Dysphagia and oesophageal disorders — branching viva

Opening — framing the problem

The examiner begins: a 14-year-old with asthma and eczema arrives drooling, unable to swallow after steak lodged in his chest, and admits to a year of slow, careful eating. Talk me through your reasoning. [1]

I would treat this as a food bolus impaction that needs urgent endoscopic disimpaction, and I would frame the impaction as the first presentation of eosinophilic oesophagitis until biopsy proves otherwise, because impaction with atopy and adaptive eating in a teenager is the classic story. I would take oesophageal biopsies at the same endoscopy. [16] [1]

Branch A — securing the diagnosis

What finding confirms eosinophilic oesophagitis, and what might you see at endoscopy? [2]

The diagnosis rests on a peak count of fifteen or more eosinophils per high-power field on oesophageal biopsy, together with symptoms of oesophageal dysfunction and after considering other causes of oesophageal eosinophilia. At endoscopy I might see concentric rings, linear furrows, white exudates and a narrow-calibre oesophagus, and I would biopsy even if the mucosa looked normal. [2] [1]

Branch B — the mechanism

Why does this happen? [1]

Eosinophilic oesophagitis is a chronic type 2 (Th2) allergic disease. Cytokines including interleukin-13, interleukin-5 and eotaxin-3 recruit eosinophils into the oesophageal epithelium, and persistent inflammation drives remodelling and subepithelial fibrosis, which is what produces the rings, strictures and impaction of long-standing disease. [1] [3]

Branch C — management

How will you treat him? [3]

I would choose with the family among three first-line options: a proton pump inhibitor, a swallowed topical corticosteroid such as budesonide or fluticasone, or an empirical food elimination diet, then confirm response on repeat biopsy. For refractory disease I would consider dupilumab, and for a fibrostenotic stricture I would add careful endoscopic dilation on a background of anti-inflammatory therapy. Maintenance is needed because it relapses. [3] [4]

Branch D — the pivot to achalasia

Now a 9-year-old has months of dysphagia to solids and liquids, regurgitation of undigested food and weight loss, treated as reflux without benefit. Does that change your thinking? [5]

Dysphagia to solids and liquids together with regurgitation of undigested food points to achalasia, not reflux. I would confirm it with high-resolution manometry showing aperistalsis with failure of the lower oesophageal sphincter to relax, supported by a bird-beak taper on barium, and I would perform endoscopy to exclude a mimic. Treatment disrupts the sphincter by pneumatic dilation, Heller myotomy or peroral endoscopic myotomy. [5] [15]

Closing — the safety rule

A toddler then presents having possibly swallowed a hearing-aid battery. What is your single priority? [13]

An oesophageal button battery is a remove-now emergency because it burns the mucosa within about two hours, so I would get an urgent radiograph looking for the double-ring sign and arrange endoscopic removal without delay, never observation, and I would watch afterwards for delayed tracheo-oesophageal fistula and vascular injury. [13] [16]