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Eosinophilic Esophagitis

By

Kristle Lee Lynch

, MD, Perelman School of Medicine at The University of Pennsylvania

Last full review/revision Sep 2020| Content last modified Sep 2020
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Eosinophilic esophagitis is a chronic immune-mediated disease of the esophagus resulting in eosinophil-predominant inflammation of the esophagus; it can cause reflux-like symptoms, dysphagia, and food impaction. Diagnosis is endoscopy with biopsy. Treatment includes proton pump inhibitors, topical corticosteroids, dietary changes, and sometimes esophageal dilation.

Eosinophilic esophagitis is an increasingly recognized disease that can begin at any time between infancy and young adulthood; it occasionally manifests in older adults. It is more common among males.

The cause of eosinophilic esophagitis is likely an immune response to dietary antigens in patients with genetic susceptibility; environmental allergens may also play a role. Untreated chronic esophageal inflammation ultimately can lead to esophageal narrowing and strictures.

Symptoms

Infants and children may present with food refusal, vomiting, weight loss, abdominal pain, and/or chest pain.

In adults, esophageal food impaction is sometimes the first manifestation, and most patients have dysphagia. Symptoms of gastroesophageal reflux disease (GERD), such as heartburn, may occur.

Patients often also have manifestations of other atopic disorders (eg, asthma, eczema, allergic rhinitis).

Diagnosis

  • Endoscopy with biopsy

  • Sometimes a barium swallow

The typical patient with eosinophilic esophagitis has dysphagia for solids and a history of atopy. The diagnosis of eosinophilic esophagitis is also considered when reflux symptoms fail to respond to acid-suppression therapy. It should also be considered in adults who present with esophageal food impaction or in adults who have noncardiac chest pain.

Diagnosis requires endoscopy with biopsy showing eosinophilic infiltration (≥ 15 eosinophils/high-powered field). Although visible abnormalities (eg, linear furrows, strictures, stacked circular rings, loss of vascular markings, white exudates) may be apparent on endoscopy, the appearance can be normal, so biopsies are essential. Because GERD can also cause eosinophilic infiltrates, patients who have mainly reflux symptoms should have biopsies; samples from the proximal and middle esophagus should be processed separately from samples from the distal esophagus.

Endoscopic Images of Eosinophilic Esophagitis Abnormalities

A barium swallow may show stacked circular rings, longitudinal furrows, a narrow-caliber esophagus, or strictures.

Testing for food allergies is often done to identify possible triggers but is of minimal benefit because eosinophilic esophagitis is not thought to be IgE-mediated.

Treatment

  • Proton pump inhibitors

  • Topical corticosteroids

  • Elimination diet

  • Sometimes esophageal dilation

In adults, first-line therapy is a proton pump inhibitor (PPI). In children, PPIs are typically used if dietary changes are ineffective. PPIs are thought to work via the eotaxin-3 pathway.

If PPI therapy fails, topical corticosteroids are often given to treat eosinophilic esophagitis. Patients may use a multi-dose inhaler of fluticasone (880 mcg twice a day); they puff the drug into their mouth without inhaling and then swallow it. Alternatively, budesonide 1 mg oral viscus slurry can be taken 30 minutes after breakfast and 30 minutes after dinner. Budesonide can also be mixed with a thickener (most often a sugar substitute) into a slurry and swallowed. Fluticasone or budesonide is given for 8 weeks to determine efficacy. If the patient achieves remission with either of these therapies, they are often continued indefinitely. Maintenance doses of these drugs are not well established.

Recent studies show that monoclonal antibodies against interleukin-13 (IL-13) and IL-5 may be beneficial; further studies are ongoing.

The six-food elimination diet is the most often recommended diet for eosinophilic esophagitis. This diet eliminates the foods most likely to causes IgE-mediated food reactions (milk, egg, soy, wheat, peanuts/tree nuts, fish/shellfish). It has been shown to be superior to an elimination diet that is based on skin and blood testing. The elemental diet is successful in both adults and children but is often not practical in adults.

Patients who have significant strictures may need careful esophageal dilation using a balloon or bougie; multiple, careful, progressive dilations are done to help prevent esophageal perforation.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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