Eosinophilic oesophagitis
Introduction
Eosinophilic oesophagitis is characterised by an allergic inflammation of the oesophagus. An oesophageal biopsy will show dense infiltrate of eosinophils in the epithelium. Although this disease is relatively poorly understood, it is thought to be caused by an allergic reaction to ingested food. The resulting oesophageal inflammation results in pain and dysphagia, amongst other symptoms.
Epidemiology
- Incidence: 9.00 cases per 100,000 person-years
- Peak incidence: 30-40 years
- Sex ratio: more common in males 2.5:1
| <1 | 1-5 | 6+ | 16+ | 30+ | 40+ | 50+ | 60+ | 70+ | 80+ |
Aetiology
Risk factors for developing eosinophilic oesophagitis:
- Allergies/ asthma: suffering from food/ environmental allergies or atopic dermatitis and asthma increases the risk of diagnosis
- Male sex
- Family history of eosinophilic oesophagitis or allergies
- Caucasian race
- Age between 30-50
- Coexisting autoimmune disease e.g. coeliac disease
Clinical features
Patients typically present with a subacute onset of:
Signs:
- In children, disease presents with failure to thrive due to food refusal
- Adults often experience dysphagia, strictures/ fibrosis (56%), food impaction (55%), regurgitation/ vomiting, anorexia
Signs:
- Signs are minimal and suspicion of this diagnosis relies mainly on the reported symptoms, past medical history and exclusion of other differential diagnoses e.g. GORD
- Weight loss
Investigations
Investigations:
- Endoscopy: diagnosis can only be made on the histological analysis of an oesophageal biopsy. There must be more than 15 eosinophils per high power microscopy field to diagnose the condition. Other findings on endoscopy include reduced vasculature, thick mucosa, mucosal furrows, strictures and laryngeal oedema. Histologically, the diagnosis is made more likely in the presence of epithelial desquamation, eosinophilic microabscesses, and abnormally long papillae
- PPI trial: persistence of eosinophilia and no improvement of symptoms after trialling a proton pump inhibitor. This can help the clinician differentiate between eosinophilic oesophagitis and GORD, which can be a tricky task
Management
As eosinophilic oesophagitis is a relatively little-known condition that is still widely misunderstood, it is recommended that patients are referred to a gastroenterologist to receive specialist care.
Management:
- Dietary modification: This is both effective in adults and children. There are three methods available to begin excluding food from the diet. The elemental diet (involves taking an amino acid mixture for six weeks), exclusion of six food groups (involves avoiding foods commonly associated with allergy e.g. nuts, soy, egg, seafood), and the targeted elimination diet (involves excluding foods that have been identified as allergy-triggering during allergy testing). It is important to involve a dietitian when attempting to modify diet.
Management:
- Dietary modification: This is both effective in adults and children. There are three methods available to begin excluding food from the diet. The elemental diet (involves taking an amino acid mixture for six weeks), exclusion of six food groups (involves avoiding foods commonly associated with allergy e.g. nuts, soy, egg, seafood), and the targeted elimination diet (involves excluding foods that have been identified as allergy-triggering during allergy testing). It is important to involve a dietitian when attempting to modify diet.
- Topical steroids e.g. fluticasone and budesonide are options when dietary modification fails. This requires the patient to swallow solutions of the steroid to line the oesophagus. This should be done for eight weeks before being reassessed
- Oesophageal dilatation: 56% of patients require this at some point in their treatment to reduce the symptoms associated with oesophageal strictures
Complications
Complications:
- Strictures of the oesophagus (56%)
- Impaction: 55% of patients experience this, and 38% of these require endoscopic removal of the impaction
- Mallory-Weiss tears
Prognosis
Prognosis:
- Eosinophilic oesophagitis is a chronic condition. It is recognised that this condition is likely to come back in patients that stop treatment so it important to gain a good balance of dietary modifications and additional pharmacological treatments when necessary.