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ACP develops three different types of clinical recommendations:

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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A 33-year-old man is evaluated in follow-up for heartburn and discomfort with swallowing. His symptoms have been present intermittently for the past year, and he notes several episodes of solid food getting "stuck" during this time. Three months ago he began treating himself with double-dose, twice-daily, over-the-counter omeprazole with some improvement of his heartburn symptoms. He has had no nausea or vomiting and has not lost weight. His medical history is otherwise significant for asthma. His medications are omeprazole twice daily and inhaled albuterol.

On examination, vital signs are normal. The remainder of the physical examination is unremarkable.

Upper endoscopy is performed and reveals moderate to severe esophagitis with edematous, fragile mucosa and discrete circular esophageal rings. Biopsies are obtained and are pending.

Q.

Which of the following is the most likely diagnosis?

The most likely diagnosis is eosinophilic esophagitis (EoE). EoE is an immune-mediated condition affecting the esophagus characterized by an infiltration of the mucosa with a predominance of eosinophils. It is commonly associated with other atopic diseases such as food allergy, asthma, or eczema and affects children as well as adults. In adults, the typical presentation of EoE is in men the third or fourth decade of life. Clinical manifestations include dysphagia to solid foods, food impaction, and heartburn. In a characteristic clinical setting, the diagnosis of EoE is typically made with upper endoscopy and mucosal biopsy. Endoscopic features are heterogenous but can include mucosal edema and friability, esophageal rings, and white exudates. The diagnosis of EoE can be made only after a trial of proton pump inhibitor (PPI) therapy of at least 8 weeks' duration; the PPI trial would treat gastroesophageal reflux disease, which may cause similar symptoms and endoscopic findings. The key to the diagnosis is the presence of eosinophilic inflammation with 15 or greater eosinophils per high powered field on biopsy. This patient fits the typical presentation, has characteristic symptoms, and has characteristic endoscopy findings after a PPI trial. Confirmation of the diagnosis will be based on the biopsy results. If EoE is documented, treatment typically includes dietary avoidance of potential food allergens and the use of topical swallowed glucocorticoids.

Achalasia is characterized by dysfunctional peristalsis in the distal esophagus, and the diagnosis is usually made with esophageal manometry. Although the symptoms of dysphagia may be similar, this patient's endoscopic features are not consistent with achalasia.

Barrett esophagus usually results from chronic acid reflux; however, it is not usually associated with dysphagia, especially in a young person. It also has a characteristic appearance on endoscopy with salmon-colored mucosa at the gastroesophageal junction, which is not present in this patient.

Esophageal spasm is usually characterized by dysphagia or chest pain but not food impaction. Longitudinal rings or furrows are typically not seen on endoscopic examination. Diagnosis is made by esophageal manometry that shows nonperistaltic contractions in response to swallowing.

Key Point

  • Eosinophilic esophagitis typically presents with dysphagia to solid foods, food impaction, and heartburn in atopic men the third or fourth decade of life; upper endoscopy and mucosal biopsy show eosinophilic inflammation with 15 or greater eosinophils per high powered field.
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