From the Guidelines
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus that should be diagnosed when there are symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field on esophageal biopsy.
Diagnosis
The diagnosis of EoE is based on a combination of clinical and histological findings, including:
- Symptoms of esophageal dysfunction, such as dysphagia or food bolus obstruction
- At least 15 eosinophils per high-power field on esophageal biopsy 1
- Comprehensive assessment of non-EoE disorders that could cause or potentially contribute to esophageal eosinophilia 1 ### Treatment The treatment of EoE typically involves a combination of medical and dietary therapies, including:
- Topical glucocorticosteroids, which have been shown to be effective in reducing esophageal eosinophilia and improving symptoms 2
- Dietary therapy, such as an elemental diet or an elimination diet, which can help to identify and avoid trigger foods 2
- Proton pump inhibitors (PPIs), which may be used to treat concomitant gastroesophageal reflux disease (GERD) or to reduce esophageal eosinophilia 3 ### Key Considerations
- EoE is a complex condition that can coexist with GERD, and a comprehensive assessment of non-EoE disorders is necessary to establish a diagnosis 3
- The use of PPIs is better classified as a treatment for esophageal eosinophilia that may be due to EoE, rather than as a diagnostic criterion 1
- The diagnosis and treatment of EoE should be guided by evidence-based recommendations, such as those provided by the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters 2
From the Research
Diagnosis of Eosinophilic Esophagitis
- Eosinophilic esophagitis (EoE) is diagnosed based on an esophagogastroduodenoscopy with biopsies of the esophageal epithelium 4
- The diagnosis can be established when both symptoms of esophageal dysfunction (usually dysphagia) and an eosinophilic infiltration of at least 15 eosinophils per high-power field (HPF) are present 4
- Recent advancements in EoE diagnosis include endoscopic functional lumen imaging probe (FLIP), transnasal endoscopy (TNE), and the emergence of non-invasive diagnostic tools including cytosponge, esophageal string test, and mucosal impedance probe 5
Treatment of Eosinophilic Esophagitis
- EoE can be treated with drugs, diet, and endoscopic dilatation 4
- In terms of diet, milk elimination appears most reasonable, particularly as first choice 4
- Drug treatment includes proton pump inhibitors (PPI), topical steroids, and the biologic agent dupilumab 4, 5
- Endoscopic dilatation is effective but does not treat the underlying inflammation, and should never be used alone, but rather as an add-on therapy 4
- Treatment options also focus on dietary therapy, particularly implementation of a 6-food elimination diet, and medical therapy, primarily the use of swallowed, topical corticosteroids 6
Management and Monitoring
- Patients with EoE continue to require a multimodal and multi-disciplinary management approach 5
- Current diagnostic and disease monitoring protocols for EoE rely on repetitive endoscopic evaluations and esophageal tissue acquisition for histopathologic analysis 5
- Biomarkers for EoE have not yet proven their clinical utility 5
- Conservative esophageal dilation is effective at ameliorating dysphagia in symptomatic patients with esophageal strictures 6