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| '''EoE contributes to or causes GERD'''
| | ==Lab== |
| *Various hypotheses have been proposed that EoE contributes to the development of GERD.
| | There are 3 main ways in which food allergies can be detected in EE. |
| *'''Mucosal barrier'''- Eosinophils secrete inflammatory mediators such as VIP (Vasoactive intestinal peptide), PAF (platelet-activating factor), IL-6 which damages the integrity of the mucosal barrier and the smooth muscles of the esophagus.
| | – Skin prick testing |
| *'''Peristalsis'''- VIP and PAF predisposes a patient to reflux by inducing relaxation of the LES, whereas the IL-6 affects the peristalsis and clearance of the acid, the alterations in oesophageal function contribute to increased acid exposure due to impaired clearance of refluxed contents
| | – Blood allergy testing (eg. RAST) |
| *'''Cytotoxic effect'''- Eosinophil cationic protein, Major basic protein, and Eosinophil peroxidase secreted by eosinophils have a direct cytotoxic effect on the mucosa, rendering the oesophageal epithelium more susceptible to caustic injury by refluxed gastric contents.
| | – Atopy patch testing |
| *'''Epithelial cells and Nerves'''- the above-mentioned events exposes the epithelial cells and nerves to further acid injury.
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| *'''Remodeling'''- fibrosis and increased thickness of the esophageal wall, eventually leads to an increase in esophageal mural stiffness causing esophageal remodeling.
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| ==Prognosis== | |
| *The prognosis of the EoE is as follows:<ref name="pmid23567357">{{cite journal |vauthors=Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA |title=ACG clinical guideline: Evidence-based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE) |journal=Am. J. Gastroenterol. |volume=108 |issue=5 |pages=679–92; quiz 693 |year=2013 |pmid=23567357 |doi=10.1038/ajg.2013.71 |url=}}</ref><ref name="pmid24703087">{{cite journal |vauthors=Lipka S, Keshishian J, Boyce HW, Estores D, Richter JE |title=The natural history of steroid-naïve eosinophilic esophagitis in adults treated with endoscopic dilation and proton pump inhibitor therapy over a mean duration of nearly 14 years |journal=Gastrointest. Endosc. |volume=80 |issue=4 |pages=592–8 |year=2014 |pmid=24703087 |doi=10.1016/j.gie.2014.02.012 |url=}}</ref><ref name="pmid26608127">{{cite journal |vauthors=Eluri S, Runge TM, Cotton CC, Burk CM, Wolf WA, Woosley JT, Shaheen NJ, Dellon ES |title=The extremely narrow-caliber esophagus is a treatment-resistant subphenotype of eosinophilic esophagitis |journal=Gastrointest. Endosc. |volume=83 |issue=6 |pages=1142–8 |year=2016 |pmid=26608127 |doi=10.1016/j.gie.2015.11.019 |url=}}</ref><ref name="pmid14724818">{{cite journal |vauthors=Straumann A, Spichtin HP, Grize L, Bucher KA, Beglinger C, Simon HU |title=Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years |journal=Gastroenterology |volume=125 |issue=6 |pages=1660–9 |year=2003 |pmid=14724818 |doi= |url=}}</ref><ref name="pmid19172120">{{cite journal |vauthors=Spergel JM, Brown-Whitehorn TF, Beausoleil JL, Franciosi J, Shuker M, Verma R, Liacouras CA |title=14 years of eosinophilic esophagitis: clinical features and prognosis |journal=J. Pediatr. Gastroenterol. Nutr. |volume=48 |issue=1 |pages=30–6 |year=2009 |pmid=19172120 |doi=10.1097/MPG.0b013e3181788282 |url=}}</ref>
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| *The long-term [[prognosis]] of the [[Eosinophilic esophagitis|EoE]] is unclear but patients [[Diagnose|diagnosed]] with [[Eosinophilic esophagitis|EoE]] have an unaffected [[lifespan]].
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| *Patients should be counseled that the disease is [[Chronic (medical)|chronic]].
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| *Patients who are untreated or have discontinued the treatment have progression of their symptoms.
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| *The [[EoE]] patients with a narrow [[esophageal]] [[lumen]] are more [[refractory]] to the [[corticosteroid]] treatment and require many [[esophageal]] [[Endoscopy|endoscopic]] [[Procedure|procedures]]..
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| *The [[dysphagia]] is common in patients with increased [[eosinophil]] count in the [[blood]].
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| *The [[Eosinophilic esophagitis|EoE]] is restricted only to the [[esophagus]] sparing the [[stomach]] and the [[duodenum]].
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| *[[Eosinophilic esophagitis|EoE]] does not progress into [[metaplasia]] or [[dysplasia]] or [[esophageal cancer]].
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| ==Endoscopy==
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| *Mucosal biopsies of the esophagus should be obtained in all patients in whom EoE is a clinical possibility regardless of the endoscopic appearance.
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| *Endoscopic abnormalities in patients with EoE are as follows:<ref name="urlTable 3: Proposed classification and grading system for the endoscopic assessment of the esophageal features of eosinophilic esophagitis (<a id=ref-link-section-1 title= href=/articles/#ref44">44</a>)">{{cite web |url=https://www.nature.com/articles/ajg201371/tables/3 |title=Table 3: Proposed classification and grading system for the endoscopic assessment of the esophageal features of eosinophilic esophagitis (<a id=ref-link-section-1 title="" href=/articles/#ref44>44</a>) |format= |work= |accessdate=}}</ref><ref name="urlVertical lines in distal esophageal mucosa (VLEM): a true endoscopic manifestation of esophagitis in children? - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/9199905?dopt=Abstract&holding=npg |title=Vertical lines in distal esophageal mucosa (VLEM): a true endoscopic manifestation of esophagitis in children? - PubMed - NCBI |format= |work= |accessdate=}}</ref><ref name="urlFragility of the esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis? - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/12612531?dopt=Abstract&holding=npg |title=Fragility of the esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis? - PubMed - NCBI |format= |work= |accessdate=}}</ref><ref name="urlEosinophilic esophagitis: red on microscopy, white on endoscopy. - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/15383737?dopt=Abstract&holding=npg |title=Eosinophilic esophagitis: red on microscopy, white on endoscopy. - PubMed - NCBI |format= |work= |accessdate=}}</ref><ref name="urlThe prevalence and diagnostic utility of endoscopic features of eosinophilic esophagitis: a meta-analysis. - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/22610003?dopt=Abstract&holding=npg |title=The prevalence and diagnostic utility of endoscopic features of eosinophilic esophagitis: a meta-analysis. - PubMed - NCBI |format= |work= |accessdate=}}</ref>
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| **Fixed esophageal ring which is corrugated
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| **White exudates or plaques
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| **Longitudinal furrows
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| **Mucosal pallor
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| **Diffuse esophageal narrowing
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| **Mucosal fragility leading to esophageal lacerations during the endoscopy
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| However, because these endoscopic features have been described in other esophageal disorders, none can be considered pathognomonic for EoE.
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| <references />
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| ==Complications== | | ==Complications== |
Lab
There are 3 main ways in which food allergies can be detected in EE.
– Skin prick testing
– Blood allergy testing (eg. RAST)
– Atopy patch testing
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