ANSWER: D
Critique
The presentation is one of intermittent solid food dysphagia in the setting of frequent heartburn in a young white male. The differential diagnosis includes reflux esophagitis and peptic stricture, as well as eosinophilic esophagitis. Sometimes, the two conditions overlap. Empiric proton pump inhibitor therapy is of value in clarifying the diagnosis of gastroesophageal reflux disease in patients with typical symptoms of heartburn and regurgitation. This is because the likelihood of gastroesophageal reflux disease is very high in patients with typical reflux symptoms. However, in this setting eosinophilic esophagitis needs to be excluded. So the optimal approach is to initiate proton pump inhibitor therapy, and then inspect and biopsy the esophagus. Treatments specific for eosinophilic esophagitis (topical fluticasone, montelukast) will only be indicated if the diagnosis of eosinophilic esophagitis is confirmed.
Prednisone is not utilized often orally for the management of eosinophilic esophagitis. Baclofen, a GABA-B receptor agonist, has been demonstrated to reduce the frequency of transient lower esophageal sphincter relaxations and improve residual symptoms in patients on PPI therapy.
