Eosinophilic Esophagitis

Eosinophilic esophagitis is an allergic inflammatory condition of the esophagus. Symptoms are swallowing difficulty, food impaction, and heartburn. The disease was first described in children but occurs in adults as well. The condition is not well understood, but food allergy may play a significant role.

Diagnosis

Diagnosis is obtained during an upper GI endoscopy where biopsies are taken of the esophagus. At the time of endoscopy, ridges or furrows may be seen in the esophagus wall. Presence of white exudates in esophagus is also suggestive of the diagnosis. Sometimes, multiple rings may occur in the esophagus, leading to the term "corrugated esophagus" or "feline esophagus" due to the similarity in the rings of the cat esophagus. A high number of eosinophils are seen on microscopic examination of the biopsy specimens.

Eosinophilic esophagitis may be present even if the esophagus appears, initially, to be normal. This is why the biopsy samples are important to making the diagnosis of EE. A high number of eosinophils(> 15 per high power field) throughout the length of the esophagus suggests the diagnosis of EE.

Skin testing can help identify which foods might contribute to this disease, but often skin testing implicates foods that are not involved. Common allergens of EE patients are cow's milk, soy, egg, fish and wheat.

Treatment

Treatment strategies include dietary modification, medical therapy, and mechanical dilatation of the esophagus. The initial approach to the disorder is often allergy evaluation as described above in an attempt to identify the allergens in the diet or environment. If the offending agent is found, the diet is modified so that these allergens are eliminated. There are cases, especially in children, where there are multiple food allergies involved. Some patients require an elemental diet through the use of a specialty formula. Sticking to this diet and drinking the required amount of formula can be difficult. The use of feeding tubes in these situations is often required.

Medical therapy begins with acid-inhibition medication. A sizable minority of patients with EE have some reflux component to their condition which warrants such treatment. Proton pump inhibitors are often the first-line medical therapy. EE patients by definition have persistent symptoms even with acid-inhibition therapy. For this reason, alternative medical therapies are often employed. Treatment that targets the inflammation includes swallowed corticosteroids such as fluticasone, leukotriene modifiers like montelukast, and anti-interleukins such as the anti-IL-5 monoclonal antibody mepolizumab. To swallow the medications, you must do so with a small amount of water. Swallowing these medications can cause yeast infections in the throat so beware of this method. Other drugs attempt to halt the allergic response; these include antihistamines such as loratadine. Patients with severe symptoms despite these interventions may require oral corticosteroids such as methylprednisolone.

Mechanical dilatation may be considered in severe cases of EE that have progressed to esophageal stricture or severe stenosis. Dilatation is accomplished by passing dilators through the mouth and down the esophagus to gently expand its diameter. As the esophagus of patients with EE is rather thin and delicate, care is taken not to perforate the esophagus by overzealous dilatation.