A 22-year-old man comes to the emergency department due to dysphagia for the past 3 hours. He was eating steak with his friends when he suddenly noticed a catching sensation in his throat. He tried to drink a few sips of beer, but the sensation continued to worsen. The patient has also had a hoarse voice for the last hour and difficulty swallowing his saliva. He has never had similar problems before.
Medical history includes seasonal allergic rhinitis, bronchial asthma, and gastroesophageal reflux disease. Current medications include albuterol metered-dose inhaler as needed and over-the-counter omeprazole. The patient has consumed 5 or 6 beers daily for the past 4 years but does not use tobacco or illicit drugs. His mother has atopic dermatitis.
Temperature is 37.5 C (99.5 F), blood pressure is 100/60 mm Hg, pulse is 92/min, and respirations are 14/min. Examination shows no abnormalities except for a lethargic young man who is drooling and speaking in broken sentences. An emergency endoscopy is planned.
In addition to a food bolus, which of the following would be the most likely endoscopic finding?

Question

A 22-year-old man comes to the emergency department due to dysphagia for the past 3 hours.  He was eating steak with his friends when he suddenly noticed a catching sensation in his throat.  He tried to drink a few sips of beer, but the sensation continued to worsen.  The patient has also had a hoarse voice for the last hour and difficulty swallowing his saliva.  He has never had similar problems before.
Medical history includes seasonal allergic rhinitis, bronchial asthma, and gastroesophageal reflux disease.  Current medications include albuterol metered-dose inhaler as needed and over-the-counter omeprazole.  The patient has consumed 5 or 6 beers daily for the past 4 years but does not use tobacco or illicit drugs.  His mother has atopic dermatitis.
Temperature is 37.5 C (99.5 F), blood pressure is 100/60 mm Hg, pulse is 92/min, and respirations are 14/min.  Examination shows no abnormalities except for a lethargic young man who is drooling and speaking in broken sentences.  An emergency endoscopy is planned.
In addition to a food bolus, which of the following would be the most likely endoscopic finding?

Quizplus · Accepted Answer

11ec193a_9602_b48f_853d_f57d834d53b6_MD0002_00 This patient's presentation is most consistent with eosinophilic esophagitis (EoE), which typically occurs in young men with a history of atopic conditions (eg, asthma, allergies, eczema). More than 50% of patients with EoE have a history of food impaction (as in this patient with a complete esophageal obstruction characterized by drooling and inability to handle secretions). Other typical symptoms include gastroesophageal reflux (often refractory to proton pump inhibitors [PPIs] or H2 blockers), chest and upper abdominal pain, and intermittent solid-food dysphagia. Endoscopy may be normal but usually shows various abnormalities such as longitudinal furrows, concentric rings (known as trachealization of the esophagus), and whitish papules/exudates that represent eosinophilic microabscesses. The diagnosis requires the exclusion of other causes of esophageal eosinophilia (eg, infection, graft versus host disease) and is confirmed with esophageal biopsy demonstrating ≥15 eosinophils/hpf. Although previously required for diagnosis, a 2-month trial of a PPI is no longer required for diagnosis; in fact, PPI responsiveness may represent a subset of EoE. Treatment involves an elimination diet, avoidance of allergens, acid suppression with PPIs, and topical corticosteroids (eg, budesonide, fluticasone). concentric rings (Choice A) Endoscopy usually cannot evaluate peristalsis. Also, a hiatal hernia (even a large one) should not cause food bolus impaction. (Choice B) Dilated esophagus with distal tapering is usually seen in chronic distal obstruction, such as achalasia or pseudo-achalasia (gastric fundic tumor). These conditions cause chronic lower esophageal obstruction with gradual esophageal body dilation and usually do not present acutely, as in this patient. (Choice C) A large irregular mass in the lower esophagus indicates a likely esophageal carcinoma, which can cause obstruction but would be very atypical at age 22 in the absence of a history of lye/caustic ingestion. (Choice E) A smooth tight stricture is usually benign and is often due to trauma, either mechanical (surgical) or chemical (lye ingestion). This patient has gastroesophageal reflux disease, which may cause a peptic stricture; however, these are seen more commonly in the lower esophagus than in the upper esophagus. Educational objective: Eosinophilic esophagitis typically presents in young men with a history of atopic conditions (eg, asthma, allergies). Symptoms include refractory gastroesophageal reflux, intermittent solid-food dysphagia, and chest/abdominal pain; >50% of patients develop a food impaction. Endoscopy may be normal but usually shows longitudinal furrows, concentric rings, and eosinophilic microabscesses. The diagnosis requires esophageal biopsy demonstrating ≥15 eosinophils/hpf. __________ References: Diagnosis and treatment of eosinophilic esophagitis. (http://www.ncbi.nlm.nih.gov/pubmed/28756235)

A 22-Year-Old Man Comes to the Emergency Department Due to Dysphagia