What is the best approach for managing pain in a patient with Eosinophilic Esophagitis (EOE)?

Pain Management in Eosinophilic Esophagitis

For patients with eosinophilic esophagitis (EoE) experiencing pain, treatment should focus on addressing the underlying inflammation with appropriate medical therapy while providing symptomatic relief through conservative analgesic measures. 1

Primary Treatment Approach

Address Underlying Inflammation

• First-line therapy: Proton pump inhibitors (PPIs) 2, 3

  • Effective in approximately 40% of patients
  • Helps reduce both inflammation and associated pain

• Second-line therapy: Topical corticosteroids 3

  • Swallowed fluticasone or budesonide
  • Achieves histologic remission in ~65% of patients
  • Reduces inflammation and associated pain symptoms

• Dietary therapy: Food elimination diets 4, 5

  • Removes food allergens triggering inflammation
  • May provide significant symptom relief including pain

Pain Management During Acute Episodes

• Conservative analgesic measures:

  • Acetaminophen for mild to moderate pain
  • Avoid NSAIDs when possible as they may irritate the esophageal mucosa
  • Cold liquids or ice chips may provide temporary relief

• Post-dilation pain management:

  • 74% of patients experience chest pain after dilation procedures 1
  • Prophylactic analgesia may be warranted before and after dilation
  • Monitor closely as chest pain can be underreported (documented in only 7% of charts despite 74% patient-reported incidence) 1

Endoscopic Intervention for Strictures

For patients with strictures causing pain and dysphagia:

• Endoscopic dilation is recommended for patients with dysphagia from EoE-associated strictures 1

  • Provides symptom improvement in 87% of patients
  • Should be performed with a conservative approach to minimize complications
  • Most common adverse event is post-procedure chest pain
  • Perforation risk is low (0.4%) with modern techniques 6

• Important considerations for dilation:

  • Use gentle technique with serial dilation in 1-3mm increments 6
  • Target final diameter of 15-18mm 6
  • Inform patients about high likelihood of post-procedure chest pain

Managing Persistent Symptoms

Recent evidence shows that persistent symptoms despite histologic remission may be related to:

• Fibrostenotic disease (adjusted odds ratio 3.87 for persistent dysphagia) 7
• Anxiety and depression (adjusted odds ratio 3.77 for persistent dysphagia) 7
• Partial histologic remission (5-14 eosinophils/hpf) 7

For patients with persistent pain despite treatment:

• Assess for psychological comorbidities that may amplify pain perception
• Consider complete histologic remission (<5 eosinophils/hpf) as a treatment target 7
• Evaluate for residual fibrostenotic changes that may require dilation

Cautions and Pitfalls

• Chest pain after dilation is common and should be anticipated, not mistaken for perforation
• Dilation does not address underlying inflammation and should be combined with medical or dietary therapy 1
• Avoid NSAIDs when possible as they may exacerbate esophageal irritation
• Do not rely solely on symptom improvement as a marker of disease control, as symptoms correlate poorly with histologic activity 1
• Recognize that anxiety and depression can significantly contribute to persistent pain symptoms even when inflammation is controlled 7

Remember that while addressing pain is important for quality of life, the primary goal should be treating the underlying inflammatory process to prevent progression to fibrostenotic disease.