Endoscopic Findings of Eosinophilic Esophagitis: A Case Report

CASE REPORT

Klaus Mönkemüller, MD, PhD, FASGE, FESGE, FJGES

Professor of Medicine, Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

Correspondence: Klaus Mönkemüller, MD, PhD — Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA

Abstract

Background: Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disorder of the esophagus increasingly recognized as a leading cause of dysphagia and food impaction in young adults. Diagnosis relies on recognition of characteristic endoscopic features and histopathological confirmation demonstrating eosinophilic infiltration of the esophageal mucosa.

Case: A 32-year-old man with a history of atopic dermatitis presented with intermittent dysphagia to solids. Upper endoscopy revealed classic findings of eosinophilic esophagitis including mucosal edema, concentric rings (trachealization), small white exudates and plaques, and longitudinal furrows. Biopsies were obtained for histological confirmation.

Conclusion: This case illustrates the characteristic endoscopic appearance of eosinophilic esophagitis. Recognition of these hallmark findings — rings, furrows, exudates, and edema — is essential for timely diagnosis and initiation of appropriate therapy. The association with atopic conditions should further raise clinical suspicion in patients presenting with dysphagia.

Keywords: eosinophilic esophagitis; EoE; concentric rings; longitudinal furrows; white exudates; trachealization; dysphagia; atopic dermatitis; crepe paper esophagus; esophageal biopsy

★ Key Clinical Takeaways

Eosinophilic esophagitis is characterized by four cardinal endoscopic signs: concentric rings (trachealization), longitudinal furrows, white exudates/plaques, and mucosal edema — memorized using the mnemonic EREFS (Edema, Rings, Exudates, Furrows, Stricture).
A history of atopic conditions (atopic dermatitis, asthma, allergic rhinitis, food allergy) in a young patient with dysphagia should raise immediate suspicion for EoE.
The "crepe paper esophagus" (mucosal fragility with tears during endoscope passage) and "tug sign" (resistance during scope advancement through a narrow-caliber esophagus) are additional endoscopic clues.
Endoscopic suspicion must be confirmed with esophageal biopsies — a minimum of 6 biopsies from at least 2 different esophageal levels is recommended, targeting areas with visible endoscopic abnormalities.
Early recognition and treatment with proton pump inhibitors, topical corticosteroids (swallowed fluticasone or budesonide), or dietary elimination therapy can prevent progression to fibrotic stricture formation.

Clinical History

A 32-year-old man presented with intermittent dysphagia to solids. He reported a diagnosis of atopic dermatitis five years prior. Endoscopy was performed to investigate the cause of his dysphagia.

Endoscopic Findings

Classic endoscopic findings of eosinophilic esophagitis were observed, including mucosal edema, concentric rings (trachealization), small white exudates and plaques on the mucosal surface, and longitudinal furrows running parallel to the length of the esophagus.

Additional potential findings in eosinophilic esophagitis that may be encountered include crepe paper esophagus, where the esophageal lining is fragile and tears easily during endoscope passage, and narrow-caliber esophagus, which produces a subjective feeling of resistance or stiffness during scope navigation — referred to as the "tug" sign.

Figure 1. Endoscopic views of eosinophilic esophagitis. (Left) Esophageal lumen demonstrating concentric rings (trachealization), a hallmark feature of EoE giving the esophagus a corrugated appearance. (Right) Close-up view showing longitudinal furrows (linear grooves running parallel to the esophageal axis) with scattered small white exudates and plaques on the mucosal surface, representing eosinophilic microabscesses.

Discussion

The endoscopic findings are highly suggestive of eosinophilic esophagitis (EoE), a chronic inflammatory disorder of the esophagus. The presence of concentric rings, longitudinal furrows, and white exudates are characteristic features. The patient's history of atopic dermatitis further supports the diagnosis, as EoE is often associated with other atopic conditions.

While not all classic features were explicitly mentioned as being present, the described findings are sufficient for a strong endoscopic suspicion of EoE. Confirmation typically requires histopathological analysis of esophageal biopsies demonstrating eosinophilic infiltration. Differentiation from other causes of esophagitis is crucial for appropriate management.

References

Abe Y, et al. Endoscopic diagnosis of eosinophilic esophagitis. Diagnostics (Basel). 2022;12:3202.
Pech O. Endoscopic appearance of eosinophilic esophagitis. Video Journal and Encyclopedia of GI Endoscopy. 2013;1:21–22.
Neumann H, Mönkemüller K. Endoscopic characterization of Esophageal Imaging and Swallowing (EGIS). Video Journal and Encyclopedia of Endoscopy. 2013;1:23–24.

About the author

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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