Eosinophilic esophagitis

Eosinophilic esophagitis
Micrograph showing eosinophilic esophagitis. H&E stain.
Classification and external resources
Specialty	Gastroenterology
ICD-10	K20
ICD-9-CM	530.13
eMedicine	article/1610470
MeSH	D057765

Eosinophilic esophagitis (eosinophilic oesophagitis), also known as allergic oesophagitis, is an allergic inflammatory condition of the esophagus that involves eosinophils, a type of white blood cell. Symptoms are swallowing difficulty, food impaction, and heartburn.^[1]

Eosinophilic esophagitis (EoE) was first described in children but also occurs in adults. The condition is not well understood, but food allergy may play a significant role.^[2] The treatment may consist of removal of known or suspected triggers and medication to suppress the immune response. In severe cases, it may be necessary to stretch the esophagus with an endoscopy procedure.

Signs and symptoms

EoE often presents with difficulty swallowing, food impaction, regurgitation or vomiting, and decreased appetite. In addition, young children with EoE may present with feeding difficulties and poor weight gain. It is more common in males, and affects both adults and children.^[1]

Many people with EoE have other autoimmune and allergic disease. This includes asthma^[1] and celiac disease.^[3]

Pathophysiology

EoE is a relatively poorly understood disease of which awareness is rising.^[1]^[4]

At a tissue level, EoE is characterized by a dense infiltrate with white blood cells of the eosinophil type into the epithelial lining of the esophagus. This is thought to be an allergic reaction against ingested food, based on the important role eosinophils play in allergic reactions. Eosinophils are inflammatory cells that release a variety of chemical signals which inflame the surrounding esophageal tissue. This results in the signs and symptoms of pain, visible redness on endoscopy, and a natural history that may include stricturing.^[1]

Diagnosis

Endoscopic image of esophagus in a case of eosinophilic esophagitis. Concentric rings are termed trachealization of the esophagus.

The barium swallow of the esophagus on the left side shows multiple rings associated with eosinophilic esophagitis.

The diagnosis of EoE is typically made on the combination of symptoms and findings on diagnostic testing.^[1]

Prior to the development of the EE Diagnostic Panel, EoE could only be diagnosed if gastroesophageal reflux did not respond to a six-week trial of twice-a-day high-dose proton-pump inhibitors (PPIs) or if a negative ambulatory pH study ruled out gastroesophageal reflux disease (GERD).^[4]^[5]

Endoscopically, ridges, furrows, or rings may be seen in the esophageal wall. Sometimes, multiple rings may occur in the esophagus, leading to the term "corrugated esophagus" or "feline esophagus" due to similarity of the rings to the cat esophagus. Presence of white exudates in esophagus is also suggestive of the diagnosis.^[6] On biopsy taken at the time of endoscopy, numerous eosinophils can be seen in the superficial epithelium. A minimum of 15 eosinophils per high-power field are required to make the diagnosis. Eosinophilic inflammation is not limited to the esophagus alone, and does extend through the whole gastrointestinal tract. Profoundly degranulated eosinophils may also be present, as may microabcesses and an expansion of the basal layer.^[1]^[7]

Radiologically, the term "ringed esophagus" has been used for the appearance of eosinophilic esophagitis on barium swallow studies to contrast with the appearance of transient transverse folds sometimes seen with esophageal reflux (termed "feline esophagus").^[8]

Treatment

Treatment strategies include dietary modification to exclude food allergens, medical therapy, and mechanical dilatation of the esophagus.

The initial approach to the disorder is often allergy evaluation in an attempt to identify the allergens in the diet or environment that may be triggering the condition. If the offending agent is found, the diet is modified so that these allergens are eliminated. There are cases, especially in children, where there are multiple food allergies involved. Some patients require an elemental diet through the use of a specialty formula. Sticking to this diet and drinking the required amount of formula can be difficult. The use of feeding tubes in these situations is often required.

First-line therapy is with swallowed liquid corticosteroids and other anti-inflammatories, including fluticasone, a topical viscous budesonide oral suspension. Patients with severe symptoms despite these interventions may require oral corticosteroids such as methylprednisolone. Other anti-inflammatory agents have also been trialled, including leukotriene antagonists such as montelukast, anti-interleukins such as the anti-IL-5 monoclonal antibody mepolizumab, and antihistamines such as loratadine. Unfortunately, these have shown little clinical benefit.

Mechanical dilatation may be considered in severe cases of EoE that have progressed to esophageal stricture or severe stenosis. Dilatation is accomplished by passing dilators through the mouth and down the esophagus to gently expand its diameter. As the esophagus of patients with EoE is rather thin and delicate, care is taken not to perforate the esophagus by overzealous dilatation.

Despite EoE being historically thought of as refractory to proton pump inhibitor treatment, there is some recent evidence to suggest a significant proportion of patients suffering from EoE achieving remission following PPI therapy.^[9]

References

1 2 3 4 5 6 7 Nurko, Samuel; Furuta, G T (2006). "Eosinophilic esophagitis". GI Motility online. doi:10.1038/gimo49.
↑ Blanchard C, Rothenberg ME (January 2008). "Basic pathogenesis of eosinophilic esophagitis". Gastrointest. Endosc. Clin. N. Am. 18 (1): 133–43; x. doi:10.1016/j.giec.2007.09.016. PMC 2194642. PMID 18061107.
↑ Stewart, Michael J; Shaffer, Eldon; Urbanski, Stephan J; Beck, Paul L; Storr, Martin A (1 January 2013). "The association between celiac disease and eosinophilic esophagitis in children and adults". BMC Gastroenterology 13 (1): 96. doi:10.1186/1471-230X-13-96. PMID 23721294.
1 2 Noel, Richard J.; Putnam, Philip E.; Rothenberg, Marc E. (26 August 2004). "Eosinophilic esophagitis". New England Journal of Medicine 351 (9): 940–941. doi:10.1056/NEJM200408263510924.
↑ Furuta GT, Liacouras CA, Collins MH, Gupta SK, Justinich C, Putnam PE, Bonis P, Hassall E, Straumann A, Rothenberg ME; First International Gastrointestinal Eosinophil Research Symposium (FIGERS) Subcommittees. (Oct 2007). "Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.". Gastroenterology. 133 (4): 1342–63. doi:10.1053/j.gastro.2007.08.017. PMID 17919504.
↑ Samadi F, Levine MS, Rubesin SE, Katzka DA, Laufer I (April 2010). "Feline esophagus and gastroesophageal reflux". AJR Am J Roentgenol 194 (4): 972–6. doi:10.2214/AJR.09.3352. PMID 20308499.
↑ Furuta, GT; Liacouras, CA; Collins, MH; Gupta, SK; Justinich, C; Putnam, PE; Bonis, P; Hassall, E; Straumann, A; Rothenberg, ME; First International Gastrointestinal Eosinophil Research Symposium (FIGERS), Subcommittees (October 2007). "Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.". Gastroenterology 133 (4): 1342–63. doi:10.1053/j.gastro.2007.08.017. PMID 17919504.
↑ Zimmerman SL, Levine MS, Rubesin SE, et al. (July 2005). "Idiopathic eosinophilic esophagitis in adults: the ringed esophagus". Radiology 236 (1): 159–65. doi:10.1148/radiol.2361041100. PMID 15983073.
↑ Molina-Infante, J; Hernandez-Alonso, M; Vinagre-Rodriguez, G; Martin-Noguerol, E (May 2011). "Proton pump inhibitors therapy for esophageal eosinophilia: simply following consensus guidelines.". Journal of gastroenterology 46 (5): 712–3; author reply 714–5. doi:10.1007/s00535-011-0388-8. PMID 21347633.

External links

Diseases of the digestive system (primarily K20–K93, 530–579)

Upper GI tract

Esophagus	Esophagitis Candidal Eosinophilic Herpetiform Rupture Boerhaave syndrome Mallory-Weiss syndrome UES Zenker's diverticulum LES Barrett's esophagus Esophageal motility disorder Nutcracker esophagus Achalasia Diffuse esophageal spasm Gastroesophageal reflux disease (GERD) Laryngopharyngeal reflux (LPR) Esophageal stricture Megaesophagus

Stomach	Gastritis Atrophic Ménétrier's disease Gastroenteritis Peptic (gastric) ulcer Cushing ulcer Dieulafoy's lesion Dyspepsia Pyloric stenosis Achlorhydria Gastroparesis Gastroptosis Portal hypertensive gastropathy Gastric antral vascular ectasia Gastric dumping syndrome Gastric volvulus

Lower GI tract:
Intestinal/
Enteropathy

Small intestine (Duodenum/Jejunum/Ileum)	Enteritis Duodenitis Jejunitis Ileitis Peptic (duodenal) ulcer Curling's ulcer Malabsorption: Coeliac Tropical sprue Blind loop syndrome Small bowel bacterial overgrowth syndrome Whipple's Short bowel syndrome Steatorrhea Milroy disease bile acid malabsorption

Large intestine (Appendix/Colon)	Appendicitis Colitis Pseudomembranous Ulcerative Ischemic Microscopic Collagenous Lymphocytic Functional colonic disease IBS Intestinal pseudoobstruction / Ogilvie syndrome Megacolon / Toxic megacolon Diverticulitis/Diverticulosis

Large and/or small	Enterocolitis Necrotizing Gastroenterocolitis IBD Crohn's disease Vascular: Abdominal angina Mesenteric ischemia Angiodysplasia Bowel obstruction: Ileus Intussusception Volvulus Fecal impaction Constipation Diarrhea Infectious Intestinal adhesions

Rectum	Proctitis Radiation proctitis Proctalgia fugax Rectal prolapse Anismus

Anal canal	Anal fissure/Anal fistula Anal abscess Anal dysplasia Pruritus ani

GI bleeding/BIS

Accessory

Liver	Hepatitis Viral hepatitis Autoimmune hepatitis Alcoholic hepatitis Cirrhosis PBC Fatty liver NASH Vascular Budd-Chiari syndrome Hepatic veno-occlusive disease Portal hypertension Nutmeg liver Alcoholic liver disease Liver failure Hepatic encephalopathy Acute liver failure Liver abscess Pyogenic Amoebic Hepatorenal syndrome Peliosis hepatis Metabolic disorders Wilson's Disease Hemochromatosis

Gallbladder	Cholecystitis Gallstones/Cholecystolithiasis Cholesterolosis Rokitansky-Aschoff sinuses Postcholecystectomy syndrome Porcelain gallbladder

Bile duct/ Other biliary tree	Cholangitis Primary sclerosing cholangitis Secondary sclerosing cholangitis Ascending Cholestasis/Mirizzi's syndrome Biliary fistula Haemobilia Gallstones/Cholelithiasis Common bile duct Choledocholithiasis Biliary dyskinesia Sphincter of Oddi dysfunction

Pancreatic	Pancreatitis Acute Chronic Hereditary Pancreatic abscess Pancreatic pseudocyst Exocrine pancreatic insufficiency Pancreatic fistula

Abdominopelvic

Hernia	Diaphragmatic Congenital Hiatus Inguinal Indirect Direct Umbilical Femoral Obturator Spigelian Lumbar Petit's Grynfeltt-Lesshaft Undefined location Incisional Internal hernia

Peritoneal	Peritonitis Spontaneous bacterial peritonitis Hemoperitoneum Pneumoperitoneum

Allergic conditions

Respiratory system	Allergic rhinitis Asthma Hypersensitivity pneumonitis Eosinophilic pneumonia Churg–Strauss syndrome Allergic bronchopulmonary aspergillosis Farmer's lung Laboratory animal allergy

Skin	Angioedema Urticaria Atopic dermatitis Allergic contact dermatitis Hypersensitivity vasculitis

Blood and immune system	Serum sickness

Circulatory system	Anaphylaxis

Digestive system	Coeliac disease Eosinophilic gastroenteritis Eosinophilic esophagitis Food allergy Milk intolerance

Nervous system	Eosinophilic meningitis

Genitourinary system	Acute interstitial nephritis

Other conditions	Drug allergy Allergic conjunctivitis Latex allergy

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