(See also Overview of Esophageal and Swallowing Disorders.)
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.
Infants and children may present with food refusal, vomiting, and/or chest pain.
Patients often also have manifestations of other atopic disorders (eg, asthma, eczema, allergic rhinitis).
(See also the American College of Gastroenterology’s Evidenced Based Approach to the Diagnosis and Management of Esophageal Eosinophilia and Eosinophilic Esophagitis (EoE).)
The diagnosis of eosinophilic esophagitis is often first 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 probably have endoscopy only after failure of a 2-month trial of a proton pump inhibitor.
A barium swallow may show stacked circular rings (feline esophagus), a narrow-caliber esophagus, or strictures.
Testing for food allergies is often done to identify possible triggers; alternatives include skin testing, radioallergosorbent testing (RAST), or trial of an elimination diet.
In adults, topical corticosteroids are often given to treat eosinophilic esophagitis. Patients may use a multi-dose inhaler of fluticasone (220 mcg) or budesonide (180 mcg) 30 minutes before breakfast and 30 minutes before dinner; they puff the drug into their mouth without inhaling and then swallow it. Budesonide (various doses) mixed with a thickener (most often a sugar substitute) and swallowed 30 minutes before breakfast and 30 minutes before dinner also can be mixed into a slurry and swallowed. They are given for 8 weeks to determine efficacy. If the patient achieves remission with this therapy, it is often continued indefinitely.
Recent studies show that a monoclonal antibodies against interleukin-13 (IL-13) and IL-5 may be beneficial, but further study is needed.
Dietary changes are also tried and are usually more effective in children than adults; food allergens identified by testing are eliminated from the diet or patients can follow a prespecified elimination diet (see Table: Allowable Foods in Elimination Diets*).
Patients who have significant strictures may need careful esophageal dilation using a balloon or esophageal dilator; multiple, careful, progressive dilations are done to help prevent esophageal tears or perforation.
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