What is the management plan for a 29-year-old male patient with eosinophilic esophagitis presenting with painful swallowing and inability to eat solid food for the last 24 hours?

Management of Eosinophilic Esophagitis with Painful Swallowing and Inability to Eat Solid Foods

For a 29-year-old male with eosinophilic esophagitis presenting with painful swallowing and inability to eat solid food for 24 hours, immediate management should include IV hydration, proton pump inhibitor therapy, and consultation with gastroenterology for endoscopic evaluation and possible dilation if strictures are present.

Initial Emergency Room Management

Immediate Interventions

• Continue with your plan for IV fluid administration to maintain hydration 1
• Obtain baseline laboratory studies to assess for complications and inflammatory markers
• Consult with gastroenterology for urgent evaluation

First-Line Medical Therapy

• Start high-dose proton pump inhibitor (PPI) therapy immediately:
  • Omeprazole 40 mg once daily or 20 mg twice daily 2, 3
  • PPIs are effective in approximately 40% of EoE patients 3
  • Can be administered IV initially if unable to tolerate oral medications

Next Steps in Management

Endoscopic Evaluation

• Urgent endoscopy is indicated for patients with food impaction or severe dysphagia 1
• Endoscopy should include:
  • Assessment for strictures, furrows, rings, or other EoE-related changes
  • Biopsies from multiple levels of the esophagus (at least 6 biopsies from different anatomical sites) 1
  • Possible therapeutic dilation if strictures are identified

Therapeutic Options

Pharmacologic Treatment

1. Proton Pump Inhibitors

   • First-line therapy with 40-80 mg daily of omeprazole or equivalent 2, 4
   • Continue for 8-12 weeks before assessing response 1

2. Topical Corticosteroids (if PPI therapy fails or as combination therapy)

   • Swallowed fluticasone or budesonide
   • Achieves histologic remission in ~65% of patients 4, 3
   • Should be initiated after consultation with gastroenterology

Endoscopic Intervention

• Esophageal dilation if strictures are present
• Provides symptom improvement in 87% of patients with strictures 4
• Most common adverse event is post-procedure chest pain 4
• Should be performed with a conservative approach using serial dilation in 1-3mm increments 4

Monitoring and Follow-up

Assessment of Response

• Repeat endoscopy with biopsy while on treatment (8-12 weeks) to assess histologic response 1
• Do not rely solely on symptom improvement as symptoms correlate poorly with histologic activity 4, 5
• Complete histologic remission (<5 eosinophils/hpf) should be considered a treatment target 4

Long-term Management

• Maintenance therapy is required due to high recurrence rates 6
• Follow-up endoscopies are necessary to monitor disease activity even if symptoms improve 1
• Consider dietary therapy in consultation with a dietitian for long-term management 1

Important Considerations and Pitfalls

Common Pitfalls

1. Relying only on symptom improvement

   • Symptoms may improve while inflammation persists, leading to progressive fibrosis 1
   • Endoscopic and histologic assessment is essential for monitoring disease activity

2. Inadequate endoscopic sampling

   • At least 6 biopsies from different esophageal locations are needed for accurate diagnosis 1

3. Failure to address both inflammation and strictures

   • Dilation addresses mechanical obstruction but not underlying inflammation 4
   • Combined approach with anti-inflammatory therapy and dilation may be necessary

4. Overlooking nutritional status

   • Prolonged dysphagia can lead to nutritional deficiencies and weight loss 1
   • Nutritional assessment and support may be needed

Special Considerations

• If the patient has concurrent atopic conditions, these should be optimally managed as they may exacerbate EoE 6
• Avoid NSAIDs for pain management as they may irritate the esophageal mucosa; acetaminophen is preferred 4

By following this comprehensive approach, you can effectively manage this patient's acute symptoms while establishing a foundation for long-term disease control and prevention of complications.