Eosinophilic esophagitis, also known as allergic oesophagitis, is an allergic inflammatory
condition of the esophagus that involves eosinophils, a type of white blood cell.
Symptoms are swallowing difficulty, food impaction, and heartburn.
Eosinophilic esophagitis was first described in children but occurs in adults as well.
The condition is not well understood, but food allergy may play a significant role.
Symptoms EoE is associated with oesophageal strictures,
and often presents with food impaction, dysphagia, and heartburn.
In addition, young children with eosinophilic esophagitis may present with feeding difficulties.
It is more common in males, and affects both adults and children.
Pathophysiology EoE is a relatively poorly understood disease
of which awareness is rising.
EoE is characterised by a dense eosinophilic infiltrate into the squamous epithelium of
the oesophagus.
This is thought to be probably an allergic reaction against ingested food, based on the
important role eosinophils play in allergic reactions.
Eosinophils are inflammatory cells that release a variety of cytokines which inflame the surrounding
oesophageal tissue.
This results in symptoms of pain, visible redness on endoscopy, and a natural history
that may include stricturisation.
A characteristic set of genes termed the "EE transcriptome" described by Professor Marc
Rothenberg MD, PhD, is expressed and distinguishes patients with EoE from unaffected individuals
or from patients with other forms of esophagitis.
The EE transcriptome has now been developed into a 94 gene panel, called the EE Diagnostic
Panel which provides a rapid and accurate means to diagnose EoE and monitor disease
activity.
Genetic & Autoimmune Links Many EoE patients suffer from concurrent autoimmune
and allergic disease.
This includes asthma and coeliac disease.
Diagnosis The diagnosis of EoE is typically made clinicopathologically.
Clinical Findings.
Prior to the development of the EE Diagnostic Panel, EoE could only be diagnosed if gastroesophageal
reflux is not responsive to a 6 week trial of twice-a-day high-dose proton-pump inhibitors
or if a negative ambulatory pH study rules out gastroesophageal reflux disease.
Histology.
On esophagogastroduodenoscopic biopsy, numerous eosinophils can be seen in the superficial
epithelium.
A minimum of 15 eosinophils per high-power field are required to make the diagnosis.
Eosinophilic inflammation is limited to the oesophagus alone, and does not extend into
the stomach or duodenum.
Profoundly degranulated eosinophils may also be present, as may microabcesses and an expansion
of the basal layer.
Endoscopy.
Endoscopically, ridges, furrows, or rings may be seen in the oesophageal wall.
Sometimes, multiple rings may occur in the esophagus, leading to the term "corrugated
esophagus" or "feline esophagus" due to similarity of the rings to the cat esophagus.
Presence of white exudates in esophagus is also suggestive of the diagnosis.
Radiology.
Radiologically, the term "ringed esophagus" has been used for the appearance of eosinophilic
esophagitis on barium esophagrams to contrast with the appearance of transient transverse
folds sometimes seen with esophageal reflux.
Treatment Treatment strategies include dietary modification
to exclude food allergens, medical therapy, and mechanical dilatation of the esophagus.
The initial approach to the disorder is often allergy evaluation in an attempt to identify
the allergens in the diet or environment that may be triggering the condition.
If the offending agent is found, the diet is modified so that these allergens are eliminated.
There are cases, especially in children, where there are multiple food allergies involved.
Some patients require an elemental diet through the use of a specialty formula.
Sticking to this diet and drinking the required amount of formula can be difficult.
The use of feeding tubes in these situations is often required.
First-line therapy is with swallowed liquid corticosteroids and other anti-inflammatories,
including fluticasone, a topical viscous budesonide oral suspension.
. Patients with severe symptoms despite these interventions may require oral corticosteroids
such as methylprednisolone.
Other anti-inflammatory agents have also been trialled, including leukotriene antagonists
such as montelukast, anti-interleukins such as the anti-IL-5 monoclonal antibody mepolizumab,
and antihistamines such as loratadine.
Unfortunately, these have shown little clinical benefit.
Mechanical dilatation may be considered in severe cases of EoE that have progressed to
esophageal stricture or severe stenosis.
Dilatation is accomplished by passing dilators through the mouth and down the esophagus to
gently expand its diameter.
As the esophagus of patients with EoE is rather thin and delicate, care is taken not to perforate
the esophagus by overzealous dilatation.
PPI use.
Despite EoE being historically thought of as refractory to PPI treatment, there is some
recent evidence to suggest a significant proportion of patients suffering from EoE achieving remission
following PPI therapy.
See also Eosinophilic gastroenteritis
Allergy Gastroenteritis
References
External links CURED Foundation - Non-Profit for EGID Research
American Partnership for Eosinophilic Disorders Families Affected By Eosinophilic Disorders
Canadian Council of Eosinophilic Disorders Cincinnati Center for Eosinophilic Disorders
Australian Support for Eosinophilic Disorders AEDESEO Asociación Espanola de Esofagitis
Eosinofílica