Recognising eosinophilic oesophagitis as a cause of food bolus obstruction

Abstract

BackgroundEosinophilic oesophagitis (EoE) is a chronic, inflammatory condition of the oesophagus, characterised by intermittent dysphagia, food bolus obstruction (FBO) and histologically proven, eosinophil-mediated inflammation. EoE is identified in up to 50% of FBO presentations.ObjectiveTo evaluate the management of patients presenting with FBO to our centre against current clinical guidelines.DesignA retrospective analysis of acute FBO was performed between January 2008 and August 2014. Patients were identified using the ICD 10 code T18.1, ‘foreign body in oesophagus’ in their electronic discharge document. Data were collected on admitting specialty, previous FBO, endoscopy findings, biopsy sites and findings, eosinophil count and diagnosis of EoE.Results310 acute episodes of FBO were included in the final study cohort. 202 (65.2%) flexible oesophagogastroduodenoscopies (OGDs) were performed, with 50 (34.5%) of those occurring in those admitted under ENT (n=145), versus 28 (93.3%) and 124 (91.9%) in general medicine (n=30) and surgery (n=135), respectively. 80 (39.6%) had oesophageal biopsies taken, and 21 novel diagnoses of EoE were made (26.3% biopsy-proven rate). Five (23.8%) of the novel diagnoses had a formal eosinophil count included in the histopathology report, and eight (38.1%) had up to three previous OGDs that had not diagnosed their condition of EoE.ConclusionOur study highlights wide variation in adherence to the guidelines for the management of FBO depending on admitting specialty. We advocate an FBO protocol involving single specialty management, flexible OGD, ≥6 biopsies from the upper and lower oesophagus, and standardisation of oesophageal biopsy reports with a formal eosinophil count.

British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults

“…18 A further retrospective study of 202 patients, who had endoscopy for foreign body impaction, reported that 26% of those who had oesophageal biopsies had EoE. 19 Patients with EoE also commonly present with dysphagia. In a prospective series of 400 patients undergoing endoscopy for oesophageal symptoms, 7.3% had histological evidence of EoE.…”

“… 18 A further retrospective study of 202 patients, who had endoscopy for foreign body impaction, reported that 26% of those who had oesophageal biopsies had EoE. 19 …”

Twitter debate: controversies in dysphagia

“…As the #FGDebate continued, the discussion progressed from managing food bolus obstructions to investigating and treating the underlying pathology, which can be found in over 75% of cases. Peptic strictures are the most common cause (>50%), followed by EoE in almost 40% of cases 1 5. EoE is the most common cause of food bolus obstruction in patients under the age of 50 years.…”

Recognising eosinophilic oesophagitis

“…The article by Ntuli et al published in this journal5 emphasises the variability of the clinical management of FBO and discusses the significant divergence from ‘ideal’ practice among various craft groups. With resolution of FBO, consideration of the underlying aetiology should inform commencement of treatment.…”

“…In the era of increased EoE recognition, biopsies have been advocated at the time of food bolus removal 3. Of concern, excluding all repeat presentations and considering all patients at first presentation, is that some 276 individuals presented with FBO, yet only 25 (9.1%) were diagnosed with EoE; 4 (1.4%) had a known diagnosis of EoE, with a novel diagnosis of EoE made in 21 (7.6%) subjects 2 5. Given that EoE is now recognised as a major and common cause of FBO,6 it is likely that many cases were missed in this cohort of patients presenting with FBO.…”