Rounds
Michael Goldman, M.D.
Johns Hopkins Asthma & Allergy
Center
April 2, 2004
Chief Complaint
HPI
Complains of difficulty swallowing solid foods.
Steak, chicken, pork, and bread get stuck in
the base of throat emesis, with relief of
obstruction
No pain on swallowing, no heartburn, no wt.
loss
No difficulty swallowing liquids
Only slight improvement with Nexium.
Stopped due to nausea.
Referred to GI
Work up
Normal Exam
Barium swallow: narrowing of distal
esophagus.
Differential diagnosis:
Achalasia
Schatzki Ring
Work up
Endoscopy:
Ringed esophagus
Several polypoid/nodular areas,
biopsied
Narrowing of the distal esophagus
Ringed Esophagus
Esophageal nodules
Whitish exudates
Biopsy Results
Esophagus:
Moderate chronic inflammation
Focally parakeratotic (excessive
keratin) papillary tissue with increased
areas of eosinophils in subepithelium
Read as compatible with squamous
papilloma with eosinophilia described in
reflux esophagitis.
No dysplasia
Eosinophilic Esophagitis
Allergy Consultation
Medical/Social History
Physical Exam
Normal
No edema of nasal mucosa
Clear lungs
Cardiac without murmurs
Normal abdominal exam
Skin Testing-scratch
Food
Wheal/flar
e
Food
Wheal/flar
e
Egg
Peanut
Fish Mix
Hazelnut
Almond
Other nuts
Pork
10/45
7/20
6/30
10/30
4/8
0
4/12
Malt
Wheat
Beef
Chicken
Milk
Soy
Shellfish
mix
5/12
3/5
0
0
0
0
0
Now What?
My recommendations
Blood results
Food
Egg
Peanut
Fish (cod,
tuna,salm
on)
Hazelnut
kU/L
4.88
2.56
<0.35
Food
Malt
Wheat
kU/L
3.32
12.3
3.32
Almond
3.37
Pork
4.57
Follow Up
Now What?
Adult Eosinophilic
Esophagitis
Adult Eosinophilic
Esophagitis
Pediatric Eosinophilic
Esophagitis
Pediatric Eosinophilic
Esophagitis
Treatment
Food avoidance
Effective in children
No studies in adults
Treatment
Oral corticosteroids
Treatment
Esophageal dilitation
EE vs. GERD
Characteristic
Atopy
Food sensitization
Histology
Peripheral
eosinophilia
Esophageal pH
PPI
Steroids
EE
High
High
>24
eos/hpf
~50%
GERD
Nml
Nml
0-7
eos/hpf
rare
Normal
Usually not
helpful
Helpful
Abnormal
Helpful
Not