Editing Eosinophilic oesophagitis


A chronic, immune/antigen-mediated, oesophageal disease characterised clinically by symptoms related to oesophageal dysfunction and histologically by eosinophil-mediated inflammation

* 'EoE' in USA

== Epidemiology ==

* Detected in most countries
* Maybe more common in urban     areas
* Seasonal exacerbations in     keeping with atopy
* Probable increasing incidence     over time

== Risk factors ==

* Limited data
* Not particularly increased     with smoking or NSAIDs or H. pylori
* Strongly associated with     atopic disorders - food allergies, environmental allergies, asthma, atopic     dermatitis

== Pathophysiology ==

* Subtypes:
** 1: mild, with      normal-appearing oesophagus, and mild histological changes
** 2: inflammatory subtype with      highest expression of cytokines
** 3: fibrostenotic subtype      with a narrow-calibre oesophagus, and highest degree of endoscopic and      histological severity

== Presentation ==

* Adults and teenagers     frequently present with dysphagia to solids (most commonly), food     impaction, central chest pain, GORD, upper abdominal pain
* Children present with feeding     difficulties, GORD and abdominal pain

== Diagnosis ==

* Eosinophils present on biopsy     (essential)
** Total of at least 6      biopsies: 2-4 biopsies each from the distal oesophagus and another 2-4      from the mid or proximal oesophagus, along with gastric and duodenal      biopsies looking for other diseases
** The vast majority of      patients have at least 15 eosinophils per hpf in at least one biopsy      specimen
** Also look for eosinophil      microabscesses, superficial layering of eosinophils, sheets of      eosinophils, extracellular eosinophil granules, subepithelial and lamina      propria fibrosis and inflammation, basal cell hyperplasia, papillary      lengthening, and increased numbers of mast cells/B cells/IgE-bearing      cells
* Accompanied by characteristic     symptoms (essential)
* Endoscopic appearance (not     essential)
** Feline oesophagus (stacked      circular rings) (44%)
** Strictures, especially      proximal (21%)
** Attenuation of the      subepithelial vascular pattern (41%)
** Linear furrows (48%)
** Whitish specks representing      eosinophil micro-abscesses (27%)
** Small calibre oesophagus      (9%)
* Other causes of oesophageal     eosinophilia have been excluded (essential)
** GORD
*** Favour EoE if proximal       oesophageal involvement, subepithelial lamina propria fibrosis,       eosinophilic abscesses, more severe basal cell hyperplasia, activated       mast cells
*** If histological findings       resolve with PPI alone, probably more GORD rather than EoE
*** EoE shouldn't be responsive       to PPI
** Recurrent vomiting from      other causes
** Parasitic and fungal      infections
** Allergic vasculitis
** Drug injury
** Connective tissue diseases
** Bullous pemphigoid
** Pemphigoid vegetans
** Graft-versus-host disease
** Achalasia
** Drug hypersensitivity
** Coeliac
** Vasculitis
** Carcinoma


== Management ==

=== Dietary ===

** Identify allergens and avoid
** Generally refer to allergist

=== Pharmacological ===

** Start PPI on diagnosis for      8/52 - 40mg daily
** If symptoms fail to improve      after 4/52, increase to 40mg BD

=== Endoscopic ===

** Repeat endoscopy after 8/52      of PPI
*** If there is good response       (71%), continue PPI at lowest effective dose
*** If no response, pursue       dietary modification or topical glucocorticoid (oral budesonide 2mg BD       is best-studied). Those with strictures on index endoscopy are less       likely to respond. Take the drink slowly over 5 minutes, and don't       consume anything for 30 minutes afterwards.

== Complications ==

* Strictures
** Dilation is effective, but      has no impact on underlying inflammation
** Try to reserve it for      strictures that don't respond to medical therapy.
** Perform carefully - can      cause deep mucosal tears and perforation. Limit progression per session      to 3mm or less. Multiple dilations are often required to attain a      diameter of 15-18mm.
** Unclear whether patients      with EoE are at higher risk of perforation - older studies suggested the      rate is 5-7%, but the rates are 0.03-0.7% in modern series

== Natural history ==

* Chronic disease with     recurrence likely on stopping treatment
* Does not appear to     significantly shorten lifespan
* Long-term prognosis of     dysphagia is unknown

[[Category:UGIS]]