Eosinophilic Esophagitis: Diagnosis and Current Management

Abstract

Eosinophilic esophagitis (EoE) is an eosinophil-rich, Th2 antigen-mediated disease of increasing worldwideprevalence. Originally considered common in children and young adults, it can be seen at any age, withthe highest prevalence between 30 and 40 years. Symptoms reflect esophageal dysfunction, and typicalendoscopic pictures consist of rings, furrows, exudates and edema. Progressive disease leads to pathologictissue remodeling, with ensuing esophageal rigidity and loss of luminal diameter caused by strictures. Thedefinitive diagnosis is histological (at least 15 eosinophils/HPF, high power field), upper gastrointestinalendoscopy with multiple esophageal biopsies being mandatory. Current therapeutic options include dietaryand pharmacologic treatments. Despite being successful in a high proportion of patients, elemental diet hasmultiple disadvantages. Therefore, a step-up approach (using a two-, four- and six food elimination diets) ispreferred, being globally effective in up to 79% of cases and avoiding unnecessary restrictions. Drug therapyrelies on proton pump inhibitors and topical corticosteroids. Esophageal dilation may be required to increaseluminal patency, leading to immediate symptomatic improvement in 95% of EoE patients, who have stricturesor narrow caliber esophagus. The chronic nature of the disease necessitates long-term therapy. In this review,current diagnostic and treatment options are discussed and a treatment algorithm is proposed.

Acid Suppressant Therapy: a Step Forward with Potassium-Competitive Acid Blockers

“…Symptoms reflect esophageal dysfunction, and characteristic endoscopic appearances consist of rings, furrows, exudates, and edema. Progressive disease leads to pathologic tissue remodeling, with ensuing esophageal rigidity and loss of luminal diameter caused by strictures [102]. Until recently, patients with esophageal eosinophilia responding to PPIs (PPI-REE) were excluded from the EoE spectrum [103].…”

“…Several retrospective and prospective studies have reported histological remission and symptom improvement (even with persistent eosinophilic infiltration) after an 8-week treatment course with PPIs, with established GERD having a higher chance of responding to PPIs (for review see [102]). A meta-analysis of 33 studies, including 619 patients (431 adults and 188 children) found an overall histologic remission and clinical response of 50.5% and 60.8%, respectively [106].…”

Eosinophilic esophagitis: updates on key unanswered questions

“…52 The idea of trying PPI therapy in patients with EoE arose from the observation that a subset of GERD patients present with esophageal eosinophilia, 22,53 which is usually located in the distal esophagus but rarely reaches the high density commonly observed in EoE. 54 As mentioned previously, the original aim of acid suppression in patients with EoE was to eliminate GERD as an alternative cause of eosinophilic infiltration. However, it became clear that the relationship between esophageal eosinophilia, EoE, and GERD was not this simple 40 and that the overlapping symptoms of these disorders made definitive clinical diagnosis challenging.…”

Esophageal Lesions: A High Index of Suspicion is Important for Diagnosis

“…These characteristics include linear furrows (vertical lines), esophageal rings (concentric rings), edema (decreased vascularity), plaques (white spots, exudates), strictures, and a crepe paper-like esophagus (mucosal fragility). 2 Hirano et al proposed an endoscopic classification system for EoE in an attempt to standardize the method of endoscopic diagnosis (Table 1). 3 Based on this classification, an endoscopic reference scoring system referred to as EREFS (an acronym consisting of exudates, rings, edema, furrows, and strictures) was created.…”