Discussion:
Eosinophilic esophagitis is a chronic, immune-mediated esophageal
disease first described in 1978, characterized by eosinophil-predominant
inflammation (3)(4).
It frequently coexists with other atopic disorders such as eczema,
asthma, and food allergies (5). Patients usually exhibit dysphagia and
food impaction, signs similar to those of gastroesophageal reflux
disease (GERD) (6).
Steakhouse syndrome, also termed “Backyard Barbecue Syndrome,” refers
to the condition in which patients present with acute esophageal food
impaction that manifests as obstruction, usually following meat
consumption. This syndrome is typically associated with mechanical or
functional diseases narrowing the esophagus lumen (7). Various
underlying conditions include esophageal carcinoma (primary or
metastatic), carcinoma of the gastroesophageal junction, strictures
(peptic or post-therapeutic), diverticula, hiatal hernia, and Schatzki
rings as mechanical causes (7)(8). Functional causes include achalasia,
nutcracker esophagus, and esophageal spasm (7). Eosinophilic esophagitis
has also been recognized as a hidden condition leading to esophageal
food impaction (7).
The most recent consensus recommendations (Updated International
Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings
of the AGREE Conference) for the diagnosis of eosinophilic esophagitis
(EoE) include clinical symptoms such as food impaction and dysphagia,
which are indicators of esophageal dysfunction (9). In esophageal
biopsies, histologic results must demonstrate a minimum of 15
eosinophils per high power field (eos/hpf). Proton pump
inhibitor-responsive esophageal eosinophilia (PPI-REE) is one of the
other causes of esophageal eosinophilia that must be ruled out. These
recommendations recognize the need for more research on PPI-REE and
allow for the coexistence of GERD and EoE (9).
Endoscopy is crucial in the diagnosis of EoE. Esophageal rings
(trachealization), white exudates or plaques, linear furrows, narrow
diameter esophagus, pallor/decreased vascularity, and the presence of
strictures are all significant endoscopic findings (10).
The management of eosinophilic esophagitis (EoE) requires a multifaceted
approach integrating dietary and pharmacologic therapies.
Despite its drawbacks, including psychological effects and nutritional
deficits, dietary therapy has proven to be consistently beneficial in
treating symptoms and histologic abnormalities, especially in children.
Although all EoE-diagnosed persons should follow dietary therapy,
developing a tolerance to trigger foods requires additional research.
Future studies should examine its effects on quality of life, esophageal
fibrosis, and the development of reliable methods for identifying
trigger foods (11).
In addition to dietary therapy, medication is also essential. Proton
pump inhibitors (PPIs) can treat GERD-associated esophageal eosinophilia
and help differentiate between GERD and EoE symptoms. Nevertheless, PPIs
by themselves are not sufficient for the treatment of EoE (11).
Corticosteroid therapy is also essential and beneficial in both adults
and children.
Although systemic corticosteroids can be used in emergency cases, they
should not be used for long-term treatment due to potential toxicity. To
induce remission, topical corticosteroids such as fluticasone and oral
viscous budesonide are frequently used; however, due to the possibility
of adverse effects, close monitoring is advised (11).
Early publications on the use of esophageal dilation to treat stricture
formation in EoE patients highlighted risks such as perforation and
chest pain. However, newer research indicates that the incidence of
complications is lower—just 0.8% of people undergoing dilatation
suffer from perforation, and 5% experience chest pain. These recent
findings point to a safer approach to esophageal dilatation, albeit its
appropriate role in EoE therapy is still debated and should be tailored
to each individual (11).
Advances in the field of eosinophilic esophagitis (EoE) research have
revealed various paths that hold promise for therapeutic intervention.
First, research on the involvement of microbiota in the pathogenesis of
EoE has shown unique microbial signatures in diseased individuals,
pointing to a possible target for therapeutics based on the microbiome
to modify the course of the disease (11).
Combination therapy strategies that include topical steroids, diet
changes, and proton pump inhibitors (PPIs) have also demonstrated
effectiveness, especially in patients who are not responsive to
monotherapy (12).
Immunomodulators that work by inhibiting lymphocyte proliferation and
thus reducing esophageal inflammation, such as azathioprine and
6-mercaptopurine, are also possible options for treating
steroid-dependent EoE which need to be compared to other therapies in
clinical trials (12).
Lastly, biologic therapies targeting interleukin-5 (IL-5) and
interleukin-13 (IL-13), including mepolizumab and dupilumab, have shown
efficacy in reducing disease activity and achieving histological
remission. These agents hold significant promise in altering the disease
course, although their broader impact on EoE patients, particularly
those with atopic comorbidities, warrants further investigation through
robust clinical trials (12).
In medical technology, integrating artificial intelligence (AI) is
advancing the diagnosis of complex conditions like eosinophilic
esophagitis (EoE).
AI models designed for analyzing histopathologic characteristics
associated with esophageal mucosal eosinophilia offer enhanced
diagnostic precision and reproducibility compared to conventional
methods (13).
Using sophisticated algorithms, these models quantitatively assess
microscopic features critical for EoE diagnosis, such as eosinophil
density and spatial distribution, alongside other histologic parameters.
AI also identifies additional features like basal layer hyperplasia and
subepithelial fibrosis. (13).
Recent studies have applied AI to various diagnostic tasks in EoE,
including analyzing biopsy histology, diagnostics using biopsy mRNA
transcripts, diagnosing EoE via endoscopic photos, and automating the
measurement of thickened esophageal tissue layers (14).
AI’s ability to process and analyze large datasets quickly and
accurately enhances the diagnostic process, making it more efficient and
potentially more accurate. The future for AI in EoE diagnosis is
promising, with ongoing research aiming to refine these models further,
enabling broader recognition of histologic features and adaptability to
diverse staining protocols. These advancements hold promise for
standardizing reporting practices and improving patient outcomes in EoE
and other clinical contexts (13).
In this case, the successful management of eosinophilic esophagitis
leading to steakhouse syndrome highlights the pivotal role of medical
treatment in achieving resolution without the need for invasive
procedures such as esophageal dilation. Medical therapy, consisting of
omeprazole for acid suppression and fluticasone for anti-inflammatory
effect, played a central role in reducing eosinophilic inflammation in
the esophagus. This approach not only alleviated symptoms but also led
to significant endoscopic and histologic improvements. While procedures
like dilation may be required in some cases, the favorable outcome in
this patient exemplifies how targeted medical therapy can be a primary
and effective treatment strategy for eosinophilic esophagitis-related
complications like steakhouse syndrome.
The presented case of steakhouse syndrome highlights the multifaceted
nature of esophageal disorders, underscoring the importance of thorough
evaluation and diagnosis. While eosinophilic esophagitis (EoE) was
identified as a leading cause of recurrent food impaction episodes, it
is crucial to recognize the diverse etiologies contributing to
conditions such as steakhouse syndrome. This case serves as a reminder
of the complexity inherent in diagnosing and managing esophageal
disorders, necessitating a comprehensive approach that considers both
common and rare underlying conditions. Moving forward, continued
research and clinical vigilance are paramount in enhancing our
understanding and treatment of these intricate gastrointestinal
disorders, ultimately improving patient care and outcomes.