Summary Background Limited data describe the long-term efficacy of dietary elimination in eosinophilic oesophagitis (EoE). Aim We assessed the long-term outcomes of food elimination diets (FED) for treatment of adults with EoE. Methods We conducted a retrospective cohort study at our center analyzing all EoE patients receiving a FED without concomitant steroids. Baseline data were abstracted using standardized collection forms. Follow-up data from a mean 24.9-month period were collected for patients with a histologic response to a FED during and after food reintroduction. The main outcomes were symptomatic, endoscopic, and histologic responses. Results Of 52 patients, 18 received 6FED, 32 received targeted diet, and 2 received 6FED with targeted elimination. There were 21 (40%) patients with an initial histologic response. Responders reported less dysphagia after treatment (95% baseline vs. 11%; p = 0.001) and at the end of follow-up (95% baseline vs. 33%; p =0.008). Significant and durable endoscopic improvements were recorded at the same time points: Endoscopic reference score: 3.2 vs. 0.7; p = 0.001; and 3.2 vs. 1.7; p = 0.06. Histologic findings improved after the most restrictive diet in responders (49.8 vs. 4.1 eos/hpf; p = 0.001) and remained suppressed in the 10 initial responders maintaining compliance at the end of follow-up (5.2 eos/hpf). Conclusions Among EoE patients responding to a FED and remaining adherent, maintenance dietary therapy produced durable long-term symptomatic, endoscopic, and histologic disease control. These long-term data confirm that a FED is an effective maintenance treatment option in select adults with EoE.

Previous studies have suggested that eosinophilic esophagitis (EoE) progresses from chronic inflammation to fibrostenosis. However, natural history data illustrating this progression in individual patients are lacking. Here, we present 6 patients who progressed from an inflammatory to a fibrostenotic phenotype of EoE in the absence of treatment. At the time of diagnosis, none of the patients had significant evidence of fibrostenosis, but they did have other inflammatory findings of EoE such as edema, linear furrows, or exudates. After being lost to follow-up and treatment for an average of 7.8 ± 2.0 years, strictures (n = 5; 83%) or a small-caliber esophagus (n = 4; 67%) were present in a majority of the patients, and the majority required esophageal dilation. These cases confirm that EoE can progress from an inflammation-only phenotype to a fibrostenotic phenotype in certain patients.

SUMMARY Early life exposures have been associated with pediatric eosinophilic esophagitis (EoE), but it is unknown if a similar association is present in adults. We aimed to assess the association between early life risk factors and development of EoE in adulthood. To do this, we conducted a case–control study which was nested within a prospective cohort study of adults undergoing outpatient endoscopy. Cases of EoE were diagnosed per consensus guidelines; controls did not meet these criteria. Subjects and their mothers were contacted to collect information on four key early life exposures: antibiotics taken during the first year of life, Cesarean delivery, preterm delivery (≤37 weeks’ gestation), and neonatal intensive care unit (NICU) admission. We calculated the odds of EoE given in each exposure and assessed agreement between subjects and their mothers. For the 40 cases and 40 controls enrolled, we observed a positive association between each of the early life exposures and development of EoE (antibiotics in infancy, OR = 4.64, 95% CI = 1.63–13.2; Cesarean delivery, OR = 3.08, 95% CI = 0.75–12.6; preterm delivery, OR = 2.92, 95% CI = 0.71–12.0; NICU admission, OR = 4.00, 95% CI = 1.01–15.9). Results were unchanged after adjusting for potential confounders, though only early antibiotic use had CIs that did not cross 1.0. Moderate to strong agreement was observed between 54 subject–mother pairs (antibiotics, K = 0.44, P = 0.02; Cesarean delivery, K = 1.0, P < 0.001; preterm delivery, K = 0.80, P < 0.001; NICU, K = 0.76, P < 0.001). In sum, antibiotics in infancy was significantly associated with increased risk of EoE diagnosed in adulthood, while positive trends were seen with other early life factors such as Cesarean delivery, preterm delivery, and NICU admission. This may indicate persistent effects of early life exposures and merits additional study into conserved pathogenic mechanisms.

There are few data exploring modifiable risk factors for eosinophilic esophagitis (EoE). We aimed to determine if smoking, alcohol consumption, and nonsteroidal anti-inflammatory drug (NSAID) use were risk factors for EoE, and to assess their impact on EoE phenotypes and treatment outcomes. We performed a case-control study analyzing data collected from a prospective cohort of adults undergoing upper endoscopy for symptoms of esophageal dysfunction. Incident EoE cases were diagnosed via consensus guidelines. Exposure data were collected via standardized patient questionnaire. Follow-up assessments for cases were made after treatment, with histologic response defined as <15 eosinophils per high-power field (eos/hpf). Exposures were compared between EoE cases and controls, among EoE cases with and without fibrostenosis, and among EoE responders and nonresponders. A total of 115 cases and 225 controls were analyzed. Cases were less likely to have ever smoked cigarettes (23% vs. 47%, P < 0.001) or currently use NSAIDs (17% vs. 40%, P < 0.001) compared to controls. These relations persisted after multivariate analysis. Although alcohol use was more common among cases (75% vs. 51%, P < 0.001), the effect was abrogated after multivariate analysis. Smoking, alcohol, and NSAID use were not associated with the fibrostenotic phenotype. There was a trend toward improved histologic response among EoE patients concomitantly using NSAIDs (87% vs. 63%, P = 0.08; aOR 6.97 (95% CI: 0.81-60.3). In conclusion, NSAID and smoking were inversely associated with EoE compared to endoscopy-based controls. Alcohol use was more prevalent in the EoE cases, although not an independent risk factor. Concomitant NSAID use may improve treatment response and is worthy of future study.

Aim Because no approved medications exist for eosinophilic esophagitis (EoE), patients must use off-label drugs or create their own formulations. We assessed the efficacy of a standardized compounded budesonide suspension for treatment of EoE. Materials and methods We conducted a retrospective cohort study of EoE patients at the University of North Carolina treated with compounded budesonide dispensed by a specialty compounding pharmacy. Outcomes (symptomatic global response [yes/no], endoscopic response [% with individual findings], and histologic response [absolute eosinophil count; % with <15 eos/hpf])were assessed after the initial and last treatment in our system. Results We identified 48 patients treated with compounded budesonide (mean age 33.6; 69% male; 96% white; 2.4 mg mean initial dose). After a mean length of follow-up of 17.0 months (range: 4.2 - 56.3), there was a significant decrease in symptoms of dysphagia (95% vs. 32%, p < 0.001), improvements in heartburn (37% vs. 11%, p=0.06) and global symptom response (81%). The median of the peak eosinophil counts decreased from 55 to 20 eos/hpf (p<0.001) with 42% achieving a response of <15 eos/hpf. Esophageal candidiasis was rare (6%). In the 18 patients with prior non-response to corticosteroids or dietary elimination, 83% had symptomatic and 38% had histologic response. Conclusion Compounded budesonide suspension produced a durable symptomatic, endoscopic, and histologic response in a cohort followed for more than a year. Many patients previously refractory to prior therapy responded to compounded budesonide. This formulation can be used clinically until there are approved drugs with esophageal formulations for EoE.