A 28-year-old man with a history of seasonal allergic rhinitis, asthma, and atopic dermatitis presents with acute food impaction after swallowing grilled chicken. Endoscopy reveals the striking appearance shown in the diagram. The structure marked **A** (concentric fixed esophageal rings) is pathognomonic for eosinophilic esophagitis. After confirming the diagnosis with targeted biopsies showing ≥15 eosinophils per high-power field, which of the following is the MOST appropriate first-line management according to the 2024 ACG/AGA guidelines?

Question

Accepted Answer

C. Topical swallowed fluticasone or oral viscous budesonide for 8 weeks. ## Why Topical swallowed fluticasone or oral viscous budesonide is correct

The 2024 ACG/AGA guidelines for eosinophilic esophagitis identify topical swallowed corticosteroids (fluticasone or oral viscous budesonide) as one of the three first-line management options alongside high-dose PPI and six-food elimination diet. Topical corticosteroids achieve histologic and clinical remission in approximately 60–70% of patients, making them superior to high-dose PPI alone (40–50% remission). In this patient with confirmed EoE presenting with food impaction and severe endoscopic findings (EREFS score 9), topical corticosteroids represent evidence-based first-line therapy. The structure marked **A** (trachealization/fixed concentric rings) is the pathognomonic endoscopic hallmark that triggers this diagnostic and therapeutic pathway.

## Why each distractor is wrong

- **High-dose PPI twice daily for 8 weeks**: While this is a first-line option per guidelines, it has lower remission rates (40–50%) compared to topical corticosteroids (60–70%). The patient has already failed a trial of once-daily PPI for 8 weeks without improvement, making a higher-dose PPI less likely to succeed than a mechanistically distinct agent.
- **Dupilumab as initial therapy**: Dupilumab (anti-IL-4Rα) is FDA-approved for refractory or moderate-to-severe EoE but is reserved for disease not responding to first-line medical therapy or dietary intervention, not as initial treatment.
- **Immediate endoscopic dilatation followed by medical therapy**: Endoscopic dilatation is reserved for symptomatic strictures (marked by the structure **D** in the diagram) despite adequate medical therapy. It is not a first-line intervention and carries risk of esophageal perforation.

**High-Yield:** The trachealization pattern (**A**) is pathognomonic for EoE; topical corticosteroids are the most effective first-line pharmacologic therapy (60–70% remission vs. 40–50% for PPI).

[cite: Hirano I. AGA Institute and JTF Clinical Guidelines on Eosinophilic Esophagitis 2024. ACG EoE guideline 2023.]

Answer

A. Immediate endoscopic dilatation followed by medical therapy

Answer

B. High-dose PPI (omeprazole 40 mg twice daily) for 8 weeks

Answer

D. Dupilumab (anti-IL-4Rα monoclonal antibody) as initial therapy

Explanation

Why Topical swallowed fluticasone or oral viscous budesonide is correct

Why each distractor is wrong

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