Eosinophilic Esophagitis
Chronic immune-mediated esophagus inflammation with GI overlap requiring specialized care.
Overview
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory condition of the esophagus characterized by eosinophilic infiltration. It's a relatively newly recognized condition that has become increasingly common, affecting both children and adults. EoE is often associated with other allergic conditions and requires a multidisciplinary approach involving allergists and gastroenterologists.
epidemiology
prevalence
Increasing prevalence, now estimated at 1 in 2,000 people
demographics
More common in males (3:1 ratio), Caucasians, and those with atopic conditions
age
Can present at any age, but often diagnosed in childhood or early adulthood
association
Strong association with other allergic conditions (asthma, allergic rhinitis, food allergies, atopic dermatitis)
pathophysiology
mechanism
Immune-mediated response to food or environmental allergens leading to eosinophilic inflammation
process
- Allergen exposure triggers Th2 immune response
- Release of cytokines (IL-4, IL-5, IL-13)
- Eosinophil recruitment and activation in esophagus
- Chronic inflammation leads to tissue remodeling
- Fibrosis and stricture formation over time
triggers
Food allergens are primary triggers, environmental allergens may also play a role
symptoms
adults
- Dysphagia (difficulty swallowing) - most common
- Food impaction
- Chest pain
- Heartburn (not responsive to PPI)
- Regurgitation
- Upper abdominal pain
children
- Feeding difficulties
- Vomiting
- Abdominal pain
- Failure to thrive
- Reflux-like symptoms
- Food refusal
chronic
Symptoms may be chronic and progressive, leading to stricture formation
diagnosis
criteria
- Symptoms of esophageal dysfunction
- ≥15 eosinophils per high-power field (eos/hpf) in esophageal biopsies
- Exclusion of other causes of eosinophilia (GERD, PPI-responsive esophageal eosinophilia)
- Persistence despite PPI therapy (if PPI trial performed)
endoscopy
findings
- Rings (trachealization)
- Furrows (vertical lines)
- White plaques/exudates
- Strictures
- Narrowing of esophagus
- Normal appearance possible (up to 10% of cases)
importance
Endoscopy with biopsies is essential for diagnosis
histology
requirement
≥15 eos/hpf in esophageal biopsies (normal is < 5 eos/hpf)
distribution
Eosinophils may be patchy - multiple biopsies recommended
other
May see microabscesses, basal cell hyperplasia, lamina propria fibrosis
differential
- GERD (gastroesophageal reflux disease)
- PPI-responsive esophageal eosinophilia (PPI-REE)
- Eosinophilic gastroenteritis
- Connective tissue disorders
- Infectious esophagitis
- Drug-induced esophagitis
ppi Trial
Trial of PPI therapy to rule out PPI-REE before confirming EoE diagnosis
evaluation
history
- Detailed symptom history
- Feeding/swallowing difficulties
- Food impaction episodes
- Allergic history (personal and family)
- Response to previous treatments
- Impact on quality of life
allergy Testing
role
Allergy testing helps identify potential food triggers
methods
- Skin prick testing
- Serum-specific IgE testing
- Atopy patch testing (less commonly used)
limitation
Testing may not identify all triggers - elimination diets often needed
endoscopy
Esophagogastroduodenoscopy (EGD) with biopsies - essential for diagnosis and monitoring
imaging
Barium swallow may show strictures, rings, or narrowing
treatment
approach
Multimodal approach combining dietary therapy, medications, and dilation when needed
dietary
elimination
six Food
Elimination of 6 most common triggers: milk, wheat, egg, soy, nuts, fish/shellfish
four Food
Elimination of top 4: milk, wheat, egg, soy
targeted
Elimination based on allergy testing results
elemental
Amino acid-based formula (most restrictive, most effective)
process
- Eliminate suspected triggers for 6-8 weeks
- Repeat endoscopy to assess response
- Gradual reintroduction to identify specific triggers
- Maintain elimination of confirmed triggers
challenges
Dietary restrictions can be difficult to maintain, require dietitian support
medications
ppi
Proton pump inhibitors - may help some patients, required to rule out PPI-REE
topical Steroids
fluticasone
Swallowed fluticasone MDI - most commonly used
budesonide
Swallowed budesonide slurry
mechanism
Topical anti-inflammatory effect on esophagus
administration
Swallow, don't inhale - no eating/drinking for 30 minutes after
systemic Steroids
Reserved for severe cases, food impaction, or failure of other therapies
biologics
dupilumab
Dupixent (dupilumab) - FDA-approved for EoE in adults and children ≥12 years
mechanism
IL-4/IL-13 inhibitor
indication
For patients with inadequate response to other therapies
dosing
Weekly subcutaneous injection
dilation
indication
For strictures causing significant dysphagia
approach
Gradual dilation to avoid perforation
note
Dilation treats symptoms but not underlying inflammation - must continue medical/dietary therapy
monitoring
symptoms
Regular assessment of symptoms and quality of life
endoscopy
Repeat endoscopy to assess histologic response (typically after 6-8 weeks of therapy)
goal
Both symptom improvement and histologic response (< 15 eos/hpf)
frequency
Ongoing monitoring based on response and stability
complications
strictures
Chronic inflammation can lead to esophageal strictures and narrowing
impaction
Food impaction requiring emergency endoscopy
quality Of Life
Significant impact on eating, social activities, and quality of life
progression
Untreated EoE can lead to progressive fibrosis and stricture formation
special Considerations
children
- May present with feeding difficulties and failure to thrive
- Dietary therapy requires careful nutritional monitoring
- Family education and support essential
adults
- Often presents with dysphagia and food impaction
- May have long-standing symptoms before diagnosis
- Stricture formation more common in adults
pregnancy
Management during pregnancy requires careful consideration of medications and nutritional needs
referral
- All patients with suspected or confirmed EoE should be referred to gastroenterologist for endoscopy and diagnosis
- Refer to allergist for comprehensive allergy evaluation and dietary management
- Dietitian consultation for dietary therapy
- Consider referral to specialized EoE center for complex cases
prognosis
EoE is a chronic condition requiring long-term management. With appropriate treatment (dietary therapy, medications, or both), most patients can achieve symptom control and histologic remission. Early diagnosis and treatment can prevent complications like stricture formation. Ongoing monitoring and adjustment of therapy is typically needed.
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