Eosinophilic oesophagitis

Oesinophilic oesophagitis is an immune-allergic pathology of multifactorial aetiology (genetic and environmental) that affects both paediatric and adult patients

• epidemiological studies indicate a multifactorial origin for, where environmental and genetic factors take part
  • current prevalence estimates in North America and Europe range from 1 to 6 per 10,000 persons
    
    
  • in addition to gender (male predominance) and race (mainly a disease of Caucasian individuals), established risk factors include atopy and other allergic conditions (e.g., allergic rhinitis, elevated serum immunoglobulin E [IgE] to common aeroallergens, asthma, and atopic dermatitis)
    
    
  • affects both children and adults
    
    
  • diagnosis of coeliac disease also increases the risk of eosinophilic oesophagitis (5)
    
    
• symptoms, which include heartburn, regurgitation, and oesophageal stenosis (with dysphagia being more frequent in eosinophilic oesophagitis in young adults and children), are similar to those of gastrooesophageal reflux disease, causing delays in diagnosis and treatment
  
  

• endoscopic findings such as furrows, oesophageal mucosa trachealization, and whitish exudates may suggest its presence, this diagnosis should be confirmed histologically based on the presence of more than 15 eosinophils per high-power field and the exclusion of other causes of eosinophilia (parasitic infections, hypereosinophilic syndrome, inflammatory bowel disease, among others) for which treatment could be initiated
  • presence of the following diagnostic criteria is required for the diagnosis:
    • (a) symptoms of esophageal dysfunction; (b) eosinophilic esophageal inflammation,
    • with >15 eosinophils per high-power field (eos/hpf), affecting the esophagus alone;
    • and (c) excluding other causes of esophageal eosinophilia
      
      
• the 3 "D"s ("Drugs, Diet, and Dilation") are considered the fundamental components of treatment
  • the first 2 components, which involve the use of proton pump inhibitors, corticosteroids, immunosuppressants and empirical diets or guided food elimination based on allergy tests, are more useful in the initial phases, whereas endoscopic dilation is reserved for oesophageal strictures
    • primary drugs used in the treatment of eosinophilic oesophagitis are proton pump inhibitors (PPIs) (5)
      • reduce the secretion of gastric acid by inhibiting parietal cell H+-K+ATPases
      • reduce the expression of eotaxin-3, a Th-2 cytokine involved in inflammation
        • can also inhibit the expression and inflammatory functions of adhesion molecules, such as oxidative burst
      • optimal dose in adults is 20–40 mg of omeprazole or an equivalent twice per day for 8 weeks
  • NICE state (4):
    • budesonide as an orodispersible tablet (ODT) is recommended as an option for inducing remission of eosinophilic oesophagitis in adults

Reference:

• Carr S et al. Eosinophilic esophagitis. Allergy Asthma Clin Immunol. 2018; 14(Suppl 2): 58.
• Cavalli E et al. Eosinophilic esophagitis in children: doubts and future perspectives. J Transl Med. 2019; 17: 262.
• Lucendo AJ et al. Guidelines on eosinophilic esophagitis: evidencebased statements and recommendations for diagnosis and management in children and adults. United Eur Gastroenterol J. (2017) 5:335-58.
• NICE (June 2021). Budesonide orodispersible tablet for inducing remission of eosinophilic oesophagitis
• Wąsik J, Małecka-Wojciesko E. Eosinophilic Esophagitis-What Do We Know So Far? J Clin Med. 2023 Mar 14;12(6):2259.