Overlap of reflux and eosinophilic esophagitis in two patients requiring different therapies: A review of the literature

Abstract

Eosinophilic esophagitis (EE) and gastroesophageal reflux disease (GERD) have overlapping clinical, manometric, endoscopic and histopathologic features. The diagnosis of EE is nowadays based upon the presence of 15 or more eosinophils per high power field (eo/HPF) in esophageal biopsies. We report the cases of two young males suffering from dysphagia and recurrent food impaction with reflux esophagitis and more than 20 eo/HPF in upper-mid esophagus biopsies, both of which became asymptomatic on proton pump inhibitor (PPI) therapy. The first patient also achieved a histologic response, while EE remained in the other patient after effective PPI treatment, as shown by 24-h esophageal pH monitoring. Topical steroid therapy combined with PPI led to complete remission in this latter patient. GERD and EE may be undistinguishable, even by histology, so diagnosis of EE should only be established after a careful correlation of clinical, endoscopic and pathologic data obtained under vigorous acid suppression. These diagnostic difficulties are maximal when both diseases overlap. Limited data are available about this topic, and the interaction between EE and GERD is a matter of debate. In this setting, upper-mid esophagus step biopsies and esophageal pH monitoring of patients on PPI therapy are pivotal to evaluate the role of each disease. A PPI trial is mandatory in patients with a histopathologic diagnosis of EE; in those unresponsive to PPI treatment, EE should be suggested. However, a clinical response to PPI may not rule out quiescent EE, as shown in this report.

A Japanese case series of 12 patients with esophageal eosinophilia

“…Thus, based on our results, typical EoE, as strictly defined by unresponsiveness to PPI, may be rare in Japan, even among those who exhibit both typical endoscopic findings and histologically confirmed esophageal eosinophilia. However, recently, a substantial overlap of EoE and GERD has been documented in adult patients, and in a subset of these patients acid suppressive therapy with a PPI leads to symptom relief with endoscopic and histological resolution [11][12][13][14][15][16]. A mechanistic explanation for the therapeutic effect of PPIs is that the permeability of exogenous allergens to the esophageal wall is attenuated by the curing of the mucosal injury with acid suppression [22].…”

“…However, a substantial overlap of EoE and gastroesophageal reflux disease (GERD) has been documented recently [11,12]. In addition, it has been shown that acid suppressive therapy with PPIs leads to symptom relief with endoscopic and histological resolution in some patients [13][14][15][16]. Consequently, in the clinical setting, there is a possibility that EoE is confused with GERD or given a diagnosis of refractory GERD in patients who are unresponsive to PPI treatment [10].…”

Eosinophilic esophagitis: manometric and pHmetric findings

“…However, in a high percentage adult patients with eosinophilic infiltration in the esophagus present coexisting GERD (16) . This ratifies that the partial response to PPI does not exclude EoE diagnosis, and that pH monitoring and esophageal manometry should be performed in patients with atypical symptoms or when there is no diagnostic definition.…”

“…So, GERD and EoE coexist but are unrelated (16,23) . Correlation between pH monitoring and manometry findings There was no correlation between manometry and pH monitoring findings.…”

Eosinofilia esofágica em pacientes com anafilaxia à proteína do leite de vaca

“…A relação entre DRGE e EoE não está bem clara e sabe-se que as duas patologias podem coexistir ou contribuir para o aparecimento da outra (34).…”