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Eosinophilic esophagitis

Definition
EoE is chronic, immune/antigen-mediated esophageal disease characterized by eosinophilic infiltration of the esophageal epithelium.
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Pathophysiology
In patients with EoE, environmental exposures to food antigens and aeroallergens lead to recruitment of eosinophils to the esophagus. Genetic pleomorphisms (encoding thymic stromal lymphopoietin, eotaxin-3, and calpain-14 genes) are associated with an increased risk.
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Epidemiology
The incidence of EoE is estimated at 0.35-12.8 cases per 100,000 person-years, while its prevalence is estimated at 7.3-90.7 persons per 100,000 population.
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Disease course
Eosinophil-mediated inflammation and fibrosis lead to esophageal dysmotility and formation of esophageal strictures that causes clinical manifestations of dysphagia, and food impaction.
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Prognosis and risk of recurrence
In some patients, symptomatic remission occurs spontaneously or following esophageal dilation, without the need for further dietary modification or medical therapy; however, in most patients, the symptoms recur after discontinuation of treatment.
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Key sources
The following summarized guidelines for the evaluation and management of eosinophilic esophagitis are prepared by our editorial team based on guidelines from the British Society of Gastroenterology (BSG/BSPGHAN 2022), the American Gastroenterological Association (AGA 2022; 2020), the European Society of Gastrointestinal Endoscopy (ESGE 2021), the European Society of Eosinophilic Oesophagitis (EUREOS/EAACI/UEG/ESPGHAN 2017), the European Academy of Allergy and Clinical Immunology (EAACI 2014), the American Society for Gastrointestinal Endoscopy (ASGE 2014), and the American College of Gastroenterology (ACG 2013).
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Guidelines

1.Screening and diagnosis

Clinical presentation: as per BSG 2022 guidelines, recognize that:
EoE is characterized by symptoms of dysphagia and/or food impaction in adult patients with esophageal histology showing a peak eosinophil count of ≥ 15 eosinophils/hpf, or ≥ 15 eosinophils/0.3 mm² or > 60 eosinophils/mm² in the absence of other causes of esophageal eosinophilia
A
EoE responding clinically and histologically to a PPI is the same disease as EoE not responding to a PPI
B
EoE and GERD are not mutually exclusive and can coexist in the same patient
A
EoE is increasing in prevalence in both adults and children
A
EoE is more common in males than females and in people of white ethnic origin compared with other ethnic groups
B
having an affected first-degree relative increases the risk ofEoE
B
the incidence rises during adolescence and peaks in early adulthood
A
there is seasonal variation in the symptoms ofEoE in many patients, which seems to be associated with higher pollen counts
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food bolus obstruction and dysphagia are strongly associated with a diagnosis ofEoE in adult patients
B
eosinophilic oesophagitis is the most common cause of spontaneous perforation of the esophagus and this can occur at any age.
A
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  • Diagnostic criteria

  • Differential diagnosis

2.Diagnostic investigations

Allergy tests: as per BSG 2022 guidelines, do not obtain allergy testing to foods (such as skin prick test, specific IgE, or patch testing) for choosing the type of dietary restriction therapy forEoE .
D

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  • Esophageal physiologic testing

3.Diagnostic procedures

Esophageal biopsy: as per BSG 2022 guidelines, perform esophageal biopsies in all adult patients undergoing endoscopy in the presence of endoscopic signs associated withEoE , or symptoms of dysphagia or food bolus obstruction, with a normal-looking esophagus.
A
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4.Medical management

General principles: as per BSG 2022 guidelines, attempt early diagnosis and treatment ofEoE effectively to prevent long-term complications of fibrosis and strictures requiring subsequent endoscopic intervention.
B

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  • Swallowed corticosteroids

  • Systemic corticosteroids

  • PPIs

  • Anti-IgE therapy

  • Other pharmacologic therapies

  • Management of anxiety/depression

  • Maintenance therapy (indications)

  • Maintenance therapy (corticosteroids)

  • Maintenance therapy (PPIs)

5.Nonpharmacologic interventions

Dietary modifications: as per BSG 2022 guidelines, offer elimination diets to achieve clinical and histological remission in adult patients withEoE .
B
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6.Therapeutic procedures

Esophageal dilation: as per BSG 2022 guidelines, perform endoscopic dilatation to improve symptoms in patients with fibrostenotic disease due to eosinophilic oesophagitis.
B
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7.Specific circumstances

Pediatric patients, diagnosis, BSPGHAN/BSG: recognize that symptoms ofEoE in pediatric patients may be nonspecific and vary with the age of the patient.
B
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  • Pediatric patients (management)

  • Patients with esophageal perforation

  • Patients with Candida infection

8.Patient education

General counseling: counsel patients about the chronic nature of the disease and the high likelihood of symptom recurrence after discontinuation of treatment.
B

9.Follow-up and surveillance

Indications for referral: as per BSG 2022 guidelines, manage patients withEoE refractory to treatment and/or with significant concomitant atopic disease jointly by a gastroenterologist and specialist allergist to optimize treatment.
B

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  • Assessment of treatment response