Advances in Clinical Management of Eosinophilic Esophagitis

Abstract

EoE is a chronic immune/antigen-mediated clinicopathologic condition that has become an increasingly important cause of upper gastrointestinal morbidity in adults and children over the past 2 decades. It is diagnosed based on symptoms of esophageal dysfunction, the presence of at least 15 eosinophils/high-power field in esophageal biopsies, and exclusion of competing causes of esophageal eosinophilia, including proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE). We review what we have recently learned about the clinical aspects of EoE, discussing the clinical, endoscopic, and histologic features of EoE in adults and children. We explain the current diagnostic criteria and challenges to diagnosis, including the role of gastroesophageal reflux disease and PPI-REE. It is also important to consider the epidemiology of EoE (current incidence of 1/10,000 new cases per year and prevalence of 0.5-1/1,000 cases per year) and disease progression. We review the main treatment approaches and new treatment options; EoE can be treated with topical corticosteroids such as fluticasone and budesonide, or dietary strategies, such as amino acid-based formulas, allergy test-directed elimination diets, and non-directed empiric elimination diets. Endoscopic dilation has also become an important tool for treatment of fibrostenostic complications of EoE. There are number of unresolved issues in EoE, including phenotypes, optimal treatment endpoints, the role of maintenance therapy, and treatment of refractory EoE. The care of patients with EoE and the study of the disease span many disciplines—EoE is ideally managed by a multidisciplinary team of gastroenterologists, allergists, pathologists, and dieticians.

Eosinophilic esophagitis and esophageal atresia: coincidence or causality?

“…Such activated eosinophils release multiple factors that promote local inflammation and tissue injury. 7 There may be at least 3 genes with potential functional alterations in EoE; these genes encode eotaxin-3, thymic stromal lymphopoietin, and calpain-14. The esophageal tissue of patients with EoE shows dilated interepithelial spaces, altered epithelial barrier function, downregulation of proteins associated with barrier function (filaggrin and zonulin-1) and adhesion molecules (desmoglein-1) (Figure 1).…”

Principles of Management of Chronic Ezophagitis of Various Etiologies

“…В ряде случаев при тяжелых и рефрактерных формах эозинофильного эзофагита возникает необходимость назначения систем-ных кортикостероидов и даже иммунодепрессантов (аза-тиоприн) по жизненным показаниям [23].…”

Eosinophilic Esophagitis–More than Two Decades of Progress

“…Strictures form in patients with chronic inflammation and fibrosis. Further findings include small (narrow) caliber esophagus, longitudinal furrows ( Figure 2), white plaques / exudates, pallor, decreased vasculature, edema, and crêpe-paper mucosa, which is fragile esophageal mucosa that tears upon passing of the endoscope [34,35]. Interobserver agreement of endoscopic findings of EoE was shown to be fair to good when using white light and narrow band imaging (NBI) to identify rings and furrows, however it was poor for identifying plaques and intraobserver agreement varied greatly [36].…”

“…Drugs and diet, alone or in combination, are typical first-line agents. Currently the medications used in treating EoE are off-label use, as no drugs have been approved by the Food and Drug Administration for treatment of EoE [35]. As per recommendations, the endpoints in treatment of EoE include improvements in symptoms and esophageal eosinophilic inflammation [4].…”

“…In a recent meta-analysis involving 1,317 patients from 33 studies effectiveness of elemental diet was seen 90.8% of cases, 6-food elimination diet was 72.1% effective, and allergy test result-directed food elimination was 45.5% effective [74]. The disadvantages of elemental diets involve poor palatability, possible need for enteral feeding tubes, patient compliance, and cost [35]. Elimination diets can be based on direct (allergy testing) or non-direct (empiric) elimination methods.…”