How should esophageal inflammation be treated?

Treatment of Esophageal Inflammation

Start with proton pump inhibitors (PPIs) at double-dose twice daily for 8-12 weeks as first-line therapy for esophageal inflammation, regardless of whether the inflammation is due to eosinophilic esophagitis or gastroesophageal reflux disease. 1, 2

Initial Pharmacological Approach

Proton Pump Inhibitor Therapy

PPIs work through both acid suppression and direct anti-inflammatory mechanisms, making them effective for multiple types of esophageal inflammation 1:

• Administer standard-dose PPI twice daily (e.g., pantoprazole 40 mg, omeprazole 20-40 mg, or equivalent) for a minimum of 8-12 weeks before assessing response 1
• PPIs inhibit Th2 cytokine-stimulated eotaxin-3 secretion, down-regulate allergic inflammation, restore mucosal barrier function, and reduce expression of inflammatory genes 1
• Approximately 50% of patients with eosinophilic esophagitis achieve histological remission with PPI therapy alone 3
• For erosive esophagitis from acid reflux, PPIs achieve healing rates of 75-93% at 8 weeks 4, 5

Critical point: Response to PPIs does not distinguish between GERD-related inflammation and eosinophilic esophagitis, as both conditions respond to PPI therapy through different mechanisms 1, 2

Topical Corticosteroids (If PPIs Insufficient)

If symptoms persist or histology shows inadequate response after 8-12 weeks of PPI therapy 1, 2:

• Swallowed topical corticosteroids are highly effective, with fluticasone 880-1760 mcg/day (adults) or budesonide viscous suspension as preferred agents 1
• Administer via metered-dose inhaler without a spacer, spray into mouth with lips sealed, swallow immediately, and avoid eating/drinking for 30 minutes 1
• Topical steroids achieve clinical and histological remission in the majority of patients and reduce stricture development 1, 2
• Main adverse effect is esophageal candidiasis, which occurs but is generally manageable 1

Dietary Interventions

Elimination diets are effective alternatives to pharmacotherapy, particularly in children, but require significant lifestyle modification 1:

• Six-food elimination diet (removing dairy, eggs, wheat, soy, peanuts/tree nuts, fish/shellfish) achieves 74% response rate 1
• Two- or four-food elimination diets (step-up approach) reduce endoscopy burden and unnecessary restrictions while maintaining moderate effectiveness 3, 1
• Amino acid-based elemental formulas achieve 92-98% remission but have poor palatability and compliance, reserved for refractory cases 1
• Allergy testing (skin prick, specific IgE, patch testing) should NOT guide dietary elimination, as these tests have poor predictive value for esophageal inflammation 1

Dietitian consultation is strongly recommended throughout elimination and reintroduction phases to ensure adequate nutrition 1

Treatment Algorithm Based on Severity

For Mild-Moderate Inflammation

1. Start double-dose PPI twice daily for 8-12 weeks 1
2. Reassess with endoscopy and biopsy while on treatment (symptoms don't correlate with histology) 2, 1
3. If inadequate response, add topical corticosteroids or consider dietary elimination 1

For Severe Inflammation with Dysphagia/Weight Loss

1. Systemic corticosteroids (prednisone 1-2 mg/kg/day, maximum 60 mg) for rapid symptom relief 1
2. Transition to topical corticosteroids or PPIs for maintenance after acute phase 1
3. Consider endoscopic dilation if fixed strictures present 1

For Fibrostenotic Disease

• Endoscopic dilation is safe and effective using either balloon or bougie dilators 1, 2
• Combine dilation with anti-inflammatory therapy (topical steroids preferred) for better long-term outcomes 1, 2
• Medical therapy alone should be attempted first unless critical stricture exists 1

Maintenance Therapy

Long-term maintenance is required in most patients, as esophageal inflammation typically recurs after treatment discontinuation 1:

• PPIs at standard doses effectively maintain remission in responders (pantoprazole 40 mg daily achieves 83-86% maintained healing at 12 months) 4, 1
• Topical corticosteroids have high relapse rates after withdrawal, necessitating ongoing maintenance therapy 1
• Dietary elimination provides prolonged remission if trigger foods are identified and avoided 1

Monitoring Strategy

• Repeat endoscopy with biopsy no sooner than 4 weeks after initiating therapy to assess histological response 2
• Histological remission is defined as <15 eosinophils per high-power field 2, 6
• If symptoms recur on treatment, repeat endoscopy to assess for breakthrough inflammation 1
• Symptoms do not correlate with histological activity—objective endoscopic assessment is mandatory 1, 2

Critical Pitfalls to Avoid

• Do not rely on symptom improvement alone to gauge treatment success; histological assessment is essential as substantial inflammation can persist in asymptomatic patients 1, 2
• Do not combine elimination diets with pharmacological treatment routinely, as this complicates assessment of which therapy is effective 1
• Do not perform dilation without prior diagnostic endoscopy and biopsy unless critical stricture exists, as untreated inflammation increases perforation risk 1
• Do not use leukotriene receptor antagonists, cromolyn sodium, or antihistamines for esophageal inflammation—these are ineffective 1
• Avoid long-term systemic corticosteroids due to significant adverse effects (growth abnormalities, bone disease, adrenal suppression) 1