Eosinophilic esophagitis is a chronic and increasingly recognized inflammatory disorder of the esophagus characterized by abnormal infiltration of eosinophils of the esophageal mucosa, often resulting in dysphagia and food impaction. The disorder is being diagnosed with much greater frequency and increased recognition alone may not be responsible for this trend.Studies have indicated that the incidence has increased more than fourfold in the last 5–10 years.More than 80% of patients diagnosed with eosinophilic esophagitis complain of dysphagia, and between 5% and 16% of patients undergoing endoscopic evaluation for dysphagia are found to have eosinophilic esophagitis. Further,more than 50% of patients presenting with frank food impaction are diagnosed with eosinophilic esophagitis.By contrast, in children and adolescents, gastroesophageal reflux disease (GERD) and esophageal reflux symptoms are as common as food impaction and dysphagia.
Eosinophilic Esophagitis Symptoms and Signs
The leading symptom in adults is recurrent attacks of dysphagia. Mean duration of symptoms before diagnosis and initiation of treatment in one large series was 4.6 years. Recurrent dysphagia is present in the majority of patients as is the history of food impaction. A personal history of allergic diseases (ie, airway allergies, food allergies, or skin allergies) is frequently present. Serum immunoglobulin E (IgE) elevations have been documented in one series in two thirds of the patients. However, it should be emphasized that there is no difference in symptoms,endoscopic findings,or histology in patients with increased serum IgE levels versus those with normal IgE levels. Symptoms appear to be more pronounced in patients with peripheral blood eosinophilia. Another clinical feature is the presence of symptoms of GERD, dyspepsia, and xiphisternal and retrosternal discomfort that are seemingly refractory to medical management.In children and adolescents, symptoms include vomiting, regurgitation, GERD symptoms not responding to medical management, upper abdominal pain, and food impaction in the esophagus.
Eosinophilic Esophagitis Diagnostic
The usual criteria for the diagnosis of eosinophilic esophagitis are as follows:
1. Clinical symptoms of esophageal dysfunction, especially dysphagia and a history of food impaction.
2. Biopsies of the esophageal mucosa reveal a dense eosinophilic infiltration (ie,≥ 20 eosinophils/HPF).
3. Lack of responsiveness or an incomplete response to treatment of high doses of proton pump inhibitors, or normal pH monitoring of the distal esophagus, or both
Although increased eosinophilic infiltration in the esophagus is characteristic of eosinophilic esophagitis, it is not exclusively found in that disorder. Other disorders that may be associated with increased eosinophilic infiltration of the esophagitis include GERD, Crohn disease, hypereosinophilic syndrome, cardiovascular disease, drug-induced esophagitis, and infectious esophagitis (ie, herpes or Candida). Increased eosinophils can be found in the distal esophagus in reflux esophagitis but not in the mid-esophagus.
Eosinophilic Esophagitis Treatment
Several studies that have employed topical fluticasone in doses ranging from 220–440 mcg two to four times daily have demonstrated symptom improvement and complete resolution of symptoms in up to 75% of cases.Patients are generally instructed to swallow rather than inhale the fluticasone and not use a spacer. Twice-daily fluticasone is usually administered for 6–12 weeks, and during this interval clinical and histologic symptoms are improved in the vast majority of patients. Patients receiving the higher dose of fluticasone are more likely to develop esophageal candidiasis. Furthermore, higher doses of fluticasone (ie, > 440 mcg/day) have been associated with systemic side effects, including cataracts and adrenal suppression.Although the use of swallowed corticosteroids is effective in relieving symptoms for a short period of time (4 months or less), long-term efficacy remains controversial. It should be emphasized that symptoms are more likely to recur in a period of 4–18 months after therapy has been discontinued in approximately half the patients.
An alternative to swallowed fluticasone is the use of a suspension of budesonide. It has been reported that a preparation of 1–2 mL of Pulmicort Respules mixed with five 1.0-g packets of sucralose to create a volume of 8–12 mL was well tolerated in 20 children and led to a histologic response in 80% of these patients. Pulmicort Respules is a liquid-based formulation of budesonide containing 0.5 mg of budesonide, and 2 mL mixed with sucralose will make a dose of 8–12 mL that can be taken twice daily. Although data are limited, this preparation may well be a viable alternative to using swallowed fluticasone.
Systemic corticosteroids are effective in eosinophilic esophagitis but side effects limit their use,especially for periods longer than 4 weeks.They may be indicated when urgent symptom relief is required as with patients experiencing severe dysphagia, dehydration, and significant weight loss or esophageal strictures.
Esophageal dilation may be necessary in patients with strictures, but it must be done carefully as it has been associated with deep mucosal tears, esophageal perforation, increased postendoscopic analgesia, and difficulty in inserting the endoscope. Approximately half the patients treated with esophageal dilation will become asymptomatic.
Antagonists The leukotriene receptor antagonist montelukast has been studied in a small number of patients with eosinophilic esophagitis; eight patients showed a complete resolution of symptoms with a dosage of 20–40 mg/day and maintained this response for a median of 14 months. However, once the medication was discontinued, six of the eight patients had a recurrence of their symptoms. Data are insufficient to recommend leukotriene receptor antagonists for the treatment of eosinophilic esophagitis.
Cromolyn sodium, a mast cell stabilizer, has not shown any apparent benefit for patients with eosinophilic esophagitis although it has no significant adverse effects.
Specific Food Elimination
Efficacy of specific food elimination diets remains controversial.Although several studies have demonstrated a poor correlation of diagnostic skin testing, radioallergosorbent testing, and IgE skin prick tests with improvement in either symptoms or tissue inflammation, one center did report a significant improvement in patients on a specific food elimination diet. Kagalwalla and colleagues demonstrated that eliminating the six most common allergenic foods (dairy, eggs, wheat, soy, peanuts, and fish/shellfish) resulted in significant improvement in 74% of the 35 patients who received the six-food elimination diet.
Treatment of Gastroesophageal Reflux Disease
Antireflux therapy with proton pump inhibitors is usually not successful or achieves only a partial response in patients with GERD. However, some patients may have both GERD and eosinophilic esophagitis and in this setting, treatment with a proton pump inhibitor may be appropriate.
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