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Causes

• The causes of EoE are as follows:
• The food and pollen react with the lining of the esophagus, these allergens cause the multiplication of eosinophils in the layers of the esophagus and produce a protein that causes inflammation.
• The inflammation further cause scarring, excessive fibrous tissue deposition over the lining of the esophagus eventually leading to dysphagia.
• The dysphagia can sometimes worsen to cause food impaction and additional symptoms such as chest pain.

Risk factors

• The risk factors associated with EoE are as follows:
• Age- EoE has a bimodal age distribution common in both children and adults.
• Sex- Males are more prone to EoE than the females.
• Weather- Cold and dry climate triggers EoE.
• Location- EoE is common in people with a history of European ancestry.
• Season- Summer and fall, this is because people stay outdoors during this time and the higher levels of the pollen and the other allergens during these seasons.
• Family history- EoE runs in the family and it is more common in people with a positive family history of the EoE.
• History of allergies- EoE is very common in patient with a history of allergies such as asthma, industrial exposures, environmental allergies, chronic respiratory disease, food allergies and atopic dermatitis.

Prognosis

• The prognosis of the EoE is as follows:
• The long-term prognosis of the EoE is unclear but patients diagnosed with EoE have an unaffected lifespan.
• Patients should be counseled that the disease is chronic.
• Patients who are untreated or have discontinued the treatment have progression of their symptoms.
• The EoE patients with a narrow esophageal lumen are more refractory to the corticosteroid treatment and require many dilations.
• The dysphagia is common in patients with increased eosinophil count in the blood.
• The EoE is restricted only to the esophagus sparing the stomach and the duodenum.
• EoE does not progress into metaplasia or dysplasia or esophageal cancer.

Endoscopy

• Mucosal biopsies of the esophagus should be obtained in all patients in whom EoE is a clinical possibility regardless of the endoscopic appearance.
• Endoscopic abnormalities in patients with EoE are as follows:
  • Fixed esophageal ring which is corrugated
  • White exudates or plaques
  • Longitudinal furrows
  • Mucosal pallor
  • Diffuse esophageal narrowing
  • Mucosal fragility leading to esophageal lacerations during the endoscopy

However, because these endoscopic features have been described in other esophageal disorders, none can be considered pathognomonic for EoE.

Complications

• The complications of the EoE are as follows:
• Scarring of esophagus-leading to dysphagia
• Esophageal stenosis- causing food stuck
• Tears or perforation during the endoscopy or retching leading to Boar-heave syndrome.

Medical therapy

Treatment Advantages Disadvantages Medications Topical steroids (fluticasone, budesonide) Ease of administration.High degree of efficacy in randomized controlled trials. Candidiasis, Recurrent disease activity after cessation of topical steroids Systemic steroids High degree of effectiveness.Ease of administration Toxicities of systemic steroidRecurrent disease after cessation Antihistamines Ease of administration Limited data to support effectiveness Leukotriene antagonist Symptom improvement in uncontrolled studies Higher doses may be needed for effectNo change in esophageal eosinophiliaSide effects of nausea and myalgias Immunomodulator (azathioprine, 6 mercaptopurine) Steroid sparing agent ImmunosuppressionSide effect profileLimited data (3 patients) to support use Anti-TNF therapy (infliximab) Rationale based on increased tissue expression of TNF No clinical improvement in a small uncontrolled trial Anti-IL-5 therapy Rationale based on role of IL-5 in systemic eosinophilic disorders Conflicting data to support efficacy Cromolyn sodium Rationale based on asthma model Limited pediatric data does not support effectiveness Diet Elemental High degree of effectivenessSimplified initial formula dietAvoidance of long-term use of medications Poor palatabilityRequires prolonged period of foodReintroductionNeed for repeated EGD and biopsies to identify allergen Directed elimination High degree of effectivenessTheoretical advantage of more selective dietAvoidance of long-term use of medications Skin prick test with poor predictive valueAtopy patch testing not standardizedNeed for repeated EGD and biopsies to identify allergen Empiric elimination High degree of effectivenessAvoidance of long-term use of medications Need for repeated EGD and biopsy to identify allergenHigh degree of vigilance to avoid contamination Dilation High degree of effectivenessProlonged symptom response without medications Reports of esophageal laceration causing significant painReports of esophageal perforation and hospitalization