WBR0592

Author	[[PageAuthor::Rim Halaby, M.D. [1]]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathology
Sub Category	SubCategory::Gastrointestinal
Prompt	[[Prompt::A 41 year old Caucasian man presents to the physician's office complaining of dysphagia. A full history and appropriate physical examination are conducted. Appropriate work-up is initiated. A representative sample of esophageal biopsy is performed and shows the findings as seen in the image below. What is the most likely primary diagnosis of this patient's condition? ]] A B C D E F Answer A AnswerA::Gastroesophageal reflux disease (GERD) Answer A Explanation AnswerAExp::EoE is associated with GERD, but the endoscopic findings of the patient are characteristic of EoE. Answer B AnswerB::Peptic stricture Answer B Explanation AnswerBExp::Peptic strictures may be a consequence of EoE. Nonetheless, the image shown is characteristic for EoE. Answer C AnswerC::Eosinophilic esophagitis Answer C Explanation AnswerCExp::The image shows eosinophilic infiltrates characteristic of EoE. Answer D AnswerD::HIV esophagitis Answer D Explanation AnswerDExp::The eosinophilic predominance in the image makes viral etiology unlikely. Answer E AnswerE::HSV esophagitis Answer E Explanation AnswerEExp::The eosinophilic predominance in the image makes viral etiology unlikely. Right Answer RightAnswer::C Explanation [[Explanation::Eosinophilic esophagitis (EoE) is considered an emerging pathological entity that has been fairly recently described. It is described as a chronic allergic inflammatory esophageal disease possibly due to food allergy that presents with symptoms of GERD, such as dysphagia, that are refractory to proton pump inhibitor (PPI) therapy. Although it is more commonly present in children and young adults, there is no associated age range for EoE and can virtually be present at any age. The exact cause of EoE remains unknown, but it is thought to be a combination of genetic and unclear environmental factors. It is difficult to distinguish EoE from GERD or peptic strictures by mere clinical suspicion; thus, endoscopy and biopsy are required for definitive diagnosis. Endoscopy often shows nonspecific esophageal erythema and rings around the esophageal wall; whereas biopsy is characteristic for the infiltration of eosinophilic cells into the non-keratinized stratified squamous epithelium of the esophagus with microabscesses and expansion of the basal layer. Treatment is by diet therapy, PPI, and possibly corticosteroids. Educational Objective: Eosinophilic esophagitis is characterized by the presence of eosinophilic infiltrates in the esophageal mucosa with thickening of the basal layer. Reference: 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. Educational Objective: References: ]] Approved Approved::No Keyword WBRKeyword::eosinophilic, WBRKeyword::esophagitis, WBRKeyword::dysphagia, WBRKeyword::eosinophilia, WBRKeyword::endoscopy, WBRKeyword::gastroscopy, WBRKeyword::ring, WBRKeyword::esophagus, WBRKeyword::eosinophil, WBRKeyword::eosinophils, WBRKeyword::esophagitis, WBRKeyword::difficulty, WBRKeyword::swallowing, WBRKeyword::HSV, WBRKeyword::HIV, WBRKeyword::strictures, WBRKeyword::stricture, WBRKeyword::peptic, WBRKeyword::gastroesophageal, WBRKeyword::reflux, WBRKeyword::disease, WBRKeyword::GERD Linked Question Linked:: Order in Linked Questions LinkedOrder::