The small-caliber esophagus: an unappreciated cause of dysphagia for solids in patients with eosinophilic esophagitis

Dysphagia for solids usually indicates a structural esophageal abnormality. This article is a description of a group of 5 young men referred with chronic dysphagia for solids. Esophagoscopy and barium esophagogram failed to show a cause. Our evaluation showed that these patients had eosinophilic esophagitis and a "small-caliber esophagus," This article describes the clinical features, diagnosis, and management of the small-caliber esophagus. Methods: Patients were evaluated by barium esophagogram with marshmallow challenge, esophageal manometry, Bernstein test, and EGD with biopsies. All patients underwent empiric esophageal dilation with wire-guided dilators. Observations: A diffusely narrow esophagus was appreciated in 3 of 5 patients radiographically, endoscopically, or both. However, the latter studies showed normal findings in 2 patients. Eosinophilic esophagitis was found in all 4 patients in whom biopsy specimens were obtained. Esophageal manometry was performed in 4 patients and showed normal findings in all. The feature that most confirmed the diagnosis of small-caliber esophagus in all patients was the unusually long rents (8 to 17 cm) in the esophageal wall after empiric dilation. Dilation relieved the symptoms in all cases. Conclusions: The small-caliber esophagus is a cause of dysphagia for solids in young men with eosinophilic esophagitis. It frequently defies detection by routine diagnostic studies. The clue to diagnosis lies in endoscopic reinspection after dilation and the finding of unusually long rents in the esophageal wall.