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Dilation

• Dilation is considered safe and effective in relieving the dysphagia in patients with Eosinophilic esophagitis.
• Esophageal dilation has a very good acceptance in patients and it does not influence eosinophilic inflammation.
• Patients with esophageal strictures can be treated by esophageal dilation.
• Esophageal dilation is contraindicated in patients with endoscopic signs of acute inflammation.
• Postprocedural pain is very common with esophageal dilation.
• The use of swallowed topical steroids before dilation reduces the risk of endoscopic complications such as bleeding, perforation, and postprocedural pain.
• Delaying the procedure in patients with strictures can lead to acute food bolus impactions.
• Food impactions should be should be dealt carefully as they can cause spontaneous esophageal perforation, procedure-induced complications.

Lab

There are 3 main ways in which food allergies can be detected in EE are as follows

Skin prick testing

• A small amount of allergen is introduced into the skin of the patient through a gentle puncture with a prick device.

• The allergens that are used for this purpose are either from a laboratory manufacture or freshly prepared by the doctor before the test.

• Allergy skin testing provides the allergist with specific information on what you are and are not allergic to.

• Patients who are sensitive to the allergen have an allergic antibody called Immunoglobulin E (IgE), which causes type-1 hypersensitivity reaction and cause an area of redness and swelling around the prick

• It takes about 15 minutes for you to see what happens from the test. However, these tests may have limited use in identifying foods causing or driving EoE.

Blood allergy testing

• Serum specific immune assay can be done for the allergen testing especially in patients with food allergies.

• Although there are many limitations for the prick testing and the blood testing for the allergy in patients with EoE, prick testing is considered more efficient than the blood testing in EoE.

Atopy patch testing

• Atopy patch testing is another way of identifying the allergies in patients with EoE.
• This more useful in pediatric population than in the adults.
• Patch testing used to identify patients with delayed reactions to a food.
• Procedure:
  • A small amount of a fresh food in a small aluminum chamber called a Finn chamber.
  • The Finn chamber is then taped on the person’s back.
  • The food in the chamber stays in contact with the skin for 48 hours.
  • It is then removed and the allergist reads the results at 72 hours.
  • A positive delayed reaction to the food is determined by the inflamed area of the skin around the Finn chamber.
• The results from the food patch test helps the physician to determine which foods can be avoided
• All the above mentioned tests can have false positive tests, it is also possible to have a false negative test, meaning that the prick, blood or patch tests are negative yet the allergen can contribute towards a patient’s 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