1. Eosinophillic Oesophagitis

 

 

Overview

  • Chronic, immune-mediated, inflammatory condition of the oesophagus.
  • Characterized by oesophagal dysfunction and increased eosinophils in the oesophagal epithelium.
  • Commonly associated with allergic conditions (e.g., asthma, allergic rhinitis, food allergies).

Epidemiology

  • Prevalence: ~5–10 per 100,000 in Europe and the UK.
  • Male predominance (~70%).
  • Commonly presents in young adults and children.

Pathophysiology

  • Triggered by allergenic antigens (typically food-related or environmental allergens).
  • Dysregulated Th2-mediated immune response → recruitment of eosinophils.
  • Eosinophilic infiltration leads to fibrosis, strictures, and remodeling.

Clinical Features

Adults:

  • Dysphagia (especially for solids).
  • Food impaction.
  • Heartburn or chest pain unresponsive to proton pump inhibitors (PPIs).
  • Upper abdominal pain (less common).

Children:

  • Failure to thrive.
  • Vomiting.
  • Abdominal pain.
  • Refusal to eat (food aversion).

Diagnostic Criteria (BSG and EUREOS Guidelines)

  • Endoscopic Findings:
    • Rings (trachealization of the esophagus).
    • Linear furrows (longitudinal lines in the esophagus).
    • White exudates or plaques.
    • Strictures or esophageal narrowing.
  • Histological Criteria:
    • ≥15 eosinophils per high-power field (HPF) in esophageal biopsy.
    • Biopsies should be taken from at least 6 locations along the esophagus (proximal, mid, and distal).
  • Exclusion of Secondary Causes:
    • Rule out gastroesophageal reflux disease (GERD) and infections (e.g., candida, herpes).

Differential Diagnosis

  • GERD.
  • Esophageal strictures.
  • Achalasia.
  • Infections (candida, viral esophagitis).

Management (BSG and European Guidelines)

First-line Therapy: 3D Approach (Diet, Drugs, and Dilation)

  1. Dietary Therapy:
    • Six-food elimination diet (SFED): Avoid dairy, wheat, eggs, soy, nuts, and seafood.
    • Stepwise elimination: Remove suspected allergens, followed by reintroduction.
    • Elemental diet: Amino acid-based formulas for refractory cases.
  2. Drug Therapy:
    • Proton Pump Inhibitors (PPIs):
      • High-dose PPI (e.g., omeprazole 20–40 mg BD).
      • PPIs act by reducing inflammation and eosinophil infiltration, independent of acid suppression.
    • Topical Steroids (preferred):
      • Budesonide oral viscous slurry or swallowed fluticasone inhaler (off-label use).
      • Dosage: Budesonide 1 mg BD or Fluticasone 880–1760 mcg/day (swallowed).
    • Systemic steroids: Reserved for severe cases with significant inflammation.
  3. Endoscopic Dilation:
    • Indicated for significant strictures causing dysphagia or food impaction.
    • Performed cautiously due to the risk of perforation.

Monitoring and Follow-up

  • Initial Assessment: Repeat endoscopy and biopsy after 8–12 weeks of therapy.
  • Long-term Follow-up:
    • Symptom monitoring (dysphagia scores).
    • Regular surveillance endoscopy every 1–2 years if there is a history of strictures.

Indications for Escalation of Care

  • Persistent symptoms despite initial therapy.
  • Evidence of worsening strictures or fibrosis.
  • Consideration of biologic therapy for refractory cases.

Biologic Therapy

  • Emerging treatments include monoclonal antibodies targeting IL-4, IL-5, and IL-13.
  • Dupilumab (anti-IL-4 receptor antagonist) has shown efficacy in clinical trials.

Prognosis

  • Chronic disease with remissions and exacerbations.
  • Early intervention reduces the risk of strictures and improves long-term outcomes.

Complications

  • Esophageal strictures.
  • Food impaction.
  • Malnutrition (especially in children).

References

  1. British Society of Gastroenterology (BSG) Guidelines.
  2. European Society of Eosinophilic Esophagitis (EUREOS).
  3. Dellon ES, et al. "Management of eosinophilic esophagitis: Updated consensus statements." Gastroenterology. 2021.