Eosinophilic Esophagitis Presenting With Food Impaction

A 24-year-old man presents to the emergency department with a food impaction after eating roast beef for dinner. He is able to control his secretions. He notes that he has had difficulty in swallowing certain solid foods during the past few months and has been eating more slowly than than others. His only medication is ibuprofen as needed. Upper endoscopy demonstrates concentric rings and longitudinal furrows in his esophagus. Which of the following is the most likely diagnosis?

a. Pill induced esophagitis
b. Erosive esophagitis
c. Peptic stricture
d. Eosinophilic esophagitis
e. Candidal esophagitis

ANSWER: D

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition believed to be secondary to an allergic trigger (food vs environmental). The patient’s age and endoscopic features suggest this diagnosis. Ibuprofen may lead to pill-induced esophagitis; however, mucosal breaks would be expected to be seen on endoscopy. Erosive esophagitis and peptic strictures are features of long-standing GERD. Of note: since the introduction of acid suppressants, peptic strictures are no longer commonly seen on endoscopy; they present as a smooth taper in the lower esophagus. Finally, candidal esophagitis would more likely present in immunocompromised patients or with the use of steroids. This classic presentation would be odynophagia: endoscopically, white plaques are typically seen on the mucosa.