Eosinophilic esophagitis: Current concepts in diagnosis and treatment

Abstract

Eosinophilic esophagitis is an immune-allergic pathology of multifactorial etiology (genetic and environmental) that affects both pediatric and adult patients. Its symptoms, which include heartburn, regurgitation, and esophageal stenosis (with dysphagia being more frequent in eosinophilic esophagitis in young adults and children), are similar to those of gastroesophageal reflux disease, causing delays in diagnosis and treatment. Although endoscopic findings such as furrows, esophageal mucosa trachealization, and whitish exudates may suggest its presence, this diagnosis should be confirmed histologically based on the presence of more than 15 eosinophils per high-power field and the exclusion of other causes of eosinophilia (parasitic infections, hypereosinophilic syndrome, inflammatory bowel disease, among others) for which treatment could be initiated. Currently, the 3 “D”s (“Drugs, Diet, and Dilation”) are considered the fundamental components of treatment. The first 2 components, which involve the use of proton pump inhibitors, corticosteroids, immunosuppressants and empirical diets or guided food elimination based on allergy tests, are more useful in the initial phases, whereas endoscopic dilation is reserved for esophageal strictures. Herein, the most important aspects of eosinophilic esophagitis pathophysiology will be reviewed, in addition to evidence for the various treatments.

Health Service Use and Treatment Choices for Pediatric Eosinophilic Esophagitis: Findings From a Cross-Sectional Survey of Australian Carers

“…Our study showed that most (86.2%) children had been given a pharmaceutical at some stage to treat their EoE. Reflux medications such as proton pump inhibitors are a first-line treatment option for EoE (7) and were the most commonly used pharmaceutical. However, proton pump inhibitors may be associated with adverse side effects when used for a long term (51), and almost one quarter of those respondents who had used # The total number of practitioners is greater than the number of responses as some respondents listed more than one other practitioner.…”

“…EoE incidence is increasing globally, with an estimated prevalence of one in every 2,000 people (2)(3)(4). International clinical guidelines list EoE first-line treatment options as proton-pump inhibitors, swallowed topical steroids, elimination diets, and elemental formula (5)(6)(7)(8). While there are no national guidelines in Australia for the management of EoE, international guidelines are usually applied (9).…”

Diet and Nutrients in Gastrointestinal Chronic Diseases

“…It is based on the role that dietary antigens play in the pathogenesis of this disease. Currently, there are two main choices for initial diet therapy for EoE: elementary diets, based on the administration of simple amino acids, and elimination diets [8]. A group of 10 children with EoE were evaluated through an elementary diet [156].…”

Correlation of clinical symptoms, endoscopic features and density of oesophageal eosinophilia in children with newly-diagnosed eosinophilic esophagitis

“…These changes include fixed oesophageal rings (trachealisation), transient rings (felinisation), white exudates, longitudinal furrows, oedema, oesophageal narrowing, mucosal fragility, and a tendency for lacerations (crepe paper oesophagus). In addition to EoE patients with these characteristic changes, a macroscopically-normal oesophagus is also seen in up to 30% of paediatric EoE patients [10,11].…”

“…The minimum threshold for a diagnosis of EoE is 15 eosinophils per high-power field (hpf) in at least one specimen. Other histopathological changes observed in patients with EoE include eosinophilic micro-abscesses, surface layering of eosinophils, extracellular eosinophil granules, basal cell hyperplasia, lamina propria fibrosis and dilated intercellular spaces [10,11].…”