Eosinophilic Oesophagitis (EO)
What is EO?
- Chronic oesophageal inflammation of unknown origin that is characterized by dense infiltration of eosinophils.
- It has been described in patients of all ages, however it is most common in the childhood
- It predominantly affects males
- Possibly allergic in aetiology as majority of patients have a personal or family h/o allergy
- New disease with an increasing incidence
Discuss the clinical manifestations of EO?
- Intermittent dysphagia
- Food impaction
- GORD like symptoms unresponsive to PPI
- Vomiting
- Chest pain.
Discuss the diagnosis?
- Endoscopy- endoscopic findings are usually subtle and a careful examination is needed along with biopsies. Endoscopic findings
- Strictures
- Trachealized oesophagus,
- Whitish elevated papules that resemble candidiasis
- Longitudinal linear furrows (also called oesophageal corrugation)
- Biopsies
- Eosinophilic infiltration involves the entire oesophagus, but often in a patchy manner.
- At least 5 biopsies should be obtained from the proximal and distal third of the oesophagus for optimal sensitivity.
- The current accepted number of eosinophils needed for diagnosis is 15 eosinophils/HPF in the presence of a consistent clinical context.
- Eosinophils may coalesce to form micro abscesses. Micro abscesses are exclusive to EO and do not occur in GORD.
- Peripheral eosinophilia may occur
Discuss the management of EO?
Optimal treatment is still uncertain
- Dietary management- exclusion of sensitising foods by an elimination diet may be successful in children, but is often difficult in adults due to lack of motivation to follow an elimination diet. Thus in adults, an empirical exclusion of foods may be attempted but it might not eliminate a food necessary for remission, or may be too strict and include unnecessary exclusions.
- PPI treatment- PPI’s are used to rule out GORD as a cause of oesophageal eosinophilia. Alternatively pH studies could be used to exclude GORD.
- Oral Prednisolone (0.5-1.5 mg/kg/day) are effective, however the use is discouraged in view of the chronic course and uncertain long term prognosis
- Topical steroids
- Fluticasone propionate is most commonly used with effectiveness similar to systemic steroids.
- It has low systemic bioavailability through the inhaled route (negligible through the gastrointestinal route, < 1%) and is non-absorbable by the oesophageal mucosa.
- Fluticasone metered-dose inhaler (MDI) is used without a spacer, and patients are instructed to swallow rather than inhale. Patients should not eat or drink for 30 minutes following administration otherwise the steroid would be washed into the stomach; a mouthwash is recommended after use to prevent oral candidiasis.
- The dose is 1000 micrograms per day (220 microgram per puff, so 2 puffs twice a day)
- Duration of treatment- 6-8 weeks. Response is rapid, usually within a week
- Treatment can be repeated if symptoms recur.
- Endoscopy and dilatation- may be needed for rings and strictures. However, dilatation in EO is associated with an increased risk of mucosal tears or perforation. Thus dilatation should be attempted only if the medical treatment has failed.
Who should be offered treatment?
- Symptomatic patients
- Experts recommend that treatment should be offered for abnormal histology even in the absence of symptoms, due to the potential risks posed by oesophageal fibrosis and remodelling, and stenosis formation.
Discuss the prognosis?
The long-term prognosis of EO is unknown.
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