Eosinophilic Esophagitis: Diagnosis and Current Management

Abstract

Eosinophilic esophagitis (EoE) is an eosinophil-rich, Th2 antigen-mediated disease of increasing worldwide prevalence. Originally considered common in children and young adults, it can be seen at any age, with the highest prevalence between 30 and 40 years. Symptoms reflect esophageal dysfunction, and typical endoscopic pictures consist of rings, furrows, exudates and edema. Progressive disease leads to pathologic tissue remodeling, with ensuing esophageal rigidity and loss of luminal diameter caused by strictures. The definitive diagnosis is histological (at least 15 eosinophils/HPF, high power field), upper gastrointestinal endoscopy with multiple esophageal biopsies being mandatory. Current therapeutic options include dietary and pharmacologic treatments. Despite being successful in a high proportion of patients, elemental diet has multiple disadvantages. Therefore, a step-up approach (using a two-, four- and six food elimination diets) is preferred, being globally effective in up to 79% of cases and avoiding unnecessary restrictions. Drug therapy relies on proton pump inhibitors and topical corticosteroids. Esophageal dilation may be required to increase luminal patency, leading to immediate symptomatic improvement in 95% of EoE patients, who have strictures or narrow caliber esophagus. The chronic nature of the disease necessitates long-term therapy. In this review, current diagnostic and treatment options are discussed and a treatment algorithm is proposed.