Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 30-year-old man is evaluated for ongoing symptoms of dysphagia. He was previously diagnosed with eosinophilic esophagitis on upper endoscopy and has completed an 8-week course of swallowed aerosolized fluticasone, which did not alleviate his symptoms. He takes no other medications.
On physical examination, vital signs are normal; BMI is 25. Other findings, including those of an abdominal examination, are unremarkable.
Upper endoscopy shows an area of high-grade stenosis in the distal esophagus.
Which of the following is the most appropriate treatment?
A. Increase fluticasone
B. Endoscopy with dilation
C. Omeprazole
D. Oral prednisone
MKSAP Answer and Critique
The correct answer is B. Endoscopy with dilation.
Endoscopy with dilation is the most appropriate treatment for this patient, who has eosinophilic esophagitis, refractory symptoms of dysphagia despite fluticasone therapy, and the finding of an esophageal stricture on endoscopy. Eosinophilic esophagitis can cause patients to develop a fibrostenotic esophageal stricture, which can be treated using endoscopy with dilation. Endoscopic dilation relieves the dysphagia but has no effect on underlying inflammation; therefore, medical therapy must be maintained. For unclear reasons, patients with eosinophilic esophagitis are more prone to mucosal tears with dilation than are patients with other stricturing diseases. It is imperative that the extent of dilation be limited in amount to avoid these complications; multiple dilations may be required to adequately treat the dysphagia.
Most patients respond quickly after initiation of the fluticasone; therefore, continued or increased fluticasone alone will not alleviate the patient’s dysphagia symptoms. Continued fluticasone may be necessary as maintenance therapy for this patient. Eosinophilic esophagitis is a chronic disease that often recurs after treatment is stopped; therefore, repeat or maintenance therapy may be needed.
Omeprazole and other proton pump inhibitors (PPIs) are not effective in relieving dysphagia due to stricture. PPIs can reduce inflammation and eosinophil count and are often used before initiating fluticasone therapy to determine if the patient has PPI-responsive eosinophilic esophagitis.
Limited data suggest that prednisone may be useful in patients with eosinophilic esophagitis who do not experience relief of symptoms with fluticasone therapy. However, like the swallowed aerosolized glucocorticoids, relapse is common when the medication is stopped, and relatively high doses are typically required, which carry associated risks of immunosuppression and other side effects. Additionally, this patient’s esophageal stricture is fibrotic rather than inflammatory, so oral prednisone would not be effective for his dysphagia symptoms.
Key Point
- Esophageal stricture in patients with eosinophilic esophagitis requires treatment with endoscopic dilation when symptoms do not respond to medical therapy.
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