Monday, January 12, 2015

Eosinophilic Esophagitis Diagnosis on the Rise

By: Rajat N. Parikh, MD, Birmingham Gastroenterology Associates

Eosinophilic esophagitis (EoE) has been more and more frequently diagnosed in young adults at Birmingham Gastroenterology Associates in recent years. EoE is defined as a chronic immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. EoE was a diagnosis discovered in the early 1990's initially on patients that did not respond to standard anti-secretory therapy for GERD. The prevalence in the United States is estimated to be 55 per 100,000. The recent incidence rates of EoE in children exceed those of Inflammatory Bowel Disease.

Clinical manifestations in adults include dysphagia, food impaction, central chest pain, GERD-like symptoms/refractory heartburn, and upper abdominal pain. Younger children most commonly present with abdominal pain and difficulty feeding. There is a strong association of EoE with allergic conditions such as asthma, food allergies, environmental allergies, and atopic dermatitis. Multiple studies also note an association with celiac disease.

Diagnosis is made based on symptoms, endoscopy findings and histology of esophageal biopsies. Characteristically more than 15 eosinophils are seen per high power field on histology of esophageal biopsies. This finding should persist after at least two months of daily PPI therapy. Endoscopic appearance is classically a feline esophagus or ringed esophagus; however, endoscopy can be relatively normal appearing with mild narrowing or linear furrows and small whitish micro-abscesses. The disease can be patchy so biopsies are taken from the lower, mid, and upper esophagus. Imaging and labs do not play a major role in diagnosis.

Typical treatment for EoE include: elimination and elemental diets to decrease allergen exposure, acid suppression for reflux symptoms, topical glucocorticoids, and esophageal dilation for strictures. Other therapies being studied include systemic steroids, antihistamines, immunosuppressants and immunomodulators. Empiric elimination diets are quite effective but difficult to adhere to. Generally, the diet eliminates the most common foods that cause hypersensitivity in the U.S. including milk, egg, soy, wheat, peanuts/tree nuts, and fish/shellfish. This is also known as the six-food elimination diet (SFED). A patient with EoE will eliminate all of these food groups simultaneously and then reintroduce one at a time over a planned period to see which food group causes symptoms and should therefore be avoided. While effective, most patients have difficulty being compliant with elimination diets. Therefore, we commonly have assistance from allergists creating a testing-directed elimination diet based on skin prick testing (SPT) or atopy patch testing (APT).

Pharmacological therapy in addition to acid suppression and esophageal dilation where indicated revolves around use of topical steroids to coat the esophagus and decrease inflammation without causing significant systemic side effects. Options for adults include fluticasone by metered dose inhaler sprayed into the patient's mouth and then swallowed, not inhaled. Typical adult dosing is 220 mcg x 2 sprays twice daily. Lower dosing is used in younger children. Patients who do not respond to fluticasone are normally switched to a oral viscous budesonide which is normally prescribed at a compounding pharmacy. Adult dosing is normally 2 mg daily and lower dosing for children. This is normally made by mixing pulmicort respules with sucralose.

EoE is being diagnosed more commonly and incidence is on the rise. Current therapy is quite effective with more research into newer therapies is on the horizon. The American Partnership for Eosinophilic Disorders ( is an advocacy group for patients with eosinophilic gastrointestinal disorders. Birmingham Gastroenterology Associates ( has been treating EoE for years and continually pursues the newest and best evidence-based therapies available.

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