A 17-year-old girl presented with progressive dysphagia. Congenital esophageal stenosis
had been diagnosed 8 years previously on the basis of similar symptoms. After repeated
esophageal dilation at that time, she had remained asymptomatic for several years.
Achalasia was excluded by manometry, which documented complete lower esophageal sphincter
relaxation and uncoordinated contractions. A barium swallow examination showed a long-segment
stenosis of the esophagus (Figure [1]). Endoscopy revealed a long-segment stenosis, which was dilated to a diameter of
11 mm to allow multiple biopsies to be taken. Minor bleeding and mucosal tears were
observed after the dilation. A check-up gastroscopy showed signs of esophagitis and
white pin-point plaques (Figure [2]), and multiple biopsies were taken. Computed tomography showed that there was air
in the paraesophageal space, and perforation of the esophagus was assumed (Figure
[3]). Four weeks later, no further extramural air was detected, and the patient remained
clinically stable.
Histological analysis identified basal-zone hyperplasia with increased intercellular
clefts, variable but high numbers of intraepithelial eosinophils, focally exceeding
100 per high-powered field. Focally, the immediate subepithelial stroma also contained
numerous eosinophils (Figure [4]). No parasites, fungi, or other causes of eosinophilic aggregates were identified,
and the patient was therefore diagnosed as having eosinophilic esophagitis.
Figure 1 The barium swallow at admission. The extended filiform esophageal stenosis should
be noted.
Figure 2 The macroscopic findings at endoscopy. There is no dominant stenosis, but signs of
esophagitis and white pin-point plaques were observed.
Figure 3 Computed tomography of the esophagus. Air is visible in the paraesophageal space (arrow).
Figure 4 Esophageal biopsy, showing numerous scattered intraepithelial eosinophils (hematoxylin-eosin,
original magnification × 100).
The endoscopic findings in eosinophilic esophagitis most commonly include mucosal
fragility, strictures, whitish papules, and a small-caliber esophagus [1]. Eosinophilic esophagitis is best defined by the presence of eosinophils within
the epithelium. The presence of more than 15 - 20 eosinophils per high-powered field
is considered to be diagnostic of eosinophilic esophagitis [2]
[3].
Perforation of the esophagus occurred following dilation. Dilation treatment should
be reserved for patients suffering from dysphagia related to the eosinophilic esophagitis
who do not respond to medical therapy. Topical steroid treatment has been shown to
be safe and effective [4]
[5]. The endoscopic findings in eosinophilic esophagitis can be very subtle and easily
misinterpreted. In patients presenting with dysphagia in whom proton-pump inhibitor
treatment fails, a histological diagnosis should be obtained.
Competing interests: None
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