Teaching Case

A man with dysphagia and chest pain for three months without resolution despite the treatment with proton pump inhibitors. No previous history of diseases or allergies.

The biphasic oesophagography identified an area of narrowing in the proximal third of the oesophagus with strictures and concentric rings.

Background

Eosinophilic oesophagitis (EoE) is a chronic disease characterised by eosinophilic infiltration of the oesophageal mucosa [1, 2, 3]. The aetiology is uncertain, however, there is an association with allergies and positive family history [1, 2]. The diagnosis is determined by histopathology and the presence of an eosinophilic infiltrate with an increased number of intraepithelial eosinophils (more than 15 eosinophils per high-power field) in endoscopic biopsy specimens from the oesophagus [3, 4]. Most authors believe that EoE develops as an inflammatory response to ingested food allergens [1, 2, 3].
The prevalence of EoE has been estimated at 1-5 per 10, 000 people [3]. EoE has been described in all age groups, but it predominantly affects males (3:1), with an onset from school age to midlife.

Clinical perspective

Eosinophilic esophagitis was initially described as a manifestation of gastroesophageal reflux disease (GERD). Teenagers and adults present with dysphagia, episodes of food impaction, chronic reflux symptoms and heartburn [1-5]. In rare cases, EoE may manifest with spontaneous rupture of the oesophagus [3].

Imaging perspective

The fluoroscopic images show multiple concentric, thin, closely-spaced ring-like strictures on the oesophagus, that results in the so called "ringed" oesophagus, which is the most characteristic finding in EoE [2, 3]. Additional findings reported include longer strictures, webs, spasms, signs of oesophageal dysmotility and diffuse oesophageal narrowing that produces a small-calibre oesophagus [4]. The last one can be more difficult to recognise than shorter segments of narrowing on barium study images, because of their long length, uniform luminal diameter and smooth contour, without the obvious demarcations from a normal-calibre oesophagus [2, 5]. However, although characteristic, these findings are not pathognomonic of the disease, and often the diagnosis is due to the correlation of these findings with histopathology.

Outcome

Anti-reflux therapy has been found to have little or no value in these patients [1-5]. On the basis of the hypothesis of an allergic disease, many authors advocate various forms of anti-allergy therapy, including oral steroids, topical steroids and restrictive diets (wheat, milk, soy, nuts, eggs and seafood) [1, 3, 4].

Teaching points
- In patients with dysphagia or gastroesophageal reflux symptoms an oesophagram study should be considered.

- The findings of strictures, “ringed“ oesophagus and diffuse oesophageal narrowing should include EoE as a differential diagnosis.

- Young patients with a history of allergies, presenting symptoms of dysphagia, should alert radiologists to consider EoE as a differential possibility.