EOSINOPHILIC ESOPHAGITIS
EOSINOPHILIC ESOPHAGITIS
DISEASE WITH MANY NAMES
Congenital esophageal stenosis
Feline esophagus
Ringed esophagus
Corrugated esophagus
Small caliber esophagus
Stiff or non-compliant esophagus
DIAGNOSTIC GUIDELINES OF EOSINOPHILIC
ESOPHAGITIS
• Clinical symptoms of esophageal dysfunction
• More than 15 eosinophil in 1hpf ( x400)
• Lack of response to high dose ppi (2mg/kg/d)
Or
• Normal pH monitoring of distal esophagus
EOSINOPHILIC ESOPHAGITIS
DEMOGRAPHICS AND PRESENTING SYMPTOMS
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Male gender: 75%
Age: mean between 36 to 42 yrs
Westernized countries: US, Europe, Australia, Japan
May be seen in other first degree relatives
Presenting symptoms:
Dysphagia: >90%
Food impaction: 50%
Heartburn: 33%
Chest pain/vomiting
Most carry a diagnosis of GERD
• Extraesophageal symptoms:
Asthma: 50%
food allergies: 10-30%
Potter JW GI Endo 2004, Desai TK GI Endo 2005, Remedios M GI Endo 2005
Differential Diagnosis of
Esophageal Eosinophilia
• GERD
• Eosinophilic esophagitis
• Eosinophilic gastroenteritis
• Crohn’s disease
• Connective tissue disease
• Hypereosinophilic syndrome
• Infection
• Drug hypersensitivity response
Symptoms Suggestive of
Eosinophilic Esophagitis
CHILDREN
Feeding aversion/intolerance
Vomiting/regurgitation
“GERD refractory to ppi “
“GERD refractory to surgical rx”
Food or foreign body impaction
Epigastric pain
Dysphagia
Failure to thrive
Slow eating
ADULT
Dysphagia
Food impaction
“GERD refractory to ppi”
Slow eating
Heartburn
RINGED ESOPHAGUS
Endoscopic Features Associated With
Eosinophilic Esophagitis
• Linear furrowing, vertical lines of the esophageal mucosa
• White exudates, white specks, nodule, granularity
• Circular rings, transient or fixed, felinization
• Linear shearing/ crepe paper mucosa with passage of
endoscope or dilator
• Stricture: proximal, middle, or distal
• Normal
EOSINOPHILIC ESOPHAGITIS
Histologic Features Associated with
Eosinophilic Esophagitis
• More than 15 intraepithelial eos/ 1 HPF
• Eosinophil microabcess
• Superficial layering of eosinophils
• Basal zone hyperplasia
• Increase papillary height
• Increase in lamina propria and papillae
fibrosis
ESOPHAGEAL EOSINOPHILIA WITH
DYSPHAGIA AND NORMAL ENDOSCOPY
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12 patients (10M, 32yrs) with > 20 eos/HPF
• 3 pts 1986-88 and 9 pts between 1988-1990
• All had dysphagia with normal endoscopy
• 7 had hypersensitivity (3 asthma) and 1periph
eosinophila
• esophageal manometry- nonspecific EMD in 10
and normal LES in all
• Esophagel pH- abnormal in 1
• Treatment- all required frequent dilatations, one
resolved with oral steroids
Treatment Of Eosinophilic Esophagitis
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Acid suppression
Esophageal dilatation
Elimination diets
Systemic corticosteroids
Topical corticosteroids
Antihistamines and cromolyn
Montelukast (leukotriene inhibitor, Singulair)
Mepolizumab (anti IL-5)
Purine analogues (Azathioprine or 6MP)
USE OF INHALED STEROIDS IN
EOSINOPHILIC ESOPHAGITIS
• Fluticasone 4 puffs (220mcg/puff)
• Twice daily before breakfast and dinner
• Duration: 6 weeks
• Insure delivery to esophagus by removing the
spacer
• Inspire deeply, depress the inhaler, and swallow
the aerosol
• Rinse mouth with water and avoid food and
drink for 1-3 hours
ORAL PREDNISONE VS TOPICAL FLUTICASONE IN
TREATMENT OF EOSINOPHILIC ESOPHAGITIS
• Systemic and topical steroids are effective in
achieving histologic and clinical improvement
• Prednisone results in greater histologic
improvement, without associated clinical
advantage over fluticasone
• Symptom relapse is common in both group upon
therapy discontinuation
Clinical Gastroentrol and Hepatol 2008;6:165-173
MONTELUKAST IN EOSINOPHILIC
ESOPHAGITIS
• Montelukast (Singulair) is leukotriene receptor
antagonist which blocks leukotriene D4
receptors, reducing the inflammatory action of
eosinophils
• 8 patients with EE with montelukast
- starting dose 10 mg AM increased to 100 mg
- maintenance dose: 20-40 mg/day
• 6 of 8 reported complete resolution of dysphagia with
median 14 months follow-up
• However, esophageal eosinophilia persisted
• Side effects: nausea, myalgias
Attwood SE et al. Gut 2003
EOSINOPHILIC ESOPHAGITIS
ESOPHAGEAL TEARS AND PERFORATION
• Esophageal tears or rents in the muscle layer may occur
even with passage of endoscope
• Frequency is variable
-Kaplan 5/8 (63%)
-Potter 10/13 (77%)
-Younes 1/10 (10%)
mean 3 year fu- no further dilatations
-Straumann 0/11-mean fu 7 yrs
7 once and 4 repeated dilatations
• No evidence of true perforation- but painful in some
needing narcotics
• Key: start small caliber < 10 mm dilator, gradually advance
and stop with blood on bougie
Kaplan Clin Gastro Hep 2003, Younes Dig Dis 1999, Strauman Gastro 2003
EXAMPLE CASE
A 22 year old man for the evaluation of solid
food dysphagia. He has had 2 episodes of
food impaction in the last year.
He is a slow eater, solid foods stick
intermittently in the midchest, but no liquid
dysphagia. Rare heartburn but no weight
loss. History of mild asthma since childhood
and can’t eat some nuts. Omeprazole hasn’t
helped
Physical exam and complete blood count is
unremarkable