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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • In adults, a major symptom is recurrent dysphagia, often with food impaction; mean duration of symptoms before treatment is 4–6 years.

  • Esophageal biopsy shows dense eosinophilic infiltration (≥15 eosinophils per high-power field [HPF]).

  • Full diagnostic criteria are (1) clinical symptoms of esophageal dysfunction; (2) increased eosinophils in esophageal mucosal biopsies; (3) secondary causes of esophageal eosinophilia have been excluded; (4) lack of sustained response to high-dose proton pump inhibition treatment or normal pH monitoring of the distal esophagus; (5) response to treatment (elimination diet, topical glucocorticoids) supports the diagnosis.

GENERAL CONSIDERATIONS

Eosinophilic esophagitis is a chronic and increasingly recognized inflammatory disorder of the esophagitis characterized by abnormal infiltration of eosinophils of the esophageal mucosa, often resulting in dysphagia and food impaction. The disorder is being diagnosed with much greater frequency, and increased recognition, by virtue of increased endoscopic volume, alone may not be responsible for this trend. Studies have indicated that the incidence has increased more than fourfold in the last 5–10 years. More than 80% of patients diagnosed with eosinophilic esophagitis complain of dysphagia, and between 5% and 16% of patients undergoing endoscopic evaluation for dysphagia are found to have eosinophilic esophagitis. Further, more than 50% of patients presenting with frank food impaction are diagnosed with eosinophilic esophagitis. By contrast, in children and adolescents, gastroesophageal reflux disease (GERD) and esophageal reflux symptoms are as common as food impaction and dysphagia.

EPIDEMIOLOGY

Eosinophilic esophagitis occurs in both the pediatric age group and adults. About 70–75% of the patients are male, and the commonest age of presentation is in the 20s and 30s. In older series the mean age at diagnosis was 34 years. In addition, in the older literature, symptom duration prior to diagnosis averaged 4.5 years. For reasons that are not clear the disease is more common in Caucasians. The incidence appears to be increasing and this is not only due to increased recognition of the disorder as a consequence of increased endoscopic volume, but perhaps due to other factors as well. This is evidenced by a population-based study that documented incidence of eosinophilic esophagitis in Olmsted County, Minnesota, where the incidence was 9.5 per 100,000 patients per year, and the prevalence 55 patients per 100,000. Similar population-based studies in Switzerland have also concluded that the incidence of eosinophilic esophagitis is increasing and may actually be approaching that of inflammatory bowel disease.

PATHOGENESIS

The pathogenesis of eosinophilic esophagitis is incompletely defined. However, considerable evidence suggests that eosinophilic esophagitis is an allergic disorder induced by antigen sensitization either through foods and/or aeroallergens.

A majority of patients have evidence of food allergies and a concurrent history of respiratory allergies. A seasonal variation has been documented in the diagnosis of eosinophilic esophagitis that correlated with pollen counts. By contrast, food anaphylaxis is uncommon, occurring in ...

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