What is the management approach for Eosinophilic (EOS) esophagitis?

Management of Eosinophilic Esophagitis (EoE)

Topical corticosteroids are the first-line pharmacological treatment for eosinophilic esophagitis, with high-quality evidence supporting their effectiveness in achieving histological remission and improving symptoms. 1

Diagnostic Criteria

• Diagnosis based on ≥15 eosinophils per high-power field (eos/hpf) on esophageal biopsy
• Exclusion of other causes of esophageal eosinophilia
• Clinical symptoms:
  • Adults/adolescents: dysphagia, food impaction
  • Children: failure to thrive, feeding problems, vomiting, heartburn, abdominal discomfort

Treatment Algorithm

First-Line Therapy Options

1. Pharmacological Approach:

   • Topical corticosteroids (high-quality evidence)

     • Recommended for both induction and maintenance therapy 1
     • New formulations (effervescent orodispersible tablets and viscose formulations) provide increased effectiveness at reduced doses 2
     • Continue maintenance therapy after achieving histological remission 1

   • Proton Pump Inhibitors (PPIs)

     • May be considered as initial therapy (very low certainty evidence) 1
     • Double doses induce remission in approximately 50% of patients 2
     • Most responders maintain long-term remission with standard PPI doses 2

2. Dietary Approach:

   • Step-up strategy recommended (starting with less restrictive diets) 1, 3
     • Two-food elimination diet (milk and wheat) as initial approach
     • Four-food elimination diet if needed
     • Six-food elimination diet (milk, wheat, egg, soy, nuts, fish/shellfish) as last resort
   • Elemental diet has moderate certainty evidence but poor practicality 1, 3
   • Allergy testing-directed elimination is not recommended (low efficacy) 4

Management of Complications

• Esophageal strictures:

  • Endoscopic dilation for patients with dysphagia from strictures 4, 1
  • Dilation should be combined with anti-inflammatory therapy (doesn't address underlying inflammation) 1

• Esophageal perforation:

  • CT contrast study to assess extravasation
  • Conservative management with multidisciplinary input for limited extravasation 1

Monitoring and Follow-up

• Repeat endoscopy to assess treatment response 1
• Monitor for potential side effects of topical steroids:
  • Candida infection
  • Adrenal suppression (with long-term use) 1

Treatment Goals

• Symptom improvement
• Resolution of esophageal eosinophilia (<15 eos/hpf)
• Endoscopic improvement
• Prevention of disease progression and complications 1

Important Considerations

• Symptoms alone may not correlate with histological activity 1
• Discontinuing treatment prematurely results in high relapse rates 1
• The British Society of Gastroenterology strongly recommends that patients embarking on dietary management should be managed by a multiprofessional team including an experienced clinician, specialist dietitian, and in selected cases, an allergist 4
• Combination therapy (drugs and diet) should be reserved for selected patients who fail monotherapy 4

Common Pitfalls to Avoid

1. Relying solely on symptoms to assess disease activity
2. Overreliance on allergy testing-directed food restrictions (ineffective, especially in adults)
3. Treating with dilation alone without addressing underlying inflammation
4. Discontinuing treatment prematurely (high relapse rate)
5. Failing to provide adequate dietary support for patients on elimination diets

By following this evidence-based approach, clinicians can effectively manage EoE while minimizing complications and improving patients' quality of life.