Eosinophilic esophagitis: An increasingly recognized cause of dysphagia, food impaction, and refractory heartburn
ABSTRACTEosinophilic esophagitis is an increasingly recognized cause of a variety of esophageal symptoms, including dysphagia, food impaction, atypical chest pain, and heartburn that does not respond to medical therapy. Its cause is unknown, but allergic and immunemediated mechanisms similar to those of asthma and other atopic diseases are implicated.
KEY POINTS
- The diagnosis is made with upper endoscopy and esophageal biopsies that show diffuse infiltration of eosinophils.
- Current treatment in adults is limited and consists of either swallowed fluticasone (Flonase) or a proton pump inhibitor.
- Because many patients with eosinophilic esophagitis have atopic disease, a complete evaluation for dietary allergens and aeroallergens is recommended, as avoidance of these allergens may be helpful in some adults.
- Cautious endoscopic dilation is a treatment option in patients with evidence of esophageal stenosis. Systemic corticosteroids and novel biologic therapy have been used in refractory cases.
RECOMMENDED APPROACH
The approach to diagnosing and treating eosinophilic esophagitis begins with being aware of its prevalence. One should suspect it more in younger patients presenting with intermittent dysphagia, food impaction, or heartburn that does not respond to maximal doses of a proton pump inhibitor. Special attention should be paid to a personal or family history of allergic diseases or similar symptoms.
According to the consensus recommendations, barium esophagography is useful if the presentation suggests long-standing disease and associated esophageal stricture.
Upper endoscopy is performed, with biopsies obtained in the proximal, middle, and distal esophagus regardless of the appearance of the esophageal mucosa. Biopsies of the stomach and duodenum are also recommended to rule out eosinophilic gastroenteritis.19
After biopsy confirms the diagnosis, a trial of a proton pump inhibitor in maximum doses (usually twice daily) for 8 weeks is recommended if not already tried. If there is evidence of eosinophilic esophagitis on repeat endoscopy and biopsy studies after proton pump inhibitor therapy, the next step is swallowed fluticasone (220 μg, up to four puffs twice daily) for 6 to 8 weeks, with follow-up visits to confirm resolution of symptoms. Without a spacer, the fluticasone is swallowed after maximal expiration. Patients are instructed to avoid food and liquids for at least 30 minutes after use.
Optimal strategies for monitoring in adults have yet to be established, and following symptoms alone may or may not be sufficient.19 Our approach is to follow for symptomatic improvement after treatment is completed, and to consider repeat endoscopy with biopsy if the patient’s symptoms do not improve or if the patient has a recurrence after treatment.
In patients with evidence of long-standing esophageal narrowing or poor response to drug therapy, esophageal dilation can be performed after careful consideration.
Although data are limited as to the role of specific allergens in adult eosinophilic esophagitis, patients with eosinophilic esophagitis are referred to an allergist for allergy testing. Offending food or aeroallergens are removed for a period of time and patients are followed for changes in symptoms.
For patients who do not respond to swallowed fluticasone, proton pump inhibitors, or both, other medications such as systemic steroids, montelukast, or cromolyn can be considered. In the near future, anti-interleukin 5 therapy may be another option.
Patients are asked to return periodically for evaluation after treatment. Due to the chronic and relapsing nature of eosinophilic esophagitis, various therapies (especially fluticasone) are often restarted or continued because of symptom recurrence.
