Eosinophilic Esophagitis

Background

Association with atopy (asthma, allergies, eczema, rhinitis)
Symptoms: Dysphagia (most commonly to solid foods), food impaction, central chest pain, GERD/refractory heartburn, upper abdominal pain
Clinical presentation may vary based on age:
- Children < 4 years often have feeding concerns and growth issues
- Children 4-11 years often have frequent regurgitation, abdominal pain, and vomiting
- Adolescents & adults may present with food impactions, dysphagia, and chest pain

Diagnostic criteria
- Symptoms related to esophageal dysfunction
- EGD with >15 eos/hpf on biopsy
- Exclusion of other causes for esophageal eosinophilia
50-60% pts will have elevated serum IgE lvl; peripheral eosinophilia can be seen but is generally mild

Management depends on patient’s preference
Elimination diet: 1FED (animal milk; most common), 2FED (milk and wheat), 6FED (milk, egg, wheat, soy, fish and nut)
High-dose PPI for 8 weeks ± elimination diet. Use lowest PPI dose that maintains symptom remission
Alternative treatment is oral budesonide suspension 2mg twice daily x12 weeks or fluticasone propionate (18+ yo: >220 mcg/spray, four sprays daily in divided doses; 12- 17yo: 220mcg/spray, eight sprays daily in divided doses; 1-11yo: 110 mcg/spray, eight sprays daily in divided doses)
After the above trials, repeat EGD in 8-12 weeks to assess response. If on stricter elimination diets than 1FED, can reintroduce food groups and repeat assessment. If treatment ineffective at inducing remission, modulate dose or switch modality.
May require intermittent dilation of strictures to relieve dysphagia
Evaluation by an allergist is recommended given strong association with allergies
Dupilumab and Eohilia are alternative treatment options and are the only FDAapproved agents for EoE