ATILLA ERTAN, MD, FACP, AGAF, MACG
F.G.# 02020323-8
A 87 y/o male with a h/o mild fluctuating HTN &
over 50 yrs GERD who was diagnosed as having
S.S. Barrett’s esophagus with intramucosal ca &
multifocal HGD on 07/22/03.
MED: Aciphex, Lisinopril & ASA.
PMH, PSH, SH, FH, ROS & PE: Essentially
unremarkable.
Chest/abd./pelvic CT scan & esophageal EUS
findings were c/w intramucosal Barrett’s cancer.
He was referred for PDT & performed on 08/23/03.
F G # 02020323-8
Barrett’s Ca, T1N0MX, 8/23/2003
Post-PDT F/U EGD, 3/01/2004
PDT, 8/23/2003
Post-PDT F/U EGD, 2/03/2005
F. G. # 02020323-8
S.S. Barrett’s with recurrent HGD
10/04/2007
S/P HALO-360 ablation
10/04/2007
F. G. # 02020323-8
S/P HALO-90 ablation, 12/04/2007
A.P.# 01911497-4
A 47 y/o male with a more than 9 yrs h/o GERD &
intermittent dysphagia who has had 6-7 episodes of food
impaction within last 2 years. He has been diagnosed as
having L.S. Barrett’s with HGD/LGD & eosinophilic
esophagitis.
MED: Zegerid 40 mg BID
PMH/PSH & FH: Unremarkable.
SH: Married, IT technician, no tobacco, ETOH or IVDA.
ROS: Gained 40 lbs within last 10 yrs.
PE: Essentially unremarkable except moderate obesity.
LAB: Unremarkable CBC-diff, SMA-6 & other blood tests.
Chest/abd CT scan
EUS
Case AP
Previous history of food impactions:
A.P. #01911497-4
L.S. Barrett’s esophagus & E.E. with transient circular rings
Case AP
• Pathology
Basal zone hyperplasia, increased eosinophils
Luminal accumulation
of eosinophils
EUS
What would you do next?
• Stage:
• T3N0M0 Esophageal Cancer
• GEJxn Type II Tumor
A.P. # 019114974 L.S. Barrett’s with HGD & E.E. , S/P HALO-360
EOSINOPHILIC ESOPHAGITIS [EE] & BARRETT’S ESOPHAGUS
• “Barrett’s esophagus or esophageal adenocarcinoma has not
been reported in patients with EE” (1,2).
• “EE is not a disease characterized by mucosal ulceration or
destruction. Therefore, it seems likely that the pathologic
process of EE is different from that of GERD and that
adenocarcinoma or squamous cancer of the esophagus are
not the spectrum of EE, other than perhaps as coincidental
occurences” (2).
Natural history & long-term follow-up studies are needed to
provide more information in this relation.
1. Am J Gastroenterol, 101: 1900, 2006.
2. Gastroenterology, 133: 1342, 2007.
D.W.S.# 1740111-8
A 37 y/o male with a 5 yrs h/o intermittent solid food
dysphagia, food impaction episodes who had many related
ER visits. He has had minimal GERD complaints between
these episodes. During one of these episodes, he came to
TMH ER.
MED: None
ALL: Penn, shellfish
PMH/PSH: Unremarkable
SH: Married, lawyer, denied T, ETOH & IVDA
FH: Noncontributory
ROS/PE: Unremarkable
Emergent EGD & biopsy findings
D.W.S. # 1740111-8
Food impaction 3-20-2003
Post food impaction 3-20-2003
D.W.S. # 1740111-8
Linear furrowing, vertical lines & white specks
D.W.S. # 1740111-8
Duodenal adenoma
Duodenal ulcer
EOSINOPHILIC ESOPHAGITIS [EE]
___________________________________________________
During the last decade, we saw a rapid increase of patients with
esophageal intraepithelial eosinophilia who were thought to be
GERD but who did not respond to GERD management.
Subsequent studies showed that these patients had a “new “
disease termed EE which is a disease characterized by:
• Symptoms including but not restricted to food impaction &
dysphagia in adults , and feeding intolerance & GERD
symptoms in children.
•≥15 intraepithelial eosinophilis/HPF
• Exclusion of other disorders associated with similar clinical,
histological, or endoscopic features, especially GERD.
___________________________________________________
FIGERS; Gastroenterol 133:1342-63, 2007.
ENDOSCOPIC FEATURES ASSOCIATED WITH E.E.
______________________________________
• Unremarkable endoscopic mucosa & lumen.
• Circular rings, transient or fixed, “feline esophagus”
• Linear furrowing, vertical lines of the mucosa
• Linear shearing/crepe paper mucosa with passage
•
of endoscope or dilator
White exudates, white specks, nodules or
granularity
Stricture/rings: proximal, middle, or distal.
•
______________________________________
FIGERS: Gastroenterol, 133: 1342, 2007 (modified).
* None of the features are pathogonomic of EE.
J.M.H. # 2096026-6
Linear shearing
A.E. # 2096036-5
Circular rings, “feline esophagus”
I.E. # 3659813-1
Barrett’s islands & E.E. with transient circular rings
Differential Diagnosis of Eosinophilic Esophagitis
_______________________________________
 Crohn’s disease*
 Connective tissue disorders*
 Hypereosinophilia syndrome
 Infections [herpes & candida]*
 Drug sensitivity response
 Eosinophilic gastroenteritis
_______________________________________
*These diseases may have intraepithelial eosinophilia but less than
15/HPF in one or more biopsy specimens.
ALLERGY EVALUATION IN PATIENTS WITH E. E.
• The majority of patients with EE is atopic based
on the coexistence of atophic dermatitis, allergic
rhinitis, and/or bronchial asthma & the presence
of allergic antigen skin sensitization or
measurement of plasma antigen-specific IgE.
• 10%-50% of adults had peripheral eosinophilia.
• Most patients improve on allergen-free diets.
• Allergist consultation may be recommended.
Clin Gastroenterol Hepatol 3:1198-206, 2005.
J Pediatr Gastroenterol Nutr 42:22-6, 2006.
MEDICAL MANAGEMENT OF E. E.
• Removal of allergenic foods [diary, eggs, wheat, soy, peanuts,
fish/shellfish], without unpredictive allergy testing, demonstrated
significant efficacy (1). The elemental diet was very effective in
severe cases with EE (1).
• Only 16% of patients with EE showed symptomatic improvement
with PPI treatment (2).
• Systemic and topical corticosteroids resolve acute symptoms of EE.
Fluticasone propionate 440 mcg BID for 6-8 weeks may be effective
for induction therapy (3).
• Endoscopic dilatation is useful in patients with fixed strictures/rings
causing food impaction. However, the risk of mucosal tearing and
perforation are relatively higher (4,5).
1. Clin Gastroenterol Hepatol 4: 1097-102, 2006.
2. Am J Gastroenterol 101: 1666-70, 2006.
3. Gastrointest Endosc 63:3-12, 2006.
4 & 5. Gastroenterology 127: 364-5, 2004; 133:1342, 2007.