Managing eosinophilic esophagitis: challenges and solutions

Abstract

Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated condition defined by symptoms of esophageal dysfunction and dense eosinophilic infiltration of the esophageal mucosa. Therapies consist of anti-eosinophilic medications and specialized diets aimed to decrease the progression of EoE and alleviate its symptoms, namely, dysphagia and food impaction. Assessing response to therapy remains challenging, as treatment end points are not well defined and currently consist of clinical, histologic, and endoscopic features. Newer validated measures may help standardize treatment end points. Emerging data support the use of maintenance therapy, which may reduce disease progression. Optimal dosages, delivery techniques, and duration of treatment need to be determined. When features of fibrostenosis develop, esophageal dilation is a safe and effective adjunctive strategy for improving symptoms. In EoE cases refractory to conventional treatments, newer therapies targeting inflammatory mediators and cytokines are on the horizon.

Keywords: allergy; corticosteroids; dietary treatment; dilation; dysphagia; eosinophilia; eosinophilic esophagitis; esophagitis.

Figure 1

Treatment algorithm for EoE. Notes: *Swallowed fluticasone or budesonide; **six-food elimination diet, four-food group elimination diet, elemental diet, allergy-test targeted elimination diet. Abbreviations: EoE, eosinophilic esophagitis; eos, eosinophils; hpf, high-power field; PPI, proton pump inhibitor; REE, responsive esophageal eosinophilia.