Next patient is helen foale f o a l e 884692 49 year old lady investigations ogd may 2025 for dysphagia appearance of early trachealization of mucosa mainly in the upper esophagus with some patchy erythema in mid esophagus g and j at 40 centimeters that looks slightly narrow but method escapes easily histology taken multiple linear erosions in the antrum biopsies taken ology antral biopsies chemical / reactive gastropathy no evidence of active inflammation or h pylori biopsy is from the esophagus mild chronic inflammatory infiltrate comprising lymphocytes and eosinophils throughout the biopsies eosinophils number greater than 15 in keeping with eosinophilic esophagitis hi there is that helen folt hi my name is doctor rob miller I'm 1 of the gastroenterology registrars here at derrifed how are you I'm sorry I'm running a bit late how are you not so well I'm sorry to hear that why is that yeah of course and so when you eat something does it do you associate it with any food in particular no fine and and in terms of the swelling it you say it stops you from breathing or okay poor thing yeah fine and and obviously it's limiting your intake have you noticed sort of losing weight or anything like that okay that's good yep fine so just increasing the healthiness but you find that soy is is more of a trigger for you of course and have you had any episodes of food becoming stuck are you no and when did you and when you came to hospital did you have a did you need to have an endoscopy to push it down or did it go by itself yeah I'm fine okay fine and has has anyone explained to you what we found at your endoscopy or anything like that yeah yeah eosinophilic exactly yeah yeah yeah so which are the cells in our blood that that that are usually designed in tackling parasites so they're good at dealing with worms but in our but the possible theory is that in our you know clean environment where we don't have deal with parasites they become a bit over stimulated they don't have much to do they get a bit bored and so they start to attack different parts in our body and they're the trigger for lots of allergy do you have asthma or any other allergies no okay of course yep like tummy pain for a while obviously at that time we didn't see any sign of inflammation yeah obviously it was a challenging procedure but it didn't sound like anything that they saw were any sort of problems and no inflammation there then you saw the pelvic floor team I saw and then that all looked lovely and reassuring as well and you had the ct scan showing nothing to worry about either so I don't think this what we found in your oesophagus is what's causing tummy pain but we know that autoimmune conditions tend to go along with it you can get eosinophilic gastritis I inflammation of the stomach because of higher eosinophils and very very rarely you can have inflammation of the small bowel because of it so it's possible but we certainly didn't see any sign of inflammation of your small bowel at the colonoscopy in terms of in terms of eosinophilic esophagitis then does anyone discuss with you what it what it means and anything like that no okay yeah yeah okay sorry about that yeah fine so what have you read about it yeah exactly yeah exactly this it's probably on a spectrum with acid reflux acid reflux probably inflames the oesophagus more and means the eosinophils are more sensitive to foods that we eat but it is driven by an allergy to something and we know that there's 6 foods that are the primary allergens and then within that cow's milk is the number 1 thing that often triggers people off then following that is wheat and eggs and then further down the list things like soy and legumes it sounds like soy seems to be a trigger for you from what you've told me yeah mhmm because yeah nuts can be a trigger mhmm exactly I mean obviously if you have a 6 food elimination diet it's incredibly restrictive and there are a lot of thing you know that's cow's milk egg soy wheat nuts and fish which is a significant dietary hit but it does work really well for some people so that's 1 option is to change one's diet and think about how you can treat it dietarily another option is to suppress the acid are you on any omeprazole or anything like that you are I've found that helpful how long have you been on that for since your endoscopy really no and you're just and you're taking 1 tablet 20 mg once a day is that right yep okay fine alright is it okay so 1 option is to increase the omeprazole I think you could have more I would usually start people on once the diagnosis of eosinophilic esophagitis is confirmed I'd usually start people on 40 mg so that's 2 tablets of the ones you're taking I'd usually suggest taking it twice a day to really suppress the acid and try and improve things 40mg which is exactly 2 of the tablets that you've got at the moment twice a day that's 1 it can work really well if that's not improved things over 4 to 8 weeks then I usually suggest trying some steroids it's a type of steroid which dissolves in the mouth and only coats the oesophagus so it works really well to suppress the inflammation in the oesophagus and make people feel better if your symptoms are debilitating I'm happy to get you a course of those steroids straight away you have had a course of anti acids you know it the chance of the antacids working is is low but it's possible it depends what you want to try fair enough yeah of course it is yeah agreed agreed I think that's entirely reasonable sounds like the symptoms are really debilitating and I think getting on top of them is important how did you find having the upper gi endoscopy did you hate it yeah of course no prep makes all the difference doesn't it if you didn't find it too awful it's lovely for us to see give you steroids and then 8 weeks later if you're feeling better and if the endoscopy is better then we can be reassured that what we're doing is having an effect on your symptoms but also most importantly having an effect in the oesophagus does that make sense because the risk in the future is of narrowings in the oesophagus and sinister changes so yeah can be yeah exactly you can develop these narrowings and so we usually suggest an endoscopy after a course of steroids an 8 week course of steroids steroids to see whether things are better from a histological. Of view this condition put sorry go on no no please so it's it's up to you if you feel like you could cut soy which seems to be a trigger for you out of your diet then it probably will improve the inflammation however if you'd find that very restrictive then I think the steroids will do the vast majority of the work what the trouble will be the steroids will make things better and induce remission but we need to maintain it with something and whether that's continued long term low dose steroids or whether it's dietary changes I think is something we need to talk about following the course with the results of the histology and how you're feeling about dietary changes but if you when you're taking the steroid course try and cut soy out and just see if you if you manage it and run yep yep mhmm yep yeah try and see if that if that's transformative for you I'll ask your gp to put some steroids of course the steroids on your repeat prescriptions for you so once the letter gets through to them over the next sort of day or so then it should be ready alternatively I can I'm thinking about this I should probably just prescribe them for you is that alright do you have a boots pharmacy near you I'll send it to that 1 and it should be ready it'll it'll be over there instantly but then they may take some time to get the medicine because it's a special preparation for just this condition I say try the steroids I'll give you an endoscopy in 8 weeks time the trouble is we don't know very much about this condition it's very very rare the we look for it a lot but it is incredibly uncommon our understanding is at the very beginning really we know there's an association with allergy and we know there's association with certain food groups however more than that it's very difficult to say it's yeah very very difficult so certainly a family history of allergy is very common and a to p in terms of eczema and asthma and things like that but we don't find it it usually runs in families and there's a not strong genetic link completely yeah yeah no I think there certainly could be I think probably all things are genetic to an extent and environmental to an extent and I'm sure this is 1 of those things that there is going to be a genetic component to it to the atp what is your daughter's seafood allergy does she done a fluxes I see I see okay I understand yeah I'm sorry yes I think that is worth following up I think I was gonna say I think the inflammation that we found in your oesophagus is certainly eosinophilic oesophagitis and it's worth investigating and it's worth treating that but what's happening in the back of your mouth it may be a part of that and you can get eosinophilic inflammation of anybody it makes me worried that there may be an allergy component if you're feeling like it's swelling and I think I was gonna suggest referring you to immunology but if you've already got 1 of them then that's great yeah I'll make sure I'll write the letter to the gp and remind them to to make because yeah I think that certainly there could be an allergy for those symptoms certainly but the steroid should clear that up does that kind of make sense no it's my pleasure so you get the endoscopy in 8 weeks you'll see us and we'll be able to get a little bit of history on how things are going just before the endoscopy and then I'll book you in to see us back in clinic with the results of that in say 12 weeks time then we'll have the histology from today samples from the next endoscopy in a week's time following the course of steroids and put it all together chat sound okay no worries at all you too nice to talk to you bye bye so did you pay out the pleasure of speaking on the telephone to missus helen foe on behalf of professor lewis in gastroenterology clinic today full stop <\n\n> I'm sorry to hear she's been struggling with her health recently full stop she's been experiencing multiple episodes over the last few months of her throat swelling up and having difficulty in swallowing this culminated in a single episode of likely food bolus obstruction where she attended hospital but this resolved spontaneously without the need for endoscopic intervention full stop at this time she had absolute dysphagia and was unable to swallow her own saliva full stop <\n\n> A recent endoscopy has shown early trachealization and the possibility of a slight stricture at the goj however this did permit the gastroscope and biopsies have demonstrated signs consistent with eosinophilic esophagitis full stop <\n\n> She describes an uncomfortable sensation in her esophagus and in the back of her mouth which she predominantly associates with any food but can be more associated with soy full stop she's reassuring not had any weight loss full stop <\n\n> Also note she's been investigated back in 2023 for right iliac fossa pain with a colonoscopy which was challenging due to tender sigmoid looping however was normal colonoscopically a ct scan of her abdomen and pelvis which did not show any cause for abdominal pain apart from moderate fecal loading of the right: and anorectal manometry which was normal we've today this <\n\n> We've today discussed the diagnosis of eosinophilic esophagitis the association with various food groups and that dietary elimination of food groups that trigger the symptoms can be very beneficial when maintaining remission full stop <\n\n> She's tried a course of an of ppi admittedly at a low dose since at least the time of her upper gi endoscopy and not found this to be effective full stop <\n\n> We discussed today that I'd usually suggest increasing these ppis to 40 however her symptoms are quite significant and she's really struggling with them and so I'll prescribe her a course of aurodispersible budesonide open brackets jorvisa close brackets which I hope will improve her symptoms full stop <\n\n> I booked her another upper gi endoscopy in 8 weeks time following this course of jorvisa in order to assess whether there's any histological improvement and then a clinic appointment in 12 weeks time to tie up all the results together and discuss about how we're going to maintain remission in the eosinophilic esophagitis full stop yours sincerely