Paeds Cases · gastroenterology-hepatology-and-nutrition
Dysphagia and oesophageal disorders — structured clinical encounter
Structured encounter testing the approach to a teenager with a food bolus impaction, solid-food dysphagia and atopy: the recognition and diagnosis of eosinophilic oesophagitis with biopsy at the impaction endoscopy, the exclusion of mimics, the first-line treatment ladder and the role of dupilumab and dilation, the monitoring to histological remission, and the conversation with the family about a chronic relapsing condition.
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Target exams
Station 1 — the emergency and the diagnosis
Asked for my first impression, I explain that this is a food bolus impaction needing urgent endoscopic disimpaction, and that in a teenager with atopy and a year of adaptive eating the impaction is almost certainly the first presentation of eosinophilic oesophagitis. I would keep him nil by mouth and arrange endoscopy, taking oesophageal biopsies at the same procedure even if the mucosa looked near-normal. [16] [1]
Station 2 — confirming and excluding mimics
Asked how I confirm the diagnosis, I state that eosinophilic oesophagitis requires a peak of fifteen or more eosinophils per high-power field on biopsy, with symptoms of oesophageal dysfunction and after considering other causes of oesophageal eosinophilia. I note the typical rings, furrows and exudates, and I remember that a proton pump inhibitor response no longer excludes the disease, so biopsy is needed regardless. [2] [1]
Station 3 — the mechanism and the treatment ladder
Asked to explain and treat, I describe a chronic Th2 allergic disease in which interleukin-13, interleukin-5 and eotaxin-3 recruit eosinophils and drive fibrosis. I would choose with the family among a proton pump inhibitor, a swallowed topical corticosteroid such as budesonide or fluticasone, or an empirical food elimination diet, confirming response on repeat biopsy. For refractory disease I would consider dupilumab, and I would dilate a fibrostenotic stricture on anti-inflammatory therapy. [3] [4]
Station 4 — monitoring and the family conversation
Asked about follow-up, I outline maintenance therapy with periodic endoscopy aiming at histological remission, not just symptom relief, because silent inflammation continues to scar. I would monitor growth and quality of life. I counsel the family that eosinophilic oesophagitis is a chronic, relapsing but treatable condition, that treatment must continue to prevent stricturing, and that the next impaction can be avoided by controlling the disease. [1] [3]
Station 5 — the safety net
Finally I flag the emergencies to safety-net: any child with a suspected oesophageal button battery needs immediate imaging and removal within hours, never observation, and a caustic ingestion is managed with no induced vomiting, no neutralisation, nil by mouth and early endoscopy. Recognising these prevents catastrophic outcomes. [13] [12]
References
- [1]Amil-Dias J; Oliva S; Papadopoulou A; et al Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr, 2024.PMID 38923067
- [2]Dellon ES; Liacouras CA; Molina-Infante J; et al Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology, 2018.PMID 30009819
- [3]Dellon ES; Muir AB; Katzka DA; et al ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol, 2025.PMID 39745304
- [4]Dellon ES; Rothenberg ME; Collins MH; et al Dupilumab in Adults and Adolescents with Eosinophilic Esophagitis. N Engl J Med, 2022.PMID 36546624
- [5]Franklin AL; Petrosyan M; Kane TD Childhood achalasia: A comprehensive review of disease, diagnosis and therapeutic management. World J Gastrointest Endosc, 2014.PMID 24748917
- [6]Khashab MA; Vela MF; Thosani N; et al ASGE guideline on the management of achalasia. Gastrointest Endosc, 2020.PMID 31839408
- [7]Zhong C; Tan S; Huang S; et al Clinical outcomes of peroral endoscopic myotomy for achalasia in children: a systematic review and meta-analysis. Dis Esophagus, 2021.PMID 33316041
- [8]Mencin AA; Kramer RE; Bortolin K; et al Peroral Endoscopic Myotomy (POEM) in Children: A State of the Art Review. J Pediatr Gastroenterol Nutr, 2022.PMID 35653433
- [9]Rosen R; Vandenplas Y; Singendonk M; et al Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr, 2018.PMID 29470322
- [10]Ebbott D; Meisner J; Rentea RM; et al Long-Term Aerodigestive Morbidities After Esophageal Atresia/Tracheoesophageal Fistula Repair. J Pediatr Surg, 2025.PMID 40441419
- [11]Bashir A; Sharma N; Rao S; et al Esophagitis, treatment outcomes, and long-term follow-up in children with esophageal atresia. J Pediatr Gastroenterol Nutr, 2024.PMID 39415542
- [12]Arnold M; Numanoglu A Caustic ingestion in children-A review. Semin Pediatr Surg, 2017.PMID 28550877
- [13]Mubarak A; Benninga MA; Broekaert I; et al Diagnosis, Management, and Prevention of Button Battery Ingestion in Childhood: A European Society for Paediatric Gastroenterology Hepatology and Nutrition Position Paper. J Pediatr Gastroenterol Nutr, 2021.PMID 33555169
- [14]Calderone A; Latella D; Cardile D; et al Swallowing disorders in cerebral palsy: a systematic review of oropharyngeal Dysphagia, nutritional impact, and health risks. Ital J Pediatr, 2025.PMID 39985076
- [15]Yadlapati R; Kahrilas PJ; Fox MR; et al Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0(©). Neurogastroenterol Motil, 2021.PMID 33373111
- [16]Esparaz JR; Jeziorczak PM; Mowrer AR; et al Esophageal Foreign Body Management in Children: Can It Wait? J Laparoendosc Adv Surg Tech A, 2020.PMID 33121359