Vol.:(0123456789) 1 3 Clinical Journal of Gastroenterology https://doi.org/10.1007/s12328-019-00990-y CASE REPORT Acute intramucosal dissection in eosinophilic esophagitis Francesca Fianchi 1  · Giuseppe De Matteis 1  · Rossella Cianci 1  · Marco Pizzoferrato 2  · Silvia Cardone 3  · Maria Anna Nicolazzi 1  · Mariella Fuorlo 3  · Maria Teresa Congedo 4  · Vincenzo Arena 5  · Maria Elena Riccioni 2  · Brunella Barbaro 6  · Giovanni Gambassi 1 Received: 26 February 2019 / Accepted: 25 April 2019 © Japanese Society of Gastroenterology 2019 Abstract Acute intramucosal dissection of the esophagus (IED) is a rare complication of eosinophilic esophagitis (EoE). Only few of such IED cases have been described in the literature. We report the case of a 32-year-old man with a 4-months diagnosis of EoE who was referred to the Emergency Department complaining of dysphagia, epigastric pain and fever and who was diagnosed, after an urgent endoscopy, an IED. After careful evaluation and multidisciplinary assessment the patient was man- aged conservatively, with specifc medical therapy—high-dose proton pump inhibitors, swallowed steroid, broad-spectrum antibiotic—and, after a period of absolute fasting, a diet regimen based on “six food elimination diet” with a stepwise increase of food consistency. The patient experienced a rapid and complete relief of symptoms, paralleled by a progressive healing of IED with no recurrence over a 6-month follow-up period. In EoE patients with a high clinical suspicion of an acute IED, we suggest an early execution of chest CT and a contrast esophagography, avoiding potentially dangerous endoscopic procedures in the acute phase that can contribute to enlargement of the dissection, or progression to perforation. Once the diagnosis of IED is confrmed, even in the presence of a contained perforation, a conservative treatment with a multidisciplinary man- agement should always be considered. Keywords Dysphagia · Eosinophilic esophagitis · Endoscopy · Esophageal dissection · Contrast esophagography Introduction Eosinophilic esophagitis (EoE) is a chronic infammatory disease of the esophagus increasingly been diagnosed in patients presenting with a history of recurrent dysphagia [1]. The etiology of the disease is a local, immune-mediated response associated with abnormalities of Th2-dependent immunity, which can be considered as a particular kind of food allergy [2, 3]. Indeed, EoE is typically associated with a history of environmental and/or food hypersensitivity, and disease activity is usually responsive to the elimination of food antigens [4]. From a clinical standpoint, EoE is characterized by symp- toms of food impaction and dysphagia in adults while Gas- tro-Esophageal Refux Disease (GERD) symptoms are com- mon in children. A correct diagnosis is established by upper endoscopy with esophageal biopsies. At endoscopy, fndings include edema and/or decreased vascularity of the mucosal surface (also referred as loss of vascular pattern), mucosal fragility (or crêpe paper mucosa), longitudinal furrows, tran- sient or fxed corrugated rings (esophageal trachealization), * Giuseppe De Matteis dr.giuseppedematteis@gmail.com 1 Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart School of Medicine, Rome, Italy 2 Division of Internal Medicine, Gastroenterology and Hepatology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy 3 Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy 4 Department of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy 5 Area of Pathology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy 6 Department of Bioimaging and Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy