Co-existence of eosinophilic esophagitis and Barrett’s esophagus: a possible association?

A 37-year-old female with no relevant previous medical history was referred to Gastroenterology consultation because of long-history of heartburn and dysphagia. She described frequent episodes of heartburn and dysphagia for solids and liquids since childhood and there was history of some episodes of food impaction. Esophagogastroduodenoscopy revealed reflux esopha- gitis and a circumferential segment of salmon-colored mucosa at distal esophagus from 27 to 34 cm from incisors, suggestive of Barrett’s esophagus (BE). This diagnosis was confirmed in biopsies of distal esophagus, which revealed intestinal metaplasia, focal papillomatosis and intra-epithelial eosinophilia with 80 eosinophils/ high-power field (HPF). Clinical and endoscopic findings were consistent with gastroesophageal reflux disease (GERD) and pantoprazole twice daily was started, with symptom improvement. After one year, esophagogastroduodenoscopy was repeated. In addition to the segment of BE previously identified from 27 to 34 cm from incisors (Figure 1A), concentric rings and longitudinal furrows were identified proximally from 20 to 27 cm (Figure 1B). Biopsies of distal esophagus expectedly demonstrated intestinal metaplasia without dysplasia (Figure 2A), whereas biopsies of proximal esophagus were remarkable for intra-epithelial eosino- philia with 15 eosinophils/HPF (despite treatment with pantoprazole) associated with acanthosis, spongiosis and basal cell hyperplasia (Figure 2B). These findings were consistent with simultaneous occurrence of eosinophilic esophagitis (EoE) and BE. Esophageal manometry did not reveal motor abnormalities. Despite symptomatic improvement with pantoprazole, occasional episodes of food impaction still occurred, most with spontaneous resolution. There was one, however, which required endoscopic resolution. Therapy with fluticasone was started with no more episodes of food impaction for several months.