.

References
1.
Dellon  ES, Liacouras  CA, Molina-Infante  J,  et al.  Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis.  Gastroenterology. 2018;155(4):1022-1033.e10.PubMedGoogle ScholarCrossref
2.
Dellon  ES, Hirano  I.  Epidemiology and natural history of eosinophilic esophagitis.  Gastroenterology. 2018;154(2):319-332.PubMedGoogle ScholarCrossref
3.
Kumar  S, Choi  S, Gupta  SK.  Eosinophilic esophagitis—a primer for otolaryngologists.  JAMA Otolaryngol Head Neck Surg. 2019;145(4):373-380.PubMedGoogle ScholarCrossref
4.
Dellon  ES, Gonsalves  N, Hirano  I,  et al; American College of Gastroenterology.  ACG clinical guideline: evidence based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE).  Am J Gastroenterol. 2013;108(5):679-692.PubMedGoogle ScholarCrossref
5.
Shah  A, Kagalwalla  AF, Gonsalves  N,  et al.  Histopathologic variability in children with eosinophilic esophagitis.  Am J Gastroenterol. 2009;104(3):716-721.PubMedGoogle Scholar
6.
Kim  HP, Vance  RB, Shaheen  NJ, Dellon  ES.  The prevalence and diagnostic utility of endoscopic features of eosinophilic esophagitis.  Clin Gastroenterol Hepatol. 2012;10(9):988-96.PubMedGoogle ScholarCrossref
7.
Straumann  A, Katzka  DA.  Diagnosis and treatment of eosinophilic esophagitis.  Gastroenterology. 2018;154(2):346-359.PubMedGoogle ScholarCrossref
8.
Gentile  N, Katzka  D, Ravi  K,  et al.  Oesophageal narrowing is common and frequently under-appreciated at endoscopy in patients with oesophageal eosinophilia.  Aliment Pharmacol Ther. 2014;40(11-12):1333-1340.PubMedGoogle ScholarCrossref
9.
Roman  S, Hirano  I, Kwiatek  MA,  et al.  Manometric features of eosinophilic esophagitis in esophageal pressure topography.  Neurogastroenterol Motil. 2011;23(3):208-214.PubMedGoogle ScholarCrossref
10.
Dellon  E, Farrell  T, Bozymski  E, Shaheen  N.  Diagnosis of eosinophilic esophagitis after fundoplication for “refractory reflux.”  Dis Esophagus. 2010;23(3):191-195. PubMedGoogle ScholarCrossref
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