Eosinophilic Esophagitis

doi:10.1016/j.gtc.2012.11.008

Gastroenterology Clinics of North America

Volume 42, Issue 1, March 2013, Pages 133-153

https://doi.org/10.1016/j.gtc.2012.11.008 Get rights and content

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Key points

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Over the past 10 years, eosinophilic esophagitis (EoE) has become a major cause of gastrointestinal symptoms, including dysphagia and food impaction in adolescents and adults, and feeding intolerance, failure to thrive, regurgitation, heartburn, and vomiting in children.
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EoE is a clinicopathologic condition, so the entire clinical and histologic picture must be considered in making a diagnosis; no single feature is diagnostic on its own.
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EoE is now diagnosed based on consensus guidelines

Patient history

EoE has been described throughout the world including North America, Europe, South America, Australia, and Asia, but the prevalence appears to be highest in the United States and Western Europe in comparison with Japan and China.9, 10, 19, 24, 25, 26 It also occurs in patients of all ages,1, 27, 28 but is more frequent in children and adults younger than 40 years.27, 28, 29 For reasons that are not understood, EoE is seen 3 to 4 times more frequently in males than in females, and is also more

Endoscopic features

Upper endoscopy is required for evaluation of clinical symptoms of EoE, assessment for other possible causes, and performance of esophageal biopsies. Multiple characteristic endoscopic findings of EoE have been reported,1, 52, 53, 54 but in up to 10% of cases the esophageal mucosa can appear normal, and biopsies are required or the diagnosis will be missed.⁵⁵ These findings have a fair to good interobserver and intraobserver reliability,56, 57 and efforts are under way to standardize reporting

Histologic features

Infiltration of the esophageal mucosa with eosinophils is the histologic hallmark of EoE.65, 66 At present, finding at least 15 eosinophils per high-power microscopy field (eos/hpf) is suggestive of EoE.¹ However, as discussed in more detail later, the finding of esophageal eosinophilia on biopsy is not specific for EoE. When biopsy samples are examined, in addition to the eosinophil count, which by convention represents the peak value in the most highly inflamed area on the biopsy, other

Consensus Guidelines

Because of heterogeneity in disease definition and reporting of data pertaining to EoE,28, 67, 68 an initial set of diagnostic guidelines was proposed in 2007 and represented a major step forward for the field.⁶⁹ These guidelines have been recently updated after taking into account advances in understanding and complexities related to diagnosis.¹ In this most recent document, EoE is defined conceptually as a “chronic immune/antigen-mediated esophageal disease characterized clinically by

Treatment

There are now several evidence-based treatment options for EoE. Pharmacologic agents are commonly used, but nonpharmacologic approaches such as dietary elimination therapy and endoscopy dilation are also effective. Of note, there are currently no medications for EoE approved by the Food and Drug Administration, so all pharmacologic treatment options are off-label. The overall goal of treating patients with EoE is to improve symptoms and normalize the esophageal mucosa without adversely

Treatment nonresponse

Whereas most patients respond to medical or dietary therapy, there are some who remain refractory to therapy. In these cases, a systematic assessment should be made to identify the reason for nonresponse, specifically determining whether ongoing esophageal eosinophilia is the cause of symptoms or if there are other contributing factors. Potential reasons for nonresponse include:

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Nonadherence to the prescribed treatment.
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Inadequate dosing of a topical steroid.
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Candidal esophagitis complicating

Summary

EoE is a chronic allergen-mediated disorder defined by symptoms of esophageal dysfunction and epithelial eosinophilia on biopsy. It has rapidly emerged as an important cause of upper gastrointestinal morbidity in patients of all ages, and is encountered in a substantial proportion of patients undergoing diagnostic upper endoscopy.

Diagnosis of EoE is based on consensus guidelines, but can be challenging because none of the symptoms, endoscopic findings, or histologic features are specific for

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Brindar orientación esencial a los equipos de salud multidisciplinarios de Latinoamérica para la evaluación y tratamiento de la disfagia orofaríngea y esofágica en los diferentes niveles de atención en salud. Este posicionamiento fue realizado con el propósito de mantener la continuidad de los servicios médicos en el contexto de una pandemia y minimizar los riesgos de propagación y contagio del virus.
Con base en la evidencia disponible y la experiencia clínica alcanzada hasta la fecha, 13 expertos en deglución convocados por la Sociedad Latinoamericana de Disfagia formularon una serie de sugerencias clínicas para el manejo de la disfagia, considerando las características de los sistemas de salud latinoamericanos.
El posicionamiento de la Sociedad Latinoamericana de Disfagia brinda a los equipos multidisciplinarios una serie de sugerencias clínicas para el manejo de personas con disfagia orofaríngea y esofágica y ofrece lineamientos para su evaluación y tratamiento en diferentes contextos, desde la hospitalización hasta la atención domiciliaria.
Este posicionamiento debe ser analizado por cada equipo o profesional de la salud, para reducir el riesgo de contagio por COVID-19 y lograr los mejores resultados terapéuticos, considerando siempre la realidad de cada país latinoamericano.
The SARS-CoV-2 virus that causes the COVID-19 disease is transmitted through the inhalation of droplets or aerosols and inoculation via the oronasal or ocular routes, transforming the management of swallowing disorders into a challenge for healthcare teams, given their proximity to the aerodigestive tract and the high probability of aerosol generation during patient evaluation and treatment.
To provide essential guidance for Latin American multidisciplinary teams, regarding the evaluation and treatment of oropharyngeal and esophageal dysphagia, at the different levels of healthcare. The position statement was formulated for the purpose of maintaining medical service continuity, in the context of a pandemic, and minimizing the propagation and infection risks of the virus.
Thirteen experts in swallowing disorders were summoned by the Latin American Dysphagia Society to formulate a series of clinical suggestions, based on available evidence and clinical experience, for the management of dysphagia, taking the characteristics of Latin American healthcare systems into account.
The position statement of the Latin American Dysphagia Society provides a series of clinical suggestions directed at the multidisciplinary teams that manage patients with oropharyngeal and esophageal dysphagia. It presents guidelines for evaluation and treatment in different contexts, from hospitalization to home care.
The present statement should be analyzed by each team or healthcare professional, to reduce the risk for COVID-19 infection and achieve the best therapeutic results, while at the same time, being mindful of the reality of each Latin American country.
Diagnostic delay and misdiagnosis in eosinophilic oesophagitis
2021, Digestive and Liver Disease
Citation Excerpt :
Indeed, dysphagia and food impaction are certainly the most distinctive features of EoE, as widely reported by other studies. [27,28] However, patients may minimise their symptoms by self-imposed dietary modifications, [29,30] thus underestimating these symptoms. Also, oesophageal biopsies are often not taken in case of food impaction, [31] when endoscopy is performed on an urgent basis.
Eosinophilic oesophagitis (EoE) may lead to severe complications if not promptly recognised.
To assess the diagnostic delay in patients with EoE and to explore its risk factors.
EoE patients followed-up at eight clinics were included via retrospective chart review. Diagnostic delay was estimated as the time lapse occurring between the appearance of the first likely symptoms indicative of EoE and the final diagnosis. Patient-dependent and physician-dependent diagnostic delays were assessed. Multivariable regression models were computed.
261 patients with EoE (mean age 34±14 years; M:F ratio=3:1) were included. The median overall diagnostic delay was 36 months (IQR 12-88), while patient- and physician-dependent diagnostic delays were 18 months (IQR 5-49) and 6 months (IQR 1-24). Patient-dependent delay was greater compared to physician-dependent delay (95% CI 5.1-19.3, p<0.001). A previous misdiagnosis was formulated in 109 cases (41.8%; gastro-oesophageal reflux disease in 67 patients, 25.7%). The variables significantly associated with greater overall diagnostic delay were being a non-smoker, >1 episode of food impaction, previous endoscopy with no biopsies, regurgitation, and ≥2 assessing physicians. Being single was significantly associated with lower overall and patient-dependent diagnostic delay.
EoE is burdened by substantial diagnostic delay, depending on both patient-related and physician-related factors.
The EsoCap-system – An innovative platform to drug targeting in the esophagus
2020, Journal of Controlled Release
Citation Excerpt :
Diagnosis of EoE is based on symptoms caused by esophageal dysfunction, endoscopic findings, or histologic features. It is challenging, however, as no single symptom in itself leads to diagnosis of EoE [9]. In clinical practice, EoE is suspected when a patient presents with symptoms of dysphagia, food impaction, or in children with feeding intolerance, abdominal pain, or vomiting.
For the therapy of esophageal diseases such as eosinophilic esophagitis, there are no possibilities of local targeted therapy. This publication describes a novel, innovative drug delivery concept, that enables a targeted, long-lasting administration of drug substances to the esophageal mucosa. In addition to a comprehensive in-vitro characterization of the dosage form, this work includes a proof-of-concept study with healthy volunteers, which shows the functionality and acceptance of this novel drug delivery concept. This novel drug delivery technology enables for the first time a targeted, local and long-lasting therapy of the esophagus.
Model to Determine the Optimal Dietary Elimination Strategy for Treatment of Eosinophilic Esophagitis
2018, Clinical Gastroenterology and Hepatology
Citation Excerpt :
Strategies 1 to 4 all eventually eliminate diary, wheat, eggs, soy, nuts or legumes, and fish or shellfish. The 6 foods and the strategy variants are based on common elimination strategies seen in clinical practice and reported literature.14,28,29 In the next 4 strategies simulated, strategies 5 to 8, we replace fish or shellfish with corn.
Elimination diets are effective treatments for eosinophilic esophagitis (EoE), but foods that activate esophagitis are identified empirically, via a process that involves multiple esophagogastroduodenoscopies (EGDs). No optimized approach has been developed to identify foods that activate EoE. We aimed to compare clinical strategies to provide data to guide treatment.
We developed a computer-based simulation model to determine promising empiric elimination strategies based on reported prevalence values for foods that activate EoE. We conducted a review, searching PubMed through October 1, 2017, for prospective and retrospective studies of EoE and diet. Each patient in our simulated cohort was assigned a profile comprising as many as 12 foods known to induce EoE, including dairy, wheat, eggs, soy, nuts, seafood, beef, corn, chicken, potato, pork, and/or rice. To balance the strategy success rate with the number of EGDs required for food identification, we applied an efficiency frontier approach. Strategies on the frontier were the most efficient, requiring fewer EGDs for higher or equivalent success rates relative to their comparable, neighboring strategies.
In all simulations, we found the 1,4,8-food and 1,3-food strategies to be the most efficient in identifying foods that induce EoE, resulting in the highest rate of the correct identification of food triggers balanced by the number of EGDs required to complete the food elimination strategy. Both strategies begin with elimination of dairy; if EoE remission is not achieved, the 1,3 diet proceeds to eliminate wheat and eggs in addition to dairy, and the 1,4,8 strategy removes wheat, eggs, dairy, and soy. In the case of persistent EoE after the second round of food elimination, the 1,3-food strategy terminates, whereas the 1,4,8-food diet eliminates corn, chicken, beef, and pork. The 1,4,8-food diet resulted in correct identification of foods that activated esophagitis in 76.68% of patients, with a mean of 4.13 EGDs and a median of 6 EGDs. The 1,3-food strategy identified foods that activated esophagitis in 42.76% of patients, with a mean of 3.36 EGDs and a median of 2 EGDs required.
In this modeling analysis, we found the 1,4,8-food and 1,3-food elimination strategies to be the most efficient in detection of foods that induce EoE in patients. However, the ideal elimination strategy will vary based on clinical priorities. Additional research on specific foods that induce EoE are needed to confirm the predictions of this model.
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: This work was supported in part by NIH award number 1K23 DK090073-01.

: Disclosures: There are no conflicts of interested pertaining to this article. Dr Dellon has received research support from AstraZeneca, Meritage Pharma, Olympus, NIH, ACG, AGA, and CURED Foundation. Dr Dellon has been a consultant for Oncoscope.

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