Eosinophilic esophagitis

Abstract

Eosinophilic esophagitis (EoE) is an atopic disease in which eosinophils infiltrate the esophageal mucosa and may result in a variety of upper gastrointestinal symptoms. Chief among these are dysphagia, heartburn, and food bolus obstruction in adults whereas children often present with abdominal pain or vomiting. Eosinophilic esophagitis is a chronic condition that if not detected and left untreated could lead to the development of subepithelial fibrosis and esophageal stenosis. The diagnosis of EoE is confirmed in a patient presenting with characteristic EoE symptoms, classic signs on endoscopy, and biopsy results showing >15 eosinophils/hpf. A number of useful treatments against EoE are currently available with new therapeutics on the horizon. The former include PPIs, topical steroids, and elimination diet; the latter comprise novel biologics including the monoclonal antibody dupilumab. All these treatments can improve symptoms and reduce esophageal eosinophil count. This brief introductory review describes the detection, diagnosis, and management of EoE.

Keywords: dupilumab; eosinophilic esophagitis; gastroesophageal reflux disease; proton pump inhibitor.

Figure 1

- Endoscopy images revealing characteristic signs in patients with eosinophilic esophagitis. A) Mild trachealization (concentric mucosal rings) and narrowing of the esophageal lumen. B) Furrows, C) whitish exudates, D) whitish exudates with furrows, E) eosinophilic abscess, F) stricture

Figure 2

- Stepwise approach to diagnosis of EoE. ^aExample target ≥3 samples from upper esophagus and ≥3 samples from lower esophagus. ^bTraditional hpf using optical microscopy is equivalent to 0.3 mm using digital microscopy.

Figure 3

- Biopsy samples obtained from proximal esophagus of a 44-year-old male patient who was diagnosed with active EoE (marked eosinophilia [>40/hpf] associated with degranulation and basal epithelial hyperplasia; A: original magnification, x400; B: x600) and subsequently achieved complete remission following treatment (no evident pathology; C: original magnification, x100; D: x200). He was prescribed omeprazole 40 mg bid plus swallowed topical steriods (fluticasone [Flixotide] 125 μg four puffs twice daily) for 8 weeks with no adverse effects.