Ring(s)-related esophageal meat bolus impaction: biopsy first, dilate later

Abstract

Distal esophageal or Schatzki's rings are a common cause of intermittent solid food dysphagia requiring endoscopic dilation for relief. Similarly, eosinophilic esophagitis (EE) is a rapidly emerging disease in both children and young adults, and manifests as dysphagia to solids and/or episodic food bolus impaction. Endoscopic findings vary considerably among patients with EE, posing significant recognition and management challenges. Esophageal dilation in EE can be painful and risky. This case report describes a patient with acute food bolus impaction due to underlying Schatzki's ring and associated but clinically indolent EE, and highlights some safety aspects of esophageal dilation.

UK guidelines on oesophageal dilatation in clinical practice

“…Obtaining a definitive diagnosis before dilatation is desirable, because this will influence the overall management and estimation of perforation risk. 8–10 Oesophageal biopsy samples can be safely obtained immediately before oesophageal dilatation 7 ; however, if the stricture is tight or when the endoscopic features suggest malignancy, the results of biopsies are best awaited. 4 Repeat biopsy after cross-sectional imaging (CT or with endoscopic ultrasound (EUS) in cases where biopsies are negative, but clinical or endoscopic features are atypical or suspicious for malignancy 11 (GRADE of evidence: low; strength of recommendation: strong) .…”

“…EUS may be a more sensitive test than CT, but passage of the EUS probe is often not successful in the case of a stricture. 11 Obtain oesophageal biopsy specimens in young patients with dysphagia or history of food impaction to exclude eosinophilic esophagitis 8 9 (GRADE of evidence: moderate; strength of recommendation: strong) . …”

“…Obtain oesophageal biopsy specimens in young patients with dysphagia or history of food impaction to exclude eosinophilic esophagitis 8 9 (GRADE of evidence: moderate; strength of recommendation: strong) .…”

Endoscopic Aspects of Eosinophilic Esophagitis: From Diagnosis to Therapy

“…These rates are substantially higher than those for esophageal dilation for other benign strictures. Most described cases of esophageal perforation (spontaneous or after endoscopic procedures) only led to pneumomediastinum (Eisenbach et al, 2006;Rajagopalan & Triadafilopoulos, 2009), but in some cases, an emergency esophagectomy by means of thoracotomy or esophagogastroplasty was required Riou et al, 1996;Liguori et al, 2008). Although no patient fatalities have been reported to date, the seriousness of these complications has led some researchers to warn that endoscopic dilation poses a higher risk of complications in patients with EoE.…”

Eosinophilic Esophagitis: Current Aspects of a Recently Recognized Disease

“…The long evolution of dysphagia, esophageal stenosis and the high density of eosinophils have been suggested to be predictive factors of these complications during dilation [88]. Most cases of esophageal perforation (spontaneous or after endoscopic procedures) described only led to pneumomediastinum [89, 90], but in two cases, an emergency esophagectomy via thoracotomy and esophagogastroplasty were required, in one case after esophageal bouginage [91] and in another following spontaneous rupture [92]. No patient fatalities have been reported, but in order to minimize complications, it seems practical to proceed slowly and carefully and dilate using smaller calibers than those used in different types of stenosis.…”