A CASE OF EOSINOPHILIC ESOPHAGITIS: HEARTBURN DOES NOT ALWAYS MEAN GASTROESOPHAGEAL REFLUX DISEASE

A 27-year-old Caucasian man visited a gastrointestinal clinic because of intermittent heartburn and substernal chest discomfort for 6 months. He did not have any allergic histories and family histories of an atopic disease, but he had obesity grade 2 and essential hypertension. Physical examination was unremarkable, and there were no abnormalities in laboratory test results. The primary care doctor diagnosed gastroesophageal reflux disease (GERD) and referred to eophagogastroduodenoscopy (EGD). EGD showed: edema, decreased vascularity, longitudinal furrows, and white exudate on the lower and mid esophagus. Biopsies were obtained: 3 specimens at the proximal and distal esophagus, and also at stomach and duodenum. Whereas histology from stomach and duodenum was normal, eosinophilic infiltration (> 80 eos/hpf) was observed on the esophageal mucosa. Moreover esophageal impedance-pH monitoring did not reveal pathological gastroesophageal reflux (acid exposure time = 0.4%). High-resolution manometry detected normal esophageal motility. Based on the clinical, endoscopic and histological findings, the patient was diagnosed with eosinophilic esophagitis (EoE). Proton pump inhibitors (PPIs) and an empiric six-food elimination diet were prescribed. The patient noted the resolution of symptoms during that therapy. After a 12-week initial therapy course the follow-up endoscopy revealed edema, decreased vascularity, longitudinal furrows, white exudate in the distal esophagus despite of treatment. Magnifying endoscopy with narrow spectrum (i-scan OE) demonstrated dot-shaped intrapapillary capillary loops (IPCL) and absent cyan vessels, which were described in literature for EoE [Tanaka K, et al., 2013] and also multiple white plaques on the mucosal surface. Mucosal biopsies showed maintenance epithelial eosinophil infiltration (> 30 eos/hpf), eosinophil microabscesses and basal zone hyperplasia. Topical corticosteroids were added to therapy. Our case report demonstrates that the proper examination of patients with heartburn provides the correct diagnosis of EoE and helps to distinguish EoE from GERD, which is the most common esophageal disorder with heartburn and sometimes esophageal eosinophilia.