What are the complications and treatment options for eosinophilic esophagitis?

From the Guidelines

Approximately 10% of patients with eosinophilic esophagitis (EoE) develop complications, with a history of food impaction and presence of a focal stricture being identified as risk factors associated with perforation, as reported in a study published in 2021 1. The time frame for developing complications can vary, but a retrospective study over a 14-year period found that perforations occurred in 2.0% of patients with EoE, with most being non-iatrogenic and some requiring surgical intervention 1. EoE complications include food impaction, esophageal strictures, esophageal narrowing, and difficulty swallowing that can impact nutrition and quality of life. Treatment options include both medication and dietary approaches, with first-line medication therapy typically involving proton pump inhibitors (PPIs) such as omeprazole 20-40mg daily or lansoprazole 30-60mg daily for 8-12 weeks. If PPIs are ineffective, topical corticosteroids like budesonide (1mg twice daily as a viscous suspension) or fluticasone (440-880mcg twice daily, sprayed and swallowed) for 8-12 weeks can reduce inflammation, as suggested by the AGA institute and the joint task force on allergy-immunology practice parameters in 2020 1. Dietary management includes elimination diets, with the six-food elimination diet (removing milk, wheat, eggs, soy, nuts, and seafood) being most common, followed by systematic reintroduction to identify triggers, as recommended by the British Society of Gastroenterology and the British Society of Paediatric Gastroenterology, Hepatology and Nutrition in 2022 1. For severe strictures, endoscopic dilation may be necessary but carries a risk of perforation, and maintenance therapy is often required as EoE is chronic, with long-term low-dose steroids or continued dietary restrictions, as suggested by the AGA institute and the joint task force on allergy-immunology practice parameters in 2020 1. Biologic therapies targeting specific inflammatory pathways, such as dupilumab, are emerging options for refractory cases, and treatment success is measured by symptom improvement and reduction in esophageal eosinophil counts on follow-up endoscopy, typically performed 8-12 weeks after initiating therapy. Some key points to consider in the management of EoE include:

• The use of PPIs as a first-line treatment, with topical corticosteroids being used if PPIs are ineffective
• The importance of dietary management, including elimination diets and systematic reintroduction to identify triggers
• The need for maintenance therapy, with long-term low-dose steroids or continued dietary restrictions
• The potential use of biologic therapies for refractory cases
• The importance of monitoring for complications, including food impaction, esophageal strictures, and perforation. It is essential to note that the management of EoE should be individualized, taking into account the patient's specific needs and circumstances, and that a multidisciplinary approach, including input from gastroenterologists, dietitians, and allergists, may be necessary to optimize outcomes, as recommended by the British Society of Gastroenterology and the British Society of Paediatric Gastroenterology, Hepatology and Nutrition in 2022 1.

From the Research

Complications of Eosinophilic Esophagitis

• Eosinophilic esophagitis (EoE) can lead to complications such as food impaction, esophageal strictures, and fibrosis if left untreated or not properly managed 2, 3, 4.
• The chronic inflammation in EoE can progress to fibrosis, resulting in the formation of strictures and leading to complications such as food impaction 2.
• Esophageal strictures in EoE develop as a consequence of long-lasting esophageal eosinophilia, with patient age and diagnostic delay as well-established risk factors 4.

Treatment Options for Eosinophilic Esophagitis

• The mainstay of management for EoE includes the 3 D's: diet, drugs, and dilation 2.
• Dietary modifications, such as elimination diets, can be effective in managing EoE symptoms 2, 3.
• Medications, including proton pump inhibitors, swallowed topical glucocorticoids, and dupilumab, can help alleviate symptoms and reduce inflammation 2, 3, 5.
• Esophageal dilation can provide immediate symptomatic relief of dysphagia in patients with esophageal strictures or narrow caliber esophagus 4.

Development of Complications and Time Frame

• The time frame for the development of complications in EoE can vary depending on several factors, including the severity of the disease, patient age, and diagnostic delay 4.
• There is no specific percentage of patients with EoE who develop complications, as it depends on various factors, including the effectiveness of treatment and patient compliance 2, 3, 4.
• However, it is known that persistent inflammation, even in the absence of symptoms, can lead to esophageal fibrosis and stricture formation over time, highlighting the importance of maintenance therapy in patients with EoE 2.