Adult Eosinophilic Esophagitis:
More Common and Treatable with Corticosteroids
The cause of eosinophilic esophagitis (EoE) in adults is largely unknown, but the leading hypothesis concerning its cause involves antigenic exposure to an airborne or food allergen that prompts a response in genetically predisposed individuals. The presentation of eosinophilic esophagitis ranges from solid-food dysphagia to food impaction, for which endoscopic dilation has been the primary treatment. However, endoscopy with dilation poses the potential complication of mucosal tears and perforation of the esophagus.
Eosinophilic esophagitis is not rare. It has an annual incidence similar to that of Crohn disease, which is 12.9/100,000 people in Olmsted County, Minn. Multiple studies have shown increased prevalence of EoE over the past decade. Whether this rise is due to increased diagnosis or to an actual increase in the number of cases is not clear. What is clear is that because of this rise, more primary care professionals are likely to encounter patients with EoE and need to be aware of improved diagnostic and treatment approaches.
In the past, adults presenting with solid-food dysphagia were examined for mechanical or anatomic reasons for obstruction, such as fibrotic strictures. If none was found, they either underwent empiric esophageal dilation or received no therapy at all. What was needed was a detailed pathologic description linked to clinical symptoms to inform diagnosis and treatment and limit the use of endoscopic dilation, with its inherent risks, to patients in whom medical therapy fails.
A New Approach
A consensus group of experts that included Mayo Clinic eosinophilic esophagitis specialists has provided new guidelines to support a diagnosis of EoE early, when it is most amenable to medical therapy. The guidelines are based on esophageal symptoms, assessment of eosinophil density of the esophageal mucosa and exclusion of gastroesophageal reflux disease (GERD). GERD requires different treatment than EoE.
Mayo Clinic specialists recommend performing esophageal biopsy on all patients with solid-food dysphagia. They also urge taking a patient history attentive to the presence of allergies, because up to 70 percent of adult EoE patients have a history of seasonal allergies, rhinitis, asthma, or allergic dermatitis. The Mayo Clinic Eosinophilic Esophagitis Interest Group has one of the largest EoE clinical practices in the United States. Mayo is a leader in EoE management, with specialists at all three Mayo Clinic sites.
Criteria That Support a Diagnosis of Adult Eosinophilic Esophagitis
The eosinophilic esophagitis consensus group to which Mayo Clinic belongs recently established three criteria that support a diagnosis of EoE:
- Presence of esophageal symptoms
In adult patients, this is primarily solid food dysphagia. Children may have various symptoms, including chest pain, vomiting, dysphagia and heartburn.
- Presence of 15 or more eosinophils/high-power field on esophageal biopsy
Eosinophils contribute to dysphagia by secreting compounds that make the esophageal lining sticky or by making the esophagus stiff and less effective in propelling food downward, thus disrupting the easy passage of food.
- Exclusion of GERD
Gastroesophageal reflux disease (GERD) has been associated with eosinophilic infiltrate in the esophagus and can be easily confused with EoE. GERD must be excluded with an ambulatory pH study of a high-dose proton pump inhibitor treatment trial to meet the consensus definition of EoE.
Mayo Clinic research has shown abnormal esophageal mucosa, such as corrugated or ringed esophagus, white plaques, or linear furrows, in 80 percent of EoE cases. The esophagus has a normal endoscopic appearance in 20 percent of cases that meet EoE histologic and clinical criteria. Abnormal findings support the EoE diagnosis but are not required for it.
Swallowed, aerosolized topical corticosteroid is the first-line medical therapy for adults with EoE. This approach, however, is an inefficient way to deliver topical corticosteroid to the esophagus. Mayo Clinic specialists use several successful alternatives to the traditional oral aerosol sprays.
One of these new approaches is a topical mucosal adherent that is squirted into the back of throat with a syringe and a gel-based corticosteroid therapy that can be swallowed to coat the inside of the esophagus. Data show swallowed topical corticosteroids provide symptom relief for 80 percent to 90 percent of EoE patients. EoE symptoms recur in 91 percent of adult patients within three years of stopping therapy, however, with an average time to recurrent symptoms of nine months. This high recurrence rate highlights the role of maintenance therapy in EoE.