Eosinophilic Esophagitis

Aka: Eosinophilic Esophagitis, Chronic Eosinophilic Esophagitis

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II. Pathophysiology

  1. IgE Immune-mediated Esophagitis ("Asthma of the Esophagus")

III. Symptoms: Teens and Adults

  1. Solid Dysphagia
  2. Food impaction (associated with Esophageal Strictures in up to 31%)
  3. Central Chest Pain refractory to Antacids
  4. Refractory GERD
  5. Upper abdominal (Epigastric Pain)

IV. Symptoms: Younger Children

  1. Feeding dysfunction
  2. Vomiting
  3. Abdominal Pain

V. Associated Conditions: Allergic Disorders

  1. Asthma
  2. Atopic Dermatitis
  3. Food Allergies
  4. Gluten Sensitive Enteropathy
  5. Environmental Allergies

VI. Diagnosis

  1. Upper Endoscopy with biopsy
    1. Esophageal Trachealization
      1. Concentric rings within Esophagus
    2. Esophageal biopsy
      1. Superficial mucosa with Eosinophil infiltration
  2. Factors more suggestive of Eosinophilc Esophagitis (in contrast to GERD)
    1. Younger age
    2. Male gender
    3. Dysphagia
    4. Food allergies
    5. Esophageal Rings, furrows or Plaques on endoscopy
    6. Hiatal Hernia absent

VII. Differential Diagnosis

  1. See Vomiting
  2. Gastroesophageal Reflux Disease
  3. Esophageal Dysmotility
  4. Inflammatory Bowel Disease
  5. Esophageal Cancer
  6. Parasitic Infection
  7. Other Esophagitis (e.g. candidal Esophagitis)

VIII. Management

  1. Manage as Gastroesophageal Reflux disease initially (prior to diagnosis by endoscopy and biopsy)
    1. Proton Pump Inhibitor
    2. GERD precautions (avoiding Alcohol, Tobacco, Caffeine, food within 2 hours of lying supine)
  2. Avoid possible food triggers
    1. Consider avoiding milk, wheat, eggs, soy, nuts and seafood
  3. Inhaled Corticosteroids (e.g. Flovent HFA, budesonide) swallowed instead of inhaled
    1. Use Metered Dose Inhalers (not Dry Powder Inhalers)
    2. Puff the Inhaler within the mouth without inspiring, and then swallow the medication
      1. Alternatively, may mix budesonide nebules with Splenda and swallow
    3. Rinse mouth of steroid, but do not swallow water, other liquid or solid for at least 30 minutes
  4. Biologic Agents
    1. Interleukin-4 Alpha Receptor Antagonist: Dupilumab (Dupixent)

IX. Complications

  1. Esophageal Stricture

X. References

  1. Bonis and Furuta (2017) ...Eosinophilic Esophagitis, UpToDate, Wolters Kluwer, accessed 11/4/2017
  2. (2017) Presc Lett 24(11): 65

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