Table of contents
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 2024,2022,2020), 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
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EoE is increasing in prevalence in both adults and children
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EoE is more common in males than females and in people of white ethnic origin compared with other ethnic groups
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having an affected first-degree relative increases the risk of EoE
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the incidence rises during adolescence and peaks in early adulthood
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there is seasonal variation in the symptoms of EoE 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 of EoE in adult patients
B
EoE is the most common cause of spontaneous perforation of the esophagus and this can occur at any age.
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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
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.
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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
Therapeutic procedures
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
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