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Understanding Eosinophilic Esophagitis: Diagnosis, Features, and Management

Eosinophilic esophagitis (EE) is an allergic disease primarily affecting males under 30. Key symptoms include dysphagia, severe pain after dilation of strictures, and a history of allergies such as rhinitis and food allergies. Diagnosis relies on identifying eosinophils (>15/hpf) in the esophagus despite proton pump inhibitor treatment. Characteristic esophageal features include strictures and mucosal rings. Management may involve a combination of dietary elimination, acid suppression, and topical glucocorticoids, with most patients showing significant improvement.

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Understanding Eosinophilic Esophagitis: Diagnosis, Features, and Management

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  1. Welcome Applicants December 3, 2010 EE

  2. Eosinophilic esophagitis

  3. When to suspect • Boys or men < age 30 • Dysphagia • Allergic history • Unexplained esophageal perforation • Severe pain after dilitation of stricture

  4. AllergyHistory • Rhinoconjunctivitis (57%) • Wheezing (37%) • Food allergy (46%) • Family history of atopy (74%) Family History • Family history of atopy (74%)

  5. Clinical Features in Children • Mean age 9 • 2/3 male

  6. EosinophilicEsophagitis • Diagnosis • Large number of eosinophils in esophagus • >15/hpf • Despite acid suppression with PPI for 2 months • OR negative pH probe study • Presence of characteristic clinical features

  7. Esophageal morphology • Narrowing/ Proximal strictures • Multiple mucosal rings • Furrowing • Ulceration • Rigid “trachea like” • Whitish papules with granular exudates • Eosinophilic abscesses • Easily confused w candida

  8. Supportive histology • Eosinophil microabscesses • Proximal esophageal involvement • Surface layering of eosinophils • Basal layer hyperplasia

  9. Supportive labs • Peripheral eosinophilia 90% • Elevated IgE • ImmunoCAP70%

  10. Diagnostic Challenge • Recruitment of eosinophils in variety of diseases • Inflammatory bowel disease • Infections • Gastroesophagealreflux

  11. Distinguishing from GERD • >20 eosinophils/hpf • >15 eosinophils/hpf on 3 different sites

  12. Pathogenesis • Incompletely understood • Familial clustering • Environmental antigens in genetically predisposed individuals • In mice: • ? Respiratory allergens ?

  13. Treatment • Collaboration: Primary, GI, A/I • Acid suppression • Elimination diet • Topical glucocorticoids • Esophageal dilation • Reserved for significant strictures refractory to medical therapy

  14. Outcome • Most respond • ? Chronic course ?

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