Type II achalasia unmasked by EndoFLIP and high-resolution manometry in a child with eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease characterized by esophageal dysfunction and eosinophilic inflammation. Persistent dysphagia despite histologic remission should prompt evaluation for alternative etiologies. A 10-year-old male with asthma and eczema presented with progressive solid food dysphagia, daily non-bilious emesis, and weight loss. Endoscopy confirmed EoE, with up to 35 eosinophils per high-power field. Despite proton pump inhibitor therapy and dairy/soy elimination, symptoms worsened, and requiring hospitalization. Repeat endoscopy showed distal eosinophilia and narrowing, initially presumed fibrostenotic, and requiring dilation. Treatment was escalated to dupilumab and enteral nutrition. Subsequent endoscopies showed histologic remission but persistent narrowing and dysphagia despite serial dilations. Esophagram raised concern for abnormal transit and retained food. Endoluminal Functional Lumen Imaging Probe and esophageal manometry diagnosed type II achalasia. Following pneumatic dilation of the lower esophageal sphincter, dysphagia resolved. This case highlights the importance of considering motility disorders in refractory EoE symptoms.