S4319 A Delayed Diagnosis of Eosinophilic Esophagitis With Dire Effects

Introduction: Although eosinophilic esophagitis (EoE) patients commonly present with dysphagia, they may also present with reflux symptoms, often prompting an empiric trial of proton pump inhibitor (PPI) for presumed gastroesophageal reflux disease (GERD) before endoscopic evaluation. Because PPIs are a treatment for EoE, performing endoscopy on PPI therapy can obscure the endoscopic and histologic findings diagnostic of EoE. This case highlights the importance of discontinuing PPI therapy prior to diagnostic endoscopy when EoE is suspected and highlights the potential consequences when EoE is missed. Case Description/Methods: A 44-year-old man with a history of childhood asthma presented with reflux and dysphagia symptoms for 20 years. He was empirically started on a PPI with incomplete symptom response. He underwent esophagogastroduodenoscopy (EGD) while on PPI therapy that showed no clear cause for his symptoms which were then attributed to GERD. Given his failed response to PPI therapy, he underwent anti-reflux surgery with no improvement. He was then referred to our esophageal center for further evaluation, and EGD was performed after PPI was held for 2 weeks. His EGD revealed rings, furrows, and exudates suggestive of EoE, and esophageal biopsies demonstrated 50 eosinophils/HPF with eosinophilic micro-abscesses. The patient was started on topical steroids for EoE with symptom resolution. Repeat EGD after 8 weeks of therapy showed endoscopic improvement and <15 eosinophils/HPF on esophageal biopsies. Discussion: This case underscores the importance of withholding PPI therapy prior to diagnostic endoscopy when EoE is suspected. As PPIs have a dual action of acid suppression and anti-inflammatory effect, their continued use at the time of endoscopy can minimize the eosinophilia found on histology in EoE and obviate endoscopic findings suggestive of GERD (i.e., reflux esophagitis). In this case, the continued use of PPI during endoscopy led to a missed diagnosis of EoE, with the patient's symptoms instead attributed to GERD, ultimately resulting in an unnecessary anti-reflux surgery. While EGD is frequently performed on PPI therapy, clinicians should strongly consider withholding PPIs beforehand to improve the diagnostic yield for both EoE and GERD. This case highlights the potential consequences of performing endoscopy on PPI therapy, including a delay in diagnosis and unnecessary invasive interventions.