Acute esophageal tear in eosinophilic esophagitis.

A 28-year-old female presented to our interdisciplinary emergency room with epigastric pressure and dysphagia. Approximately 1 h before presentation, the patient experienced sudden epigastric pain while consuming a meal of tender pork and potatoes. The patient had no record of medical conditions besides known eosinophilic esophagitis (EoE) with two prior episodes of bolus impaction in 5 years. At the time of presentation, treatment of EoE was purely dietetic with a two-food elimination diet (animal milk and gluten). An esophago-gastro-duodenoscopy was immediately performed after admission and revealed a fresh, 9–10 cm long, longitudinal tear of the inner esophageal wall stretching just before the Z-line. The tear appeared to reach at least into the submucosa without endoscopic signs of perforation (Fig. 1a). Clinical and laboratory parameters as well as a thoracic X-ray scan provided no evidence of mediastinitis. Considering the patient’s age we, therefore, refrained from computed tomography.

Figure 1

Endoscopic pictures of the esophagus of the patient at presentation (a) and after 1 week of therapy (b). The white arrows indicate the location of the esophageal tear.

EoE is a chronic, localized, immune-mediated disease of the esophagus that is associated with the migration of large numbers of eosinophils (≥15 in at least one high-power field) into the esophageal mucosa [1-3]. Typical symptoms include dysphagia, heartburn and food impaction. However, ~2% of EoE patients experience esophageal ruptures at least once [4]. Therapeutic measures are based on elimination diets, proton pump inhibitors or topical steroids [2, 3, 5]. In the present case, we initially decided on a conservative approach with an alimentary limitation to liquids, antibiotic prophylaxis and a high-dose proton pump inhibitor therapy, which resulted in very good healing of the esophageal tear after 1 week (Fig. 1b). Long-term therapy was initialized by combining a six-food elimination diet (animal milk, soy, eggs, gluten, peanuts/tree nuts and seafood) with swallowed topical steroids and no additional episodes of bolus impaction occurred during the first 3 months after the initial presentation. A long-term follow-up is recommended.