Clinical Scenario—An 18-Year-Old With Acute Dysphagia and Meat Impaction

A healthy 18-year-old male subject presented to the emergency department with acute dysphagia and odynophagia immediately after eating steak. He regurgitated several times, with no relief of his symptoms. His medical history was remarkable for asthma and seasonal and environmental allergies, for which he was treated with, as needed, albuterol inhaler and montelukast. He also had a remote episode of apparent anaphylaxis to shellfish requiring an emergency department visit. On examination he was seen in the emergency department in some distress, holding a cup into which he was periodically expectorating saliva. Emergent examination of the esophagus with a flexible endoscope revealed total blockage of the lower esophagus caused by impaction of a meat bolus. The endoscopic appearance of the esophagus above the impaction was notable for linear furrowing, concentric rings, and white pinpoint specks throughout (Figure 1). The impacted meat bolus was successfully removed with a rat tooth forceps. At the site of the impaction was an approximate 4-cm stricture with a luminal diameter of 10 mm. Biopsies were taken of the distal, mid, and proximal esophagus, which revealed dense eosinophilic infiltration with an average of more than 30 eosinophils per high-power field, consistent with a diagnosis of eosinophilic esophagitis (EE). What therapeutic options are available for this patient?

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• Figure 1. 

  Endoscopic image of esophageal body.

Abbreviations used in this paper: APT, atopy patch testing, EE, eosinophilic esophagitis, GERD, gastroesophageal reflux, GI, gastrointestinal, IL-5, interleukin-5, RAST, radioallergosorbent test