A 10-year-old boy is brought to the hospital for difficulty swallowing. During dinner a few hours ago, a piece of chicken became stuck in the patient's mid-chest region. His parents say that he has previously had the sensation of food becoming stuck, but it has never lasted this long. The patient has vomited multiple times, but the chicken has not dislodged. Medical history is significant for eczema. He is drooling and visibly uncomfortable. An upper endoscopy is performed to remove the chicken from the esophagus, which exhibits multiple stacked, circular, ringlike indentations; linear furrowing; and scattered, small, whitish papules. Which of the following findings is most likely to be seen on biopsy of this patient's esophagus?

Question

A 10-year-old boy is brought to the hospital for difficulty swallowing.  During dinner a few hours ago, a piece of chicken became stuck in the patient's mid-chest region.  His parents say that he has previously had the sensation of food becoming stuck, but it has never lasted this long.  The patient has vomited multiple times, but the chicken has not dislodged.  Medical history is significant for eczema.  He is drooling and visibly uncomfortable.  An upper endoscopy is performed to remove the chicken from the esophagus, which exhibits multiple stacked, circular, ringlike indentations; linear furrowing; and scattered, small, whitish papules.  Which of the following findings is most likely to be seen on biopsy of this patient's esophagus?

Quizplus · Accepted Answer

11ec160b_3944_bd19_9249_072a3d05e3d8_MD0001_00 This patient with a history of solid food dysphagia has an esophageal food impaction due to eosinophilic esophagitis (EOE). EOE is a chronic Th2 cell−mediated disorder triggered by food antigen exposure. When activated, Th2 cells release chemokines (eg, IL-13, IL-5) that stimulate eosinophilic recruitment to the esophageal mucosa. EOE is most common in males with a history of atopic conditions (eg, eczema, asthma). Patients often have intermittent solid food dysphagia. Other symptoms include vomiting, reflux, and chest and upper abdominal pain. When EOE is severe, food can become trapped in the esophagus (ie, esophageal food impaction), requiring urgent upper endoscopy to remove the impacted food bolus. Classic endoscopic findings include stacked, circular, ringlike indentations; linear furrowing; and scattered, small, whitish papules (ie, eosinophilic microabscesses). Biopsies demonstrate eosinophilic mucosal infiltration. (Choice B) Achalasia results from ganglionic degeneration within the esophageal myenteric plexus, leading to the inability to relax the lower esophageal sphincter. It typically causes dysphagia of both solids and liquids and is rare in children. There are no specific endoscopic findings; however, a barium swallow demonstrating a bird-beak appearance of the esophagus is characteristic. (Choice C) Barrett esophagus is a premalignant condition characterized by intestinal metaplasia of the esophageal epithelium. It typically develops in older patients with uncontrolled gastroesophageal reflux but does not usually cause food impaction. (Choice D) Systemic sclerosis results in esophageal smooth muscle fibrosis, leading to severe gastroesophageal reflux. It occurs more commonly in adult women and usually presents with thickened skin and Raynaud phenomenon. Endoscopy typically demonstrates a dilated esophagus. (Choice E) Herpes simplex virus esophagitis is characterized histologically by eosinophilic intranuclear inclusions within esophageal squamous cells. It typically occurs in immunocompromised patients and results in severe odynophagia. Endoscopy demonstrates ulcerations with a volcano-like appearance. Educational objective: Eosinophilic esophagitis is a Th2 cell−mediated disorder leading to eosinophilic infiltration of the esophageal mucosa. It occurs most commonly in males with a history of atopic conditions and typically presents with solid food dysphagia, reflux, and occasionally food impaction. Classic endoscopic findings include stacked, circular, ringlike indentations; linear furrowing; and scattered, small, whitish papules (ie, eosinophilic microabscesses). __________ References: Eosinophilic esophagitis: a 10-year experience in 381 children. (http://www.ncbi.nlm.nih.gov/pubmed/16361045) ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). (http://www.ncbi.nlm.nih.gov/pubmed/23567357)

A 10-Year-Old Boy Is Brought to the Hospital for Difficulty