Radiological features of eosinophilic oesophagitis in fluoroscopic oesophageal study with barium contrast

44-year-old male patient presented with retrosternal food impaction and dysphagia especially for solids for the past 2 years. Allergic to shellfish and cloxacillin. No toxic habits or other previous medical history records.

The patient underwent a swallowing and oesophagus fluoroscopic examination with barium contrast.

No alterations in the efficacy of the swallowing process were noticed (Fig. 1).

A small non-obstructive impression of the cricopharyngeal muscle could be seen in the superior oesophageal sphincter (Fig. 1).

The oesophagus was normal in diameter and showed a light motility dysfunction leading into a slow oesophageal emptying (Fig. 2). A mucosal abnormality could be seen especially in the proximal oesophageal third, with some ring-like small concentric strictures along its surface (Fig. 3 and 4).

Gastroscopy was recommended and biopsy was taken from both proximal and distal oesophagus. After anatomopathological examination, diagnosis was confirmed in both proximal and distal oesophageal mucosal samples.

Symptoms disappeared soon after the patient started a combinative treatment of PPIs and oral steroids. Allergy tests proved that the patient had an allergy to anisakis and some kinds of cereals, so he could change his diet habits in order to exclude potentially triggering foods. No follow-up imaging was performed after clinical improvement.

Eosinophilic oesophagitis is an immune-mediated inflammatory disease of the oesophagus characterised by the presence of eosinophils as well as other inflammatory cells in the oesophageal wall tissues, secondary to repeated exposure to food allergens [1].

It is an idiopathic disorder slightly more prevalent in males. Most patients show a previous history of food allergies or intolerance as an expression of some unknown genetic susceptibility [1].

Eosinophilic oesophagitis usually shows a chronic course marked by resolutions and relapses, symptoms including food impactation and dysphagia after some specific food exposure, which triggers the activation of eosinophils. Nevertheless a wide variety of more unspecific gastrointestinal symptoms such as vomiting could also be seen [2, 3].

Diagnosis is established anatomopathologically by demonstration of oedema and inflammatory cell infiltration in the oesophageal wall layers. Parasitic infestation and other causes of eosinophilia must be excluded [4].

Oesophageal fibrosis correlates with the extent of eosinophil activation rather than the number of intraepithelial eosinophils and could lead to some irreversible long-term structural and functional alterations [5, 6].

Imaging findings are secondary to fibrotic changes and are absent in more than half of the patients, especially in those patients with an early stage disease. Barium fluoroscopic examination is the best imaging tool in case of clinical suspicion. Ringed-appearing oesophagus secondary to thin concentric small strictures represents the most characteristic finding in addition to a slightly slow emptying. In severe cases it is possible to find longer strictures or even a diffusely narrowed oesophagus with a significant functional alteration. These findings can affect to the whole oesophagus or be limited to a segment, and are usually nonspecific so they need to be confirmed with gastroscopy [7].

Symptoms usually respond well to oral steroid therapy, sometimes avoidance of the triggering food is also required, especially in children and patients with known food allergy. Although symptomatic improvement occurs after treatment, recurrence is common after discontinuation of treatment, and maintenance therapy is necessary to prevent these recurrences.  [8].

As mentioned before, this condition will show a chronic course unless the patient is given a correct treatment. Irreversible fibrotic changes will happen over time in the oesophagus secondary to chronic uncontrolled inflammation, leading to impaired function and multiple stricture formation. Oesophageal dilatation could be useful in case of symptomatic strictures, with a highly increased risk of oesophageal perforation during this procedure. End stage alterations include diffuse narrowing and motility alteration of the oesophagus, causing a severe impairment of life quality. To this day, there has been no association with malignant conditions [7].

Teaching points:

• Eosinophilic oesophagitis is an idiopathic immune-mediated inflammatory disorder with inflammatory cell invasion of the oesophageal wall tissues.
• Symptoms include food impactation and dysphagia in patients with previous history of food allergies.
• Ringed oesophagus in barium fluoroscopic examination is the most characteristic imaging finding, but gastroscopy is needed to establish the diagnosis.
• Symptoms usually respond well to steroid therapy. Maintenance therapy may be necessary to avoid a chronic course of the disease.

Written patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.