Eosinophilic Esophagitis (EE) in Adults: Emerging Entity or Misdiagnosed Malady

Abstract

EE has been increasingly recognized as an important cause of dysphagia and food impaction in adults. Endoscopic therapy of food impactions and strictures in EE has been associated with esophageal tears and perforation. Our goal was to review demographic and endoscopic findings of our cohort of 74 adult patients (pts) to better understand the clinical course of this illness. Methods: We conducted a chart review of pts seen between 1999 and 2004 with a diagnosis of EE based on at least 15 eosinophils per high powered field. Demographic, endoscopic and histologic data were collected. Results: 74 pts were included in this analysis, the largest adult series studied to date. The mean pt age was 38 yrs (14-76) with a mean duration of symptoms of 6.9 yrs (.5-20). 57 pts (76%) were male. The most common presenting symptoms were dysphagia (90%), food impaction (55%) and heartburn (31%). 53% of pts had been to the emergency room with food impactions requiring endoscopic removal. 43% of pts had previous endoscopies an average of 5 yrs (.5-23) prior to their diagnosis of EE. The most common initial diagnosis in this group were Schatzki's rings (SR) (37%), esophageal strictures/webs (26%), reflux (22%), peptic strictures (11%) and congenital esophageal stenosis (4%). 88% of cases were diagnosed with EE after 2003. 20% of pts had bx initially read as GERD and subsequently changed to EE on repeat histologic review. 70% of pts had an allergic history; 77% having seasonal allergies, 17% having combined seasonal and food and 7% with allergic skin conditions. Of pts with a complete blood count, only 9% had a peripheral eosinophilia. The most common endoscopic findings were mucosal rings (81%) and linear furrows (74%) followed by strictures (31%), exudates (15%), small caliber (10%) and edema (8%). Incidental findings of hiatal hernia, SR and esophagitis were seen in 45%, 16% and 16% respectively. 50% of pts were treated with dilation using CRE balloon (70%), Savory (16%) and a combination of methods (8%). Conclusions: (1) 43% of pts had endoscopies for dysphagia with diagnoses other than EE an average of 5 years prior, likely representing misdiagnoses. (2) The majority of pts were diagnosed after 2003 suggesting increased recognition by gastroenterologists and pathologists. (3) Better recognition of EE should allow earlier medical treatment that may reduce the need, and thereby prevent complications associated with endoscopic procedures for EE. EE has been increasingly recognized as an important cause of dysphagia and food impaction in adults. Endoscopic therapy of food impactions and strictures in EE has been associated with esophageal tears and perforation. Our goal was to review demographic and endoscopic findings of our cohort of 74 adult patients (pts) to better understand the clinical course of this illness. Methods: We conducted a chart review of pts seen between 1999 and 2004 with a diagnosis of EE based on at least 15 eosinophils per high powered field. Demographic, endoscopic and histologic data were collected. Results: 74 pts were included in this analysis, the largest adult series studied to date. The mean pt age was 38 yrs (14-76) with a mean duration of symptoms of 6.9 yrs (.5-20). 57 pts (76%) were male. The most common presenting symptoms were dysphagia (90%), food impaction (55%) and heartburn (31%). 53% of pts had been to the emergency room with food impactions requiring endoscopic removal. 43% of pts had previous endoscopies an average of 5 yrs (.5-23) prior to their diagnosis of EE. The most common initial diagnosis in this group were Schatzki's rings (SR) (37%), esophageal strictures/webs (26%), reflux (22%), peptic strictures (11%) and congenital esophageal stenosis (4%). 88% of cases were diagnosed with EE after 2003. 20% of pts had bx initially read as GERD and subsequently changed to EE on repeat histologic review. 70% of pts had an allergic history; 77% having seasonal allergies, 17% having combined seasonal and food and 7% with allergic skin conditions. Of pts with a complete blood count, only 9% had a peripheral eosinophilia. The most common endoscopic findings were mucosal rings (81%) and linear furrows (74%) followed by strictures (31%), exudates (15%), small caliber (10%) and edema (8%). Incidental findings of hiatal hernia, SR and esophagitis were seen in 45%, 16% and 16% respectively. 50% of pts were treated with dilation using CRE balloon (70%), Savory (16%) and a combination of methods (8%). Conclusions: (1) 43% of pts had endoscopies for dysphagia with diagnoses other than EE an average of 5 years prior, likely representing misdiagnoses. (2) The majority of pts were diagnosed after 2003 suggesting increased recognition by gastroenterologists and pathologists. (3) Better recognition of EE should allow earlier medical treatment that may reduce the need, and thereby prevent complications associated with endoscopic procedures for EE.