Eosinophilic esophagitis (EoE) is an eosinophilic rich gastrointestinal/allergy disease increasing in pediatrics and adults worldwide. The diagnosis requires greater than or equal to 15 eosinophils per high-power field on light microscopy after a biopsy. Symptoms reflect esophageal dysfunction, and typical endoscopic features include linear furrows, white plaques, and concentric rings. Progressive disease leads to tissue remodeling with rigidity and strictures.
Effective treatment can reverse tissue fibrosis in some patients as well as decrease the rate of food impactions. Esophageal dilation might be required to increase luminal patency. The chronic nature of EoE necessitates long-term therapy to avoid disease recurrence and complications.
After an endoscopy is done and there are greater than 15 eosinophils per high power field, in addition to the typical symptoms and typical endoscopic features, a diagnosis of EoE can generally be made. At that point a referral to an allergist is warranted. An allergy doctor can help control environmental exposure, help manage concurrent allergic diseases and identify triggers. Next treatment is warranted which can entail:
- A proton pump inhibitor (PPI) for 8 weeks.
- Dietary therapy for 6-8 weeks. Elemental diets, allergy testing-directed elimination or an empiric elimination diets can all be tried.
- A topical corticosteroid for 8-12 weeks.
After that, a reassessment should be done. Most guidelines recommend a repeat endoscopy with another esophageal biopsy. In the practical real world setting this maybe very difficult to do, especially in pediatric patient who have to undergo repeated general anesthesia. There are currently less invasive techniques being studied to evaluate the esophagus which may play an important role in replacing repeated endoscopies for disease surveillance after treatment interventions.
If a patient has symptomatic and histologic remission (less than 15 eosinophils), a patient can be maintained on a PPI, reintroduction process to identify foods or maintenance topical corticosteroids.
If a patient has persistent symptoms and continual elevated eosinophils per high power field, the next steps would be:
- rule out non-adherence
- add ppi for uncontrolled reflux
- further elimination diet or elemental diet
- change to topical/systemic steroid
- biologic therapy
- esophageal dilation
Environmental allergens can trigger or exacerbate EoE. EoE control might be improved by optimizing the management of concurrent asthma, allergic rhintis and eczema. In this context, an allergist needs to treat the entire allergic person.