Eosinophilic esophagitis: update on management and controversies

Abstract

Eosinophilic esophagitis is a chronic allergen driven immune mediated disease that is increasingly recognized as a leading cause of dysphagia and foregut symptoms in children and adults. Much knowledge has been gained in recent years on the genetic and environmental risk factors for this disease, the associated inflammatory milieu, and the long term complications from esophageal remodeling. In this review we will highlight recent progress made in research into this disease, focusing on adults. We will discuss ongoing efforts to develop a minimally invasive technique that may obviate the need for repeated endoscopic assessment of disease activity. Moreover, we will review studies using novel tools such as mucosal impedance and functional lumen imaging as potential surrogate markers for mucosal integrity and esophageal remodeling. With regard to the treatment of eosinophilic inflammation, we will discuss the controversies surrounding responsiveness to proton pump inhibitors in some patients. Therapeutic trials continue to support the use of topical glucocorticoids and empiric food elimination diets as first line treatments. We will discuss ongoing efforts to optimize the elimination diet protocol to decrease the level and duration of food restrictions. Looking ahead, our growing knowledge on the pathogenesis of eosinophilic esophagitis has enabled further advancement of promising targeted biologic therapies.

Challenges and updates in the management of eosinophilic esophagitis

“…Around 50-60% of patients have a personal history of atopic dermatitis prior to being diagnosed with EE. A recent meta-analysis confirmed higher prevalence of EE in adults than in children, 43.4/100 000 vs. 29.5/100 000, meaning that one in every 3000 citizens in Westernized areas have EE [7,8]. However, the incidence and prevalence of EE are comparable with the values of Crohn's disease [4].…”

The use of amino acid‐based nutritional feeds is effective in the dietary management of pediatric eosinophilic oesophagitis

“…The inflammatory process of EoE involves T‐helper type 2 cells which are activated in response to offending allergens, leading to a cascading chain of events involving proliferation and maturation of eosinophils which target the epithelial barrier of the esophagus . This leads to esophageal dysfunction, inflammation, and fibrosis in the esophagus by the deposition of collagen .…”

“…1,2,4 The inflammatory process of EoE involves T-helper type 2 cells which are activated in response to offending allergens, leading to a cascading chain of events involving proliferation and maturation of eosinophils which target the epithelial barrier of the esophagus. 5,6 This leads to esophageal dysfunction, inflammation, and fibrosis in the esophagus by the deposition of collagen. 5 Elevated specific immunoglobulin E (IgE) antibodies and IgE sensitization to allergens found in food such as cow's milk and wheat, have been associated concurrently with EoE.…”

“…Both the American College of Gastroenterology (ACG) 4 and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 2 guidelines for the management of EoE describe three management options, pharmacotherapy, dietary therapy, and endoscopic guided esophageal dilatation. 2,4,5 Dietary therapy for the management of pediatric EoE takes three forms the elemental diet (ED); targeted elimination diet (TED); and the empirical elimination diet (EED); each of which removes dietary allergens by various means. Guidelines suggest the choice of dietary intervention should be individualized to the patient circumstances, led by an Allergist and Gastroenterologist with careful dietary management by a Registered Dietitian.…”

“…5,6 This leads to esophageal dysfunction, inflammation, and fibrosis in the esophagus by the deposition of collagen. 5 Elevated specific immunoglobulin E (IgE) antibodies and IgE sensitization to allergens found in food such as cow's milk and wheat, have been associated concurrently with EoE. [7][8][9] However, as EoE is a non-IgE-mediated presentation of allergic disease, guidelines do not recommend IgE testing such as skin prick tests (SPTs) which may lead to unreliable results and unnecessary food avoidance.…”