A 35-year-old white male complains of difficulty swallowing that he describes as a feeling of tightness in the chest after food ingestion as well as a sensation of the food “sticking” in his chest. He is afraid to eat and has lost 5 pounds; he is a smoker with a history of asthma and a moderate user of alcohol. He is concerned about the possibility of esophageal cancer.
Pertinent History
Patient’s symptoms are occasionally accompanied by nausea and vomiting of the ingested item. He states that his dysphagia (difficulty swallowing) can occur with both solid food and with liquids and occurs intermittently, without any warning.
The Exam
The patient is a well-developed male with no signs of cachexia, who appears to be in his usual state of health. He is not jaundiced, has normal breath sounds without wheezing and an unremarkable abdominal exam. He had a cardiac work up due to the chest tightness and any cardiac etiology was ruled out. A rectal exam showed no masses or tenderness and the stool was negative for gross or occult blood.
Diagnostic Testing
Prior to consultation, the aforementioned cardiac workup was negative, as was a UGIS that revealed no masses, strictures or obstruction of the esophagus and a normal appearance of the stomach and duodenum. There appeared to be tertiary contractions of the esophagus that were nonspecific. His WBC was 8.4 with an eosinophil count of 2000/ul (normal 0-500/ul). LFT’s and testing for connective tissue disorders were normal as were his Hgb/Hct.
Differential Diagnosis And Directed Testing
The differential diagnosis for dysphagia includes mechanical causes—such as stricture, esophageal web and neoplasm—as well as infectious esophagitis, eosinophilic esophagitis, radiation esophagitis and motility disorders such as diffuse esophageal spasm, achalasia, nutcracker esophagus and scleroderma.
In our patient, many of the obstructive disorders can be ruled out with the history and relatively normal UGIS. Typically, motility disorders and eosinophilic esophagitis (ee) present with dysphagia to both solids and liquids and occur intermittently. An upper endoscopy (egD) was performed and verified the lack of tumor. Despite the patient’s young age, cancer had been a concern because of his weight loss, smoking and alcohol use.
Biopsies of the stomach were normal without evidence of Helicobacter pylori, but biopsies of the mid-esophagus showed mild inflammation with increased eosinophils of 40/HpF. The diagnosis of eosinophilic esophagitis (ee) was made from these findings. Although esophageal manometry was not performed, this test may show several motility abnormalities like diffuse esophageal spasm or nutcracker esophagus.
Treatment
Patient was treated with Fluticasone (a topical steroid) and an antisecretory medication (PPI), to help decrease the inflammation. The patient noticed improvement in his symptoms in about 6-days and has had no recurrent episodes in several months.
Lastly, I suggest the patient see an allergist due to the high incidence of food allergies in patients with EE, especially those with a history of asthma.
Conclusion
Our patient is doing well on pantoprazole and Fluticasone and has gained weight. He was obviously relieved that he did not have cancer and this has provided the impetus for him to quit smoking and curb his alcohol ingestion.
Other patients should learn from this case and realize that their symptoms should always be evaluated, especially when they are persistent, and to remember that many of the possibilities for their symptoms can be diagnosed and treated in a timely manner.