Gastro Case Challenge: A 33-Year-Old Man Who Can’t Swallow His Own Saliva

Juan Carlos Munoz, MD; Carmela Monteiro, MD; Ivan E. Rascon-Aguilar, MD


September 06, 2022

Barium esophagography may be performed as the initial diagnostic test for eosinophilic esophagitis, but upper endoscopy is the preferred diagnostic test. Endoscopic findings include strictures, rings, and a narrowed lumen of the esophagus. Subtle but prevalent findings of eosinophilic esophagitis that are seen with endoscopy (mucosal furrowing, white spikes, the easy tearing of the mucosa) may not be seen on barium studies. Esophageal manometry studies are typically normal in patients with eosinophilic esophagitis. About 40% of cases may have uncoordinated contractions of the esophagus, which suggests involvement of the muscular layers. Monitoring with an esophageal 24-hour pH study is normal in 90% of affected patients. About 10% of patients are found to have gastroesophageal reflux disease (GERD).

An endoscopy (with biopsies taken from the upper and lower esophagus) is the test of choice for definitive diagnosis. Most patients have abnormal endoscopic findings. The most common structural alterations seen in adult patients with eosinophilic esophagitis may occur in combination or as the primary characteristics (eg, mucosal fragility, uniform small-caliber esophagus, single or multiple corrugations or rings, proximal or distal esophageal stenosis, or 1-2 mm whitish vesicles scattered over the mucosal surface, and, in rare cases, a Schatzki ring [Figure 2]).

Figure 2.

Histology is critical to the diagnosis of eosinophilic esophagitis. Extreme care must be taken when interpreting the biopsies; the histopathologic diagnostic criteria for eosinophilic esophagitis widely varies. Most studies suggest that > 20 eosinophils per high-power field (HPF) in a single field or > 15 eosinophils per HPF in two fields are findings that are diagnostic of eosinophilic esophagitis. Esophageal reflux may produce an eosinophilic infiltration (< 10 eosinophils per HPF) that is usually limited to the distal esophagus.

Treatment for eosinophilic esophagitis focuses on different aspects of the disease, including:

  • Identification and elimination of the underlying allergens that may be causing the disease (especially in pediatric and adolescent patients)

  • The use of steroids and proton pump inhibitors (PPIs)

  • Endoscopic treatment for stricture complications


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