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For further information, see CMDT Part 15-19: Benign Esophageal Lesions

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

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