Eosinophilic Esophagitis: Review and Update

Abstract

Background: Eosinophilic esophagitis (EoE) was first described in the 1990s, showing an increasing incidence and prevalence since then, being the leading cause of food impaction and the major cause of dysphagia. Probably, in a few years, EoE may no longer be considered a rare disease.Methods: This article discusses new aspects of the pathogenesis, symptoms, diagnosis, and treatment of EoE according to the last published guidelines.Results: The epidemiological studies indicate a multifactorial origin for EoE, where environmental and genetic factors take part. EoE affects both children and adults and it is frequently associated with atopic disease and IgE-mediated food allergies. In patients undergoing oral immunotherapy for desensitization from IgE-mediated food allergy the risk of developing EoE is 2.72%. Barrier dysfunction and T-helper 2 inflammation is considered to be pathogenetically important factors. There are different patterns of clinical presentation varying with age and can be masked by adaptation habits. Besides, symptoms do not usually correlate with histologic disease activity. The diagnostic criteria for EoE has evolved but mainly requires symptoms of esophageal dysfunction with histologic evidence of a peak value of at least 15 eosinophils per high-power field. Endoscopies have to be repeated in order to diagnose, monitor, and treat EoE. Treatment of EoE can be started either by drugs (PPIs and topical corticosteroids) or elimination diets. The multistage step-up elimination diet management approach of EoE is promising. Endoscopic dilation is used for patients with severe dysphagia/food impaction with inadequate response to anti-inflammatory treatment.Conclusions: Research in recent years has contributed to a better understanding of EoE's pathogenesis, genetic background, natural history, allergy workup, standardization in assessment of disease activity, evaluation of minimally invasive diagnostic tools, and new therapeutic approaches. However, several unmet needs are to be solved urgently, as finding a non-invasive disease-monitoring methods and biomarkers for routine practice, the development or new therapies, novel food allergy testing to detect triggering foods, drug, and doses required for initial therapy and safety issues with long-term maintenance therapy, amongst others. Besides, multidisciplinary management units of EoE, involving gastroenterologists, pediatricians, allergists, pathologists, dietitians, and ENT specialists are needed.

Diffusion Mapping of Eosinophil‐Activation State

“…There is a real need for noninvasive methods of diagnosing these eosinophilic gastrointestinal disorders and for biomarkers for multiple eosinophilic diseases. As an example, eosinophilic esophagitis is a disease that has emerged in the past 30 years, is associated with food allergy, afflicts children and adults, and can be diagnosed only by symptoms and histology of esophageal biopsy . More nuanced phenotyping of peripheral blood eosinophil activation status might limit the need for invasive endoscopy for tissue sampling, especially in children.…”

“…(C) Histograms of side-scatter intensity for untreated control (black) and sample exposed to eotaxin for 5 h (red), r d = 0.47. [Color figure can be viewed at wileyonlinelibrary.com] with food allergy, afflicts children and adults, and can be diagnosed only by symptoms and histology of esophageal biopsy (41). More nuanced phenotyping of peripheral blood eosinophil activation status might limit the need for invasive endoscopy for tissue sampling, especially in children.…”

Eosinophilic esophagitis: an interdisciplinary clinical problem

“…Familial occurrence is fairly frequent (10% of cases) [14]. Many studies put an emphasis on the role of genetic disorders such as Single Nucleotide Polymorphisms (SNPs) in the eotaxin-3 gene on the chromosome 7q11, polymorphism of the transforming growth factor β1 (TGF-β1) gene on the chromosome 19q33, and the polymorphism of the TSLP gene on the chromosome 5q22 [11]. Avila-Castellano et al reported that a genetic variation in the Tolllike receptor 3 (TLR3) may be a major factor predisposing to EoE [15].…”

“…and "Do you cut the food into very small pieces?" [11]. These simple questions can be very helpful in the diagnostic process.…”

“…• clinical symptoms of oesophageal dysfunction, • an oesophageal biopsy showing inflammation with at least 15 eosinophils per high-power field with 400× magnification, and • eosinophilic inflammation limited to the esophagus [9,11,13,20]. The main examination for any patient with symptoms of EoE is esophagogastroduodenoscopy.…”