WBR0592

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathology
Sub Category	SubCategory::Gastrointestinal
Prompt	[[Prompt::A 41-year-old man presents to the physician's office with complaints of dysphagia and heartburn. A full history and appropriate physical examination are conducted, and appropriate work-up is initiated. Esophagogastroduodenoscopy (EGD) is performed and representative sample of esophageal biopsy are obtained. The next day, biopsy demonstrates the findings shown in the image below. What is the most likely primary diagnosis of this patient's condition? ]]
Answer A	AnswerA::Gastroesophageal reflux disease (GERD)
Answer A Explanation	AnswerAExp::Although EoE is associated with the development of GERD-like symptoms, the endoscopic findings of the patient are characteristic of EoE.
Answer B	AnswerB::Peptic stricture
Answer B Explanation	AnswerBExp::Peptic strictures may be a complication of long-standing EoE. Nonetheless, the patient's biopsy is characteristic of EoE.
Answer C	AnswerC::Eosinophilic esophagitis
Answer C Explanation	AnswerCExp::The biopsy image demonstrates eosinophilic infiltrates in the esophageal mucosa, which are characteristic of EoE.
Answer D	AnswerD::HIV esophagitis
Answer D Explanation	AnswerDExp::The eosinophilic predominance in the biopsy image makes viral etiology unlikely.
Answer E	AnswerE::HSV esophagitis
Answer E Explanation	AnswerEExp::The eosinophilic predominance in the biopsy image makes viral etiology unlikely.
Right Answer	RightAnswer::C
Explanation	[[Explanation::Eosinophilic esophagitis (EoE) is an emerging pathological entity that has first been described fairly recently. It is characterized by a chronic allergic inflammation of the esophagus. Typically, presents present with symptoms similar to symptoms of GERD, such as dysphagia and heartburn, but are often refractory to proton pump inhibitor (PPI) therapy. Although it is more common among children and young adults, EoE may manifest at any age. The exact cause of EoE remains unknown, but it is thought to be a combination of genetic and unclear environmental factors, including food allergies. It is difficult to distinguish EoE from GERD or peptic strictures by mere clinical suspicion; thus, endoscopy with biopsy is required for definitive diagnosis. Endoscopy often demonstrates nonspecific esophageal erythema and rings around the esophageal wall. Biopsy demonstrates characteristic infiltration of eosinophilic cells into the non-keratinized stratified squamous epithelium of the esophagus with formation of microabscesses and expansion of the basal layer. Treatment is by diet therapy, PPI to reduce the symptoms associated with esophageal inflammation, topical corticosteroids (e.g. swallowed fluticasone). esophagel dilatation for strictures. The efficacy of either systemic corticosteroids or anti-histamines is still unknown and is currently being evaluated. Educational Objective: Eosinophilic esophagitis is characterized by the presence of eosinophilic infiltrates in the esophageal mucosa with thickening of the basal layer. Patients often complain of GERD-like symptoms that are refractory to PPI therapy. References: Dellon ES, Gonsalves N, Hirano I, et al. ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am J Gastroenterol. 2013;108(5):679-92. Image attribution: "Eosinophilic esophagitis - very high mag.jpg" by user:Nephron under the terms of GNU Free Documentation License v1.2 under the Creative Commons Attribution-Share Alike 3.0 Unported license.]]
Approved	Approved::Yes
Keyword	WBRKeyword::Eosinophilic esophagitis, WBRKeyword::Dysphagia, WBRKeyword::Eosinophilia, WBRKeyword::Endoscopy, WBRKeyword::Gastroscopy, WBRKeyword::Esophagus, WBRKeyword::Eosinophils, WBRKeyword::Esophagitis, WBRKeyword::Difficulty swallowing, WBRKeyword::Strictures, WBRKeyword::Gastroesophageal reflux disease, WBRKeyword::GERD
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