Diagnostic Approach and Treatment for Eosinophilic Esophagitis
Endoscopy with multiple biopsies is the essential first diagnostic step for suspected eosinophilic esophagitis (EoE), with at least six biopsies from different anatomical sites in the esophagus required for accurate diagnosis. 1
Initial Diagnostic Steps
When to Suspect EoE
- In adults, suspect EoE in patients with dysphagia, food bolus obstruction, or atopy, as these are strongly associated with EoE diagnosis 1
- In children, symptoms may be non-specific and vary with age, including feeding problems, vomiting, and abdominal pain 1
- Consider EoE in patients with refractory GERD symptoms, particularly in children 1
Diagnostic Workup
- Withdraw proton pump inhibitors (PPIs) for at least 3 weeks prior to endoscopy to ensure accurate diagnosis 1
- Perform upper endoscopy with at least six biopsies from different anatomical sites within the esophagus 1
- Diagnostic criteria: ≥15 eosinophils per 0.3 mm² (high power field) in any biopsy specimen 1, 2
- Look for additional histological features including basal cell hyperplasia, edema, eosinophil microabscesses, eosinophil layering, eosinophil degranulation, and subepithelial sclerosis 1
Endoscopic Features
- Characteristic findings include esophageal edema, rings, exudates, furrows, and strictures 2, 3
- Important: A normal-appearing esophagus does not exclude EoE; biopsies should still be taken in patients with suspicious symptoms 3
Treatment Options
First-Line Therapies
- Proton pump inhibitors (PPIs) are often used as initial therapy 2, 4
- Topical corticosteroids (oro-dispersible budesonide) are effective for inducing and maintaining remission 2
- Elimination diets to remove potential food allergens can be effective, particularly in patients with identified food triggers 4, 5
Management of Complications
- For food bolus obstruction, urgent referral to gastroenterology for endoscopic intervention is recommended 1
- Maintenance therapy with topical steroids reduces the risk of recurrent food bolus obstruction 1
- Endoscopic dilation may be necessary for patients with strictures or persistent dysphagia despite medical therapy 3
Follow-up
- Follow-up endoscopy with biopsies is recommended to assess treatment response 3
- Early diagnosis and treatment may prevent long-term complications of fibrosis and strictures 1, 6
Special Considerations
- EoE and GERD are not mutually exclusive and can coexist in the same patient 1, 2
- In patients with high suspicion for EoE but initial non-diagnostic biopsies, consider repeat endoscopy with biopsies 1
- Longer diagnostic delays are associated with increased risk of stricture formation (17% with <2 years delay vs. 71% with >20 years delay) 1
Common Pitfalls to Avoid
- Failing to take adequate number of biopsies (at least six from different sites) 1
- Not withdrawing PPIs before diagnostic endoscopy, which may mask eosinophilic infiltration 1
- Missing the diagnosis in patients with normal-appearing esophagus but typical symptoms 3
- Failing to follow up patients after food bolus obstruction, which can lead to recurrent episodes 1