NEJM reports case of “Trachealization” of the Esophagus

A case study of “Trachealization” of the Esophagus has appeared in NEJM.Dr Nina Nandy at the University of New Mexico, Albuquerque, NM and associates have reported the case.

Eosinophilic esophagitis (EE) is an inflammatory condition characterized by intense eosinophilic infiltration of the oesophagus and is frequently misdiagnosed as gastroesophageal reflux disease. The patients with EE often experience mild or no response to acid suppression and other forms of antireflux therapy. The presence of an oesophagal ring throughout the entire length of the oesophagus is a rare but characteristic endoscopic finding in EE giving a look like trachea and is called Trachealization.

According to history, a 32-year-old man presented to the emergency department with difficulty swallowing oral secretions and the feeling that food was stuck in his throat after he ate a pizza roll. He reported having similar episodes previously, but in each instance, the feeling resolved spontaneously, and he did not seek medical care. At the time of presentation, the patient was drooling. Upper endoscopy revealed impacted food material and prominent mucosal rings extending 20 cm from the incisors to the level of the gastroesophageal junction, with two discrete areas of narrowing and associated linear furrows.

Courtesy NEJM

Biopsy specimens were obtained, and esophagitis was observed, with more than 40 eosinophils per high-power field (Fig. S1 in the Supplementary Appendix). An endoscopic finding of fixed esophageal rings, or “trachealization,” is suggestive of eosinophilic esophagitis, although a definitive diagnosis is made on the basis of clinical presentation, histologic findings, and the exclusion of other causes of esophageal eosinophilia, such as proton-pump inhibitor–responsive esophageal eosinophilia.

The patient was treated with an 8-week course of omeprazole, but there was no symptom resolution or histologic improvement on repeat endoscopic biopsies, which confirmed the diagnosis of eosinophilic esophagitis. He was started on an 8-week course of both swallowed fluticasone and a six-food elimination diet (elimination of the six most commonly identified types of allergenic food — wheat, milk, soy, nuts, eggs, and seafood). No additional endoscopies were performed after completion of treatment with fluticasone and the elimination diet. At a 1-year follow-up visit, the patient reported no further symptoms of food impaction.

For more details click on the link: DOI: 10.1056/NEJMicm1807124