A 52-year-old female presented with esophageal dysphagia. The patients' past medical history was significant for GERD, constipation, hypertension, and arthritis. The patient had a 23 pack-year smoking history, history of alcohol abuse, and daily non-steroidal anti-inflammatory drugs (NSAIDs) use for her joint pain. A brief timeline of events follows (Table 1). On initial presentation, she had two episodes of food impaction. EGD showed severe circumferential ulceration in the distal esophagus with low-grade narrowing (Figure 1). Esophageal biopsy revealed reflux esophagitis without evidence of eosinophilic esophagitis and gastric biopsy revealed Helicobacter pylori-negative chronic gastritis. The lower esophagus was dilated from 15 to 18 mm with a controlled radial expansion (CRE) balloon. Proton-pump inhibitor (PPI) therapy was initiated, and the patient reported improvement of symptoms on routine follow-up.
Sixteen months later, the patient returned with 2 months of solid food avoidance due to trouble swallowing. The patient also reported increased frequency of heartburn from once or twice weekly to every day despite adherence to daily PPI therapy. Patient reported increased severity of heartburn when she drank soda. Otherwise, patient reported normal appetite and no significant weight changes. She denied nausea, vomiting, chest pain, abdominal pain, or change in bowel habits. Physical exam revealed a healthy-appearing, obese woman in no acute distress. Family history was significant for gastritis and recurrent vomiting. The patient reported she desired relief of the food stuck in her mid-chest.
Subsequent EGD revealed fine rings and diffuse yellow-white exudate (Figure 2). No esophageal stricture, ring, or hiatal hernia were seen to suspect a mechanical cause of the dysphagia (Figure 3). However, multiple openings in the esophageal mucosa were noted, suspicious for EIP (Figure 4). Random biopsies of the middle and upper esophagus also showed active esophagitis and were positive for focal Candida spp. In contrast to the H. pylori-negative gastritis at initial presentation, random gastric biopsies (Figure 5) revealed reactive gastropathy with focal H. pylori colonization. In addition, the patient underwent high-resolution esophageal manometry (HRM), which revealed strong contractions of the esophageal body with normal lower esophageal sphincter relaxation (Figure 6) with a distal contractile integral of 11,576 mm Hg s cm (normal range = <8000 mm Hg s cm). HRM findings were consistent with hypercontractile peristalsis ("Jackhammer esophagus") based on the Chicago v3.0 classification. Patient was initiated on a 14-day course of 200 mg Diflucan once daily for esophageal candidiasis. Patient was also treated for H. pylori colonization with standard quadruple therapy for 14 days, consisting of four times daily administration of bismuth subsalicylate 262 mg, metronidazole 250 mg, and tetracycline 500 mg, along with pantoprazole 40 mg twice daily. Despite adherence to therapy, patient reported symptoms of dysphagia and heartburn were not fully resolved at 1-month follow-up. Due to lack of clinical improvement, decision was made to repeat EGD to monitor for resolution of esophageal mucosal damage and undergo empiric esophageal dilation. Repeat EGD revealed normal-appearing esophageal mucosa with regular Z-line. Esophageal dilation with 16 mm Savary was successfully performed. Patient reported full resolution of her symptoms at 2-week follow-up. Patient remained asymptomatic at her most recent appointment 7 months after empiric dilation.