What are the long-term effects of Eosinophilic Esophagitis (EOE)?

Long-Term Effects of Eosinophilic Esophagitis (EOE)

Untreated EOE leads to progressive esophageal remodeling with fibrostenotic complications including food impaction, esophageal strictures, narrow-caliber esophagus, and rarely esophageal perforation, significantly impacting quality of life and increasing morbidity. 1

Major Complications of Untreated EOE

Structural Complications

• Food impaction: Occurs in 33-54% of adults with EOE 1
• Esophageal strictures: Develop due to chronic inflammation and fibrosis 2
  • Retrospective studies show prolonged, untreated disease is associated with increased prevalence of strictures 2
  • Strictures are often localized to the proximal esophagus, measuring several centimeters in length 2
• Narrow-caliber esophagus: Results from ongoing inflammation and remodeling 2
• Esophageal perforation:
  • Risk is 0.8% during esophageal dilation procedures 2
  • Can occur spontaneously or during endoscopy even without dilation 2
  • 19 cases of spontaneous or non-dilation-related perforations have been reported, with 7 requiring surgical intervention 2

Functional Consequences

• Persistent dysphagia: 91% of patients experience recurrent dysphagia even after treatment 2
• Reduced quality of life: Due to dietary restrictions, social limitations, and anxiety around eating 1
• Esophageal remodeling: Progressive fibrosis leads to permanent structural changes 1, 3

Disease Progression

• Inflammation to fibrosis: Untreated disease progresses from inflammatory to fibrostenotic phenotype 4
  • TGFβ1 drives esophageal remodeling including epithelial barrier dysfunction and subepithelial fibrosis 5
• Stricture development: Patient age and diagnostic delay are well-established risk factors 6
• Stricture improvement: Recent research shows modest improvement in esophageal strictures with continuous medical treatment, but this occurs slowly over years 7

Important Considerations

Cancer Risk

• Despite theoretical concerns, there is currently no evidence of progression to esophageal cancer 2
• Some case reports describe coexistent Barrett esophagus and EOE, but causality has not been established 2

Disease Persistence

• EOE is a chronic condition with eosinophilic inflammation persisting over time 2
• Spontaneous disease remission is uncommon in both pediatric and adult patients 2
• Symptoms often recur after discontinuation of treatment 2

Management Implications

Monitoring

• Endoscopy with biopsy is recommended 8-12 weeks after initiating treatment 1
• Symptoms and histology are often discordant; relying solely on symptoms can be misleading 2, 1

Treatment Considerations

• Maintenance therapy: Continued use of topical glucocorticosteroids is suggested to prevent recurrence and complications 2
• Esophageal dilation:
  • Provides immediate symptomatic relief in 95% of patients with strictures 6
  • Does not address underlying inflammation, so repeated procedures may be needed 6
  • Adding effective anti-inflammatory therapy reduces need for further dilations 6

Pitfalls to Avoid

1. Underestimating disease activity: Clinical symptoms often don't correlate with histological inflammation 2
2. Inadequate follow-up: The chronic nature of EOE necessitates long-term therapy to avoid recurrence and complications 4
3. Focusing only on inflammation: Addressing fibrotic changes may require different therapeutic approaches than targeting inflammation alone 3
4. Delaying treatment: Earlier intervention may prevent progression to fibrostenotic disease 2

EOE is a chronic condition requiring ongoing management to prevent long-term complications that significantly impact quality of life. While the risk of malignant transformation appears minimal, the structural and functional consequences of untreated disease are substantial.