Eosinophilic esophagitis: a practical approach to diagnosis and management

Abstract

Eosinophilic esophagitis (EoE) has emerged as a common cause of dysphagia and food impaction in children and adults. A trial of proton pump inhibitor (PPI) therapy is a mandatory diagnostic first step, given that at least one third of patients with suspected EoE will have PPI-responsive esophageal eosinophilia. Once EoE is diagnosed, short-and long-term therapeutic decision making may rely on patient symptoms, phenotype (inflammatory vs fibrostenotic) and preferences. Currently, the most reliable therapeutic targets are mucosal healing and caliber abnormalities resolution. Topical steroids followed by endoscopic dilation are recommended in symptomatic narrow caliber esophagus/strictures, whereas either topical steroids or dietary therapy are good short-term options for mucosal inflammation. Maintenance anti-inflammatory therapy is necessary to prevent esophageal fibrotic remodeling and stricture formation.

Keywords::

• eosinophilic esophagitis
• esophageal stricture
• proton pump inhibitor-responsive esophageal eosinophilia
• six-food elimination diet
• topical steroids

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Eosinophilic esophagitis (EoE) is an emerging immune allergen-driven esophageal disease, at least as prevalent as Crohn’s disease in developed countries.

• Typical EoE endoscopic features or esophageal eosinophilia (≥15 eosinophils/high power field) are not diagnostic for EoE. Diagnosis of EoE is a stepwise process comprising symptoms of esophageal dysfunction and esophageal eosinophilia ≥15 eosinophils/high power field, unresponsive to an 8-week trial of proton pump inhibitor (PPI) therapy.

• PPI-responsive esophageal eosinophilia (PPI-REE) refers to patients with clinical, endoscopic and histologic features suggestive of EoE who achieve complete remission on PPI therapy. PPI-REE occurs in at least 30% of patients with suspected EoE and these patients will not need topical steroid or dietary therapy. Patients with PPI-REE are currently indistinguishable from EoE patients without a PPI trial, so they should be carefully monitored.

• Similar to inflammatory bowel disease, two different phenotypes have been described for EoE patients: inflammatory and fibrostenotic. The natural history of the disease has been suggested as a progression from the former to the later. Currently, the most reliable end points of therapy are mucosal inflammation healing and caliber abnormalities resolution.

• EoE is a chronic disease affecting young patients, who will need maintenance therapy to prevent esophageal fibrotic remodeling and subsequent stricture formation.

• Patients with a fibrostenotic phenotype (stricture, narrow caliber esophagus) should undergo endoscopic dilation, always preceded by medical therapy to treat mucosal inflammation.

• Either topical steroids or dietary therapy are good choices for patients with mucosal inflammation and no caliber abnormalities.

Notes