Eosinophilic Oesophagitis Update

What is Eosinophilic Oesophagitis?

Eosinophilic Oesophagitis (EoE), was first reported in the late 1970s, and has become increasingly recognised in the past decade in both children and adults.

Eosinophilic Oesophagitis (EoE) has been defined as a chronic immune/antigen-mediated oesophageal disease characterised by clinical symptoms related to oesophageal dysfunction and histologically by eosinophil-predominant inflammation.

Who does it affect?

EoE affects all ages and all ethnic groups,  although most reports have emanated from developed industrialised countries. In adults it occurs most commonly in the 30s and 40s, with a male predominance.

There is also a familial predisposition, and a primary association with atopy and other allergic reactions.

How may patients present?

The most common clinical presentation in adults is of chronic intermittent, non-progressive dysphagia to solids, and food bolus impaction. The next most common presentation is of Gastro-oesophageal reflux type symptoms not responsive to proton pump inhibitors. An associated history of Atopy (asthma, atopic dermatitis, eczema, food & seasonal allergies), or a family history of Atopy, is also common.

How is Eosinophilic Oesophagitis diagnosed?

The diagnosis of EoE is based on typical clinical features, endoscopic appearance and histological criteria.

Characteristic Endoscopic Features include linear oesophageal furrows,  corrugated or ringed oesophagus, and white papules or exudates. A small calibre oesophagus and oesophageal strictures may also be found. A normal endoscopy does not exclude Eosinophilic Oesophagitis.

Since histology is critical for the diagnosis of EoE, oesophageal biopsies are essential to the diagnosis. Findings diagnostic of EoE would be of eosinophil-predominant inflammation on Oesohageal biopsy with a diagnostic threshold of ≥ 15 eosinophils per high power field. Eosinophilic Microabscesses may also be present.

What is the cause?

The pathogenesis of EoE is incompletely understood but appears to be multifactorial with an interplay between Genetic factors, environment triggers and the host immune system.

Eosinophils are not normally found in the oesophagus but the oesophagus is capable of recruiting eosinophils in response to a variety of stimuli.

The association of  EoE with allergies suggest the eosinophil recruitment to the oesohagus may be an immune response to environmental antigens in genetically predisposed individuals. This triggers an adaptive T H2 cell mediated response leading to recruitment of eosinophils to the oesophagus where they become activated.

What treatments are available?

Proton Pump Inhibitors

There is a subset of patients with EoE who achieve complete remission after PPI therapy,  these patients are classified as PPI-responsive Eoesohageal Eosinophilia.

PPIs should be therefore be the first-line therapy for patients with EoE. Those who achieve remission can avoid long-term dietary restrictions or topical corticosteroids.

Topical Corticosteroids

Topical Corticosteroids have been used successfully in the treatment of EoE in children and adults. Since there are no approved therapy for EoE available in the world, EoE patients are treated with medications used in Asthma, such as swallowed inhalers, or aqueous nebuliser solutions.

In Adults, both swallowed Fluticazone 440-880μg bd, and oral compounded viscus suspension Budesonide 1mg bd, have  been shown to be effective in achieving clinical, endoscopic and histological remission.

Since EoE is a chronic remitting disease, maintenance therapy is recommended to prevent relapse.

Is there any effective dietary therapy?

Patients with EoE are may be sensitised to several different foods and aeroallergens. Because there is a strong association of EoE with allergies, allergy testing with skin prick testing and serum IgE tests, are often performed to help identifying what foods need to be removed for the elimination diet.

However, in adults, skin allergy testing has been found to be of low diagnostic accuracy in identifying EoE trigger foods, making it insufficiency accurate for designing an effective diet. IgE based allergy testing has also met with limited success in the management of EoE.

Dietary restriction with elemental (non-allergenic’diet) or elimination diets have therefore been trialled and found to be successful in children with complete resolution of eosinophilia in their oesophagus. Dietary studies in adults are more limited. Elemental diets are not used as first line therapy in adults due to the restrictiveness of such a diet, and poor patient acceptance.

The six food elimination diet has been found to be effective in both children and adults, it is based on empirically removing from the diet the 6 types of foods most often associated with food allergies (milk protein, wheat,  eggs,  soy, peanuts/tree nuts, and fish/seafood). Studies have demonstrated that after a 6 week period of the diet, up to 74% patients achieved disease resolution.

In patients achieving remission, the next steps involve the progressive and sequential reintroduction of food(s) with repeat endoscopic and histological assessment after each reintroduction.

Once the food(s) responsible for EoE in the patient has been identified, long-term avoidance is recommended.

The 6 Food Elimination diet provides an effective alternative to topical corticosteroids in a motivated patient.

References:
1. Gonzalex-Cervera J, Lucendo AJ, Eosinophilic Esophagitis, An Evidence-Based Approach to Therapy. J Investig Allergol Clin Immunol 2016; Vol 26(1):8-18
2. Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: Updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011;128:3
3. Von Arnim, U, Malfertheiner P, Eosinophilic Esophagitis- Treatment of Eosinophilic Esophagitis with Drugs:Corticosteroids Dig Dis 2014;32:126-129


May Ling WongAUTHOR | Dr May-Ling Wong
Dr Wong is a gastroenterologist who has a special interest in endoscopy, hepatology – chronic liver disease, viral hepatitis, alcoholic liver disease, irritable bowel syndrome including fructose malabsorption and inflammatory bowel disease.
View profile on Epworth Find a Doctor
PH | 03 9826 6942  EMAIL | maylingreception@gmail.com

 

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