A 9-year-old boy is brought to the office by his father for evaluation of chest and abdominal discomfort. For the past several months, the patient has felt a "burning" sensation in his chest after eating. He was evaluated 6 weeks ago and had a normal examination and was prescribed a proton-pump inhibitor, which he has been taking daily. The patient says the medication doesn't seem to help, and now he has stomach aches after eating. His typical diet consists of soft foods, such as yogurt and mashed potatoes, and he tries to avoid solid foods due to stomach pain. He has also vomited a few times after eating, but his father is not sure if that was due to a specific food. The patient drinks water and no juice or soda. Temperature is 37 C (98.6 F). Physical examination shows eczematous patches on bilateral antecubital fossae and behind both knees. Endoscopy shows circular rings and thickened, linear furrowing of the esophagus. Histology results are pending. Which of the following is the most likely diagnosis?

Question

A 9-year-old boy is brought to the office by his father for evaluation of chest and abdominal discomfort.  For the past several months, the patient has felt a "burning" sensation in his chest after eating.  He was evaluated 6 weeks ago and had a normal examination and was prescribed a proton-pump inhibitor, which he has been taking daily.  The patient says the medication doesn't seem to help, and now he has stomach aches after eating.  His typical diet consists of soft foods, such as yogurt and mashed potatoes, and he tries to avoid solid foods due to stomach pain.  He has also vomited a few times after eating, but his father is not sure if that was due to a specific food.  The patient drinks water and no juice or soda.  Temperature is 37 C (98.6 F).  Physical examination shows eczematous patches on bilateral antecubital fossae and behind both knees.  Endoscopy shows circular rings and thickened, linear furrowing of the esophagus.  Histology results are pending.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d67a_ed7a_bc81_23c762570487_MD0003_00 This patient has abdominal pain that is related to eating and that does not respond to acid suppression (eg, proton-pump inhibitor), which is consistent with eosinophilic esophagitis. Symptoms are due to esophageal inflammation triggered by food allergens, and patients frequently have eczema (as seen in this patient) or other allergic conditions (eg, asthma, rhinitis). Presentation typically includes dysphagia (ie, difficulty swallowing), mid-chest and epigastric pain, vomiting, and food impaction. Food refusal or a preference for soft foods is common in children. These symptoms can lead to weight loss. In patients in whom eosinophilic esophagitis is suspected, a 2-month trial of proton-pump inhibitor therapy is considered part of the diagnostic evaluation; if there is no symptom improvement following this trial, endoscopy with esophageal biopsy is performed. Circular rings and esophageal furrows are nonspecific findings that may be present on endoscopy; diagnosis is confirmed by ≥15 eosinophils per high-power field on histology. First-line treatment is dietary modification to avoid potential food triggers. Pharmacologic management can include topical (eg, swallowed) fluticasone. (Choice A) Achalasia causes chronic, progressive dysphagia and chest pain but is characterized by a dilated esophagus and thickened lower esophageal sphincter muscle on endoscopy. (Choice C) Foreign body ingestion is an acute cause of chest pain and dysphagia and would be identified on endoscopy. (Choice D) Gastroesophageal reflux disease presents with chest/epigastric pain after eating and can result in esophageal eosinophilia; however, symptom improvement is expected with a proton-pump inhibitor. (Choice E) Patients with a retropharyngeal abscess are typically ill-appearing with an acute onset of fever, pain and difficulty swallowing, and neck swelling/stiffness. In contrast, this patient is afebrile with chronic symptoms. (Choice F) Vascular ring is a congenital anomaly of the aortic arch. Esophageal compression causes dysphagia, vomiting, and food impaction, but not abdominal pain. Endoscopy shows an indentation at the site of the ring. Educational objective: Eosinophilic esophagitis presents with dysphagia, epigastric pain, vomiting, and food impaction. Endoscopy with eosinophils on esophageal biopsy is diagnostic. References: Eosinophilic esophagitis: a comprehensive review. (http://www.ncbi.nlm.nih.gov/pubmed/26194940)

A 9-Year-Old Boy Is Brought to the Office by His