The diagnosis of EoE is based on clinical presentation, histological findings, and the exclusion of other gastrointestinal diseases.3 The diagnosis of EoE should be considered in patients presenting with clinical symptoms of esophageal dysfunction, such as dysphagia, heartburn, chest pain, strictures, and food impactions, and an EGD should be considered to view the mucosa and collect multiple biopsies. In patients with EoE, these biopsies commonly will reveal eosinophilia with 15 or more eosinophils per high-power field (hpf).1,3 Patients with suspected EoE should be given a trial of high-dose PPIs for 8 to 12 weeks followed by repeat EGD. If the patient is still symptomatic and biopsies reveal more than 15 eosinophils per hpf, then a diagnosis of EoE can be established.3 If both symptoms and esophageal eosinophilia improve after the PPI trial, then other disorders such as GERD or PPI-responsive esophageal eosinophilia (PPI-REE) should be considered. Differentiating EoE From PPI-REE
Proton pump inhibitor-responsive esophageal eosinophilia is a relatively new disorder that is genetically and phenotypically indistinguishable from EoE.5,6 Although PPI-REE can be clinically and histologically identical to EoE, patients with PPI-REE can achieve complete remission after high dose-PPI therapy.3 Given the similarities between EoE and PPI-REE, it is important that all patients with suspected EoE be given a PPI trial to rule out PPI-REE. Patients with PPI-REE should continue PPI therapy, tapered down to the lowest possible dose depending on clinical symptoms.5 Follow-up endoscopy should be performed 1 year after diagnosis to ensure continued histological remission.5
and budesonide.6 Although they are not indicated for EoE, corticosteroids are useful in the resolution of EoE symptoms because of their ability to reduce inflammation in the esophagus and suppress eosinophil production.6 Corticosteroids can be prescribed in a liquid or nebulized form. Nebulized corticosteroids are puffed into the mouth and swallowed, not inhaled, to coat the entire esophagus. Educating patients about how to appropriately use these medications is vital to ensure therapeutic efficacy. It also is necessary to inform patients about the possible side effects of swallowed steroid therapy, such as dry mouth, local candida infections, adrenal axis suppression, glaucoma, and bone demineralization.6 Along with diet modification, this patient was prescribed a daily PPI for the management of EoE. Although PPIs are not considered first-line therapy, they may be prescribed for symptomatic treatment. These medications can help reduce acid production, providing relief from heartburn, regurgitation, and dysphagia.6 Although PPIs are helpful in the resolution of these symptoms, they are also effective in treating the underlying inflammatory process and can be used as monotherapy.4 In some cases, patients with EoE can suffer from esophageal strictures and food impactions. Esophageal dilation is used for the immediate relief of symptoms in these patients.1 Understanding when dilation should be performed is an important aspect of managing patients with EoE.8 ■ Karmen Elsen, MPA, PA-C, works in the Digestive Health Center at Augusta University in Augusta, Georgia. References 1. Merves J, Muir A, Chandramouleeswaran PM, Cianferoni A, Wang ML, Spergel
Referral for Allergy Testing in EoE
JM. Eosinophilic esophagitis. Ann Allergy Asthma Immunol. 2014;112(5):397-403.
Once a diagnosis of EoE has been established, patients should be referred to an allergist for testing and determination of food allergens.1 When food triggers are identified and removed from the diet, patients should experience an improvement of symptoms.1 Common diet modifications include the targeted elimination and empiric 6-food elimination diets.1 The targeted elimination diet uses skin patch testing to determine which foods need to be removed from the diet.The empiric 6-food elimination diet focuses on eliminating major food allergens, such as milk, eggs, wheat, soy, peanut and tree nuts, and all seafood, from the diet.7 Although both of these dietary modification strategies are very effective, it is important that providers ensure that patients adhere to the diet.The patient in this case was prescribed a targeted elimination diet but experienced a recurrence of symptoms due to nonadherence. For patients who are nonadherent or whose symptoms are not well controlled with diet alone, providers should consider initiating corticosteroid therapy, such as fluticasone
2. Park H. An overview of eosinophilic esophagitis. Gut Liver. 2014;8(6):590-597. 3. Kia L, Hirano I. Distinguishing GERD from eosinophilic oesophagitis: concepts and controversies. Nat Rev Gastroenterol Hepatol. 2015;12(7):379-386. 4. Dellon ES, Jensen ET, Martin CF, Shaheen NJ, Kappelman MD. Prevalence of eosinophilic esophagitis in the United States. Clin Gastroenterol Hepatol. 2014;12(4):589-596.e1. 5. Molina-Infante J, Rodriguez-Sanchez J, Martinek J, et al. Long-term loss of response in proton pump inhibitor-responsive esophageal eosinophilia is uncommon and influenced by CYP2C19 genotype and rhinoconjunctivitis. Am J Gastroenterol. 2015;110(11):1567-1575. 6. Furuta GT, Katzka DA. Eosinophilic esophagitis. N Engl J Med. 2015;373(17):1640-1648. 7. Greenhawt M, Aceves S. Non-IgE medicated food allergy: eosinophilic esophagitis update on the pathogenesis, clinical features, and management of eosinophilic esophagitis in children. Curr Pediatr Rep. 2014;2(2):127-134. 8. Al-Hussaini A. Savary dilation is safe and effective treatment for esophageal narrowing related to pediatric eosinophilic esophagitis. J Pediatr Gastroenterol Nutr. 2016;63(5):474-480.
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