Esophagitis, Eosinophilic

Key Features

• A disorder in which food or environmental antigens are thought to stimulate an eosinophilic inflammatory response in the esophagus

• Initially recognized in children, it is increasingly identified in young or middle-aged adults (estimated prevalence 43/100,000)

• A history of allergies or atopic conditions (asthma, eczema, hay fever) is present in over half of patients

Clinical Findings

• Most adults have a long history of dysphagia for solid-foods or an episode of food impaction

• Heartburn or chest pain may be present

• Differential diagnosis

  • Hypereosinophilic syndrome

  • Eosinophilic gastroenteritis

  • Achalasia

  • Connective tissue disorders

  • Drug hypersensitivity

  • Crohn disease

Diagnosis

• Skin testing for food allergies may be helpful to identify causative factors

• Patients may have eosinophilia or elevated IgE levels

• Barium swallow studies may demonstrate

  • A small-caliber esophagus

  • Focal or long, tapered strictures

  • Multiple concentric rings

• Endoscopy with esophageal biopsy and histologic evaluation is required to establish the diagnosis; findings include

  • Edema

  • Concentric rings ("trachealization")

  • Exudates (white plaques)

  • Furrows (vertical lines)

  • Strictures

• The esophagus is grossly normal in up to 5% of patients

• Multiple biopsies (4–8) from the proximal and distal esophagus should be obtained to demonstrate multiple (> 15/high-powered field) eosinophils in the mucosa

Treatment

• Options include proton pump inhibitors, topical corticosteroids, food elimination diets, and esophageal dilation

• First-line therapy for most adults is a proton pump inhibitor orally twice daily for 2 months followed by repeat endoscopy and mucosal biopsy

• Proton pump inhibitor therapy should be discontinued in patients with persistent symptoms and inflammation

• Topical corticosteroids lead to symptom resolution in 70% of adults

• Either budesonide in sucralose suspension, 1 mg, or powdered fluticasone, 880 mcg (from foil-lined inhaler diskus), is administered twice daily for 6–8 weeks with similar efficacy

• Symptomatic relapse is common after discontinuation of therapy and may require maintenance therapy at reduced doses of 0.25 mg twice daily

• Graduated dilation of strictures should be conducted in patients with dysphagia and strictures or narrow-caliber esophagus but should be performed cautiously because there is an increased risk of perforation and postprocedural chest pain