What is the management approach for eosinophilic esophagitis?

Management of Eosinophilic Esophagitis

Topical corticosteroids are the first-line therapy for eosinophilic esophagitis, with strong evidence for reducing esophageal eosinophil counts to <15 per high-power field over 8-12 weeks. 1, 2

Initial Treatment Approach

Topical Corticosteroids (Preferred First-Line)

• The American Gastroenterological Association strongly recommends topical glucocorticosteroids over no treatment, with moderate quality evidence. 1
• Topical steroids are preferred over oral glucocorticosteroids due to better safety profile and similar efficacy. 1
• Treatment duration should be 8-12 weeks before evaluating histological response via endoscopy with biopsy. 2
• Systemic side effects have not been documented during long-term treatment, though monitoring bone mineral density and adrenal suppression is recommended in children and adolescents. 2
• Candida infection may occur in a small proportion of patients and should be managed with topical antifungals while continuing topical steroids. 2

Proton Pump Inhibitors (Initial Trial)

• In patients with symptomatic esophageal eosinophilia, PPI therapy is conditionally suggested over no treatment (very low quality evidence). 1
• This represents a reasonable initial trial before escalating to topical steroids or dietary therapy. 1

Dietary Therapy Options

Step-Up Empiric Elimination Approach (Most Practical)

• Empiric 2-food elimination diet (milk and wheat) is the most practical initial dietary approach, with a step-up strategy to 4-food or 6-food elimination if needed. 2, 3, 4
• The 6-food elimination diet (milk, wheat, egg, soy, peanuts/tree nuts, fish/shellfish) has a 68% histologic response rate but is more restrictive. 2
• Step-up approaches reduce the number of endoscopic procedures, shorten diagnostic times, and avoid unnecessary restrictions compared to top-down strategies. 3
• All dietary elimination must be conducted under supervision of an experienced dietitian due to risk of nutritional deficiencies and potential development of de novo IgE-mediated food allergy upon reintroduction. 2

Alternative Dietary Approaches

• Elemental diets have moderate certainty evidence and are highly effective but impractical in most patients due to poor palatability and adherence challenges. 1, 2
• Allergy testing-directed elimination has very low certainty evidence with higher failure rates compared to empiric elimination and is not recommended as first-line. 1, 2

Choosing Between Medical and Dietary Therapy

• Patients who value avoiding long-term medication use may prefer dietary therapy. 1
• Patients who value avoiding dietary restrictions and multiple endoscopies may prefer topical corticosteroids. 1
• The psychological impact of dietary therapy, including anxiety and depression related to social restrictions, should be discussed with patients. 2

Maintenance Therapy

• For patients achieving remission with topical corticosteroids, continuation of maintenance therapy is recommended rather than discontinuation to prevent recurrent dysphagia, food impaction, and esophageal stricture formation. 1, 2
• Medical treatment with topical steroids likely reduces stricture development with moderate evidence and strong recommendation. 2
• Patients who successfully identify food triggers through dietary elimination can maintain remission with ongoing dietary avoidance. 3, 4

Management of Fibrostenotic Disease

• In adult patients with dysphagia from EoE-associated strictures, endoscopic dilation in addition to anti-inflammatory therapy is recommended. 2
• Endoscopic dilation is safe and effective for improving symptoms with high certainty evidence for safety and moderate for efficacy. 2
• Dilation does not address esophageal inflammation and must be combined with effective anti-inflammatory therapy (topical steroids or dietary elimination) for optimal outcomes. 2

Monitoring and Follow-Up

• Endoscopy with biopsy is required while on treatment to evaluate histological response, as symptoms do not always correlate with histological activity. 2
• Treatment duration should be at least 8-12 weeks before evaluating histological response. 2
• For dietary therapy, endoscopic and histological assessment should be performed between 8-12 weeks after each dietary change. 4

Refractory Disease

• Patients with EoE refractory to treatment and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist. 2
• Consider escalation to more restrictive dietary elimination or combination therapy with both topical steroids and dietary modification. 5

Common Pitfalls to Avoid

• Do not rely on symptom improvement alone to assess treatment response; histological confirmation via endoscopy is mandatory. 2
• Do not use allergy testing as the sole guide for dietary elimination, as it has poor concordance with actual food triggers in EoE. 1, 2, 4
• Do not implement dietary therapy without dietitian supervision due to risk of nutritional deficiencies. 2
• Do not discontinue maintenance therapy after achieving remission, as recurrence rates are high. 1, 2