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Eosinophilic esophagitis

Background

Overview

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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Guidelines

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 American Gastroenterological Association (AGA 2022,2020), the British Society of Gastroenterology (BSG/BSPGHAN 2022), the European Society of Gastrointestinal Endoscopy (ESGE 2021), the European Society of Eosinophilic Oesophagitis (EUREOS/EAACI/UEG/ESPGHAN 2017), the American Society for Gastrointestinal Endoscopy (ASGE 2014), the ...
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Screening and diagnosis

Clinical presentation: as per BSG/BSPGHAN 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 of EoE
B
the incidence rises during adolescence and peaks in early adulthood
A
there is seasonal variation in the symptoms of EoE in many patients, which seems to be associated with higher pollen counts
B
food bolus obstruction and dysphagia are strongly associated with a diagnosis of EoE 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

Diagnostic investigations

Allergy tests: as per BSG/BSPGHAN 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 for EoE.
D

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  • Esophageal physiologic testing

Diagnostic procedures

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

General principles: as per BSG/BSPGHAN 2022 guidelines, attempt early diagnosis and treatment of EoE 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)

Nonpharmacologic interventions

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

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

Pediatric patients, diagnosis: as per BSG/BSPGHAN 2022 guidelines, recognize that symptoms of EoE 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

Patient education

General counseling: as per ACG 2013 guidelines, counsel patients about the chronic nature of the disease and the high likelihood of symptom recurrence after discontinuation of treatment.
B

Follow-up and surveillance

Indications for referral: as per BSG/BSPGHAN 2022 guidelines, manage patients with EoE 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