A 49-year-old white woman presented with dysphagia for solid food since her early in her second decade. She had one food impaction requiring a hospital visit, and had symptoms suggestive of food impaction almost every week. She rarely reported heartburn. Her past medical history included celiac sprue treated with a strict glutenfree diet for the last 20 years. Ten years prior, endoscopy with bougie dilation was associated with severe chest pain for several days. An endoscopic biopsy 5 years prior showed >15 eosinophils in 2 HPF consistent with EoE.
Subsequently, she was treated with fluticasone (2 puffs BID) then budesonide (1 gm BID slurry); both were associated with side effects (headaches, sore throat, and thrush) resulting in termination after 2-3 weeks. She had taken PPIs in the past, including dexlansoprazole 30 mg for several months in the last year, but these medications did not help her symptoms. Repeat biopsy was not performed. Six months prior to her presentation she was placed on a 6-food elimination diet, to which she was adhering with the aid of a dietician. She avoids nuts and seafood due to an oral allergy syndrome, wheat, and now eggs, dairy products, and soy. Currently, this is her only active treatment for EoE.
On initial endoscopy, the 10-mm adult scope could not be passed due to esophageal narrowing 20 mm from the teeth; a 5 mm pediatric scope was used. The entire esophagus was pale and narrowed throughout, with no exudate, rare furrows, and incomplete rings in the mid-esophagus. At the Z line (37 cm) was a peptic-appearing ring with a 2-cm hiatal hernia. Four biopsies were obtained from the distal and 2 from the proximal esophagus. Savary dilation was performed from 9 mm to 12 mm with moderate resistance. Following the dilation, she had mild-moderate pain for 5 days, requiring narcotic analgesia.
Initial biopsies showed 400 eosinophils per HPF from both the proximal and distal esophagus, associated with lamina propria fibrosis, despite 6 months of the 6-food elimination diet (Figure 1). She was started on dexlansoprazole 60 mg AM. Three further endoscopies and dilation followed at monthly intervals (Figure 2). The final 2 dilations were performed with Maloney bougies.
After 2 months on PPI, there was a dramatic decrease in eosinophils, but still in the abnormal range (55 distal; 15 proximal; Figure 3). By 4 months, esophageal histology had normalized (5 distal; 2 proximal; Figure 4). The esophageal lumen was progressively dilated to 17 mm diameter; all signs of inflammation had resolved and the normal vascular pattern returned. The patient is currently eating more foods without difficulty or transient food impactions. She will remain on dexlansoprazole 60 mg AM, and the eliminated foods will be slowly re-introduced into her diet.