Management Of Eosinophilic Esophagitis Research Articles

Current Management of Eosinophilic Esophagitis 2015.

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by esophageal dysfunction and eosinophilic infiltrate (≥15/hpf) in the esophageal epithelium and the absence of other potential causes of eosinophilia. The prevalence is increasing and is the most common cause of solid food dysphagia in children and young adults. This article will review the diagnosis and management of EoE based on consensus conferences, systematic reviews, and meta-analysis and highlights seminal studies in our evolving treatment of this disease. However, all answers are not available and I will remark about the lessons learned in my clinical practice seeing EoE patients over the last 25 years. The complicated etiology of the complaint of dysphagia in EoE patients will be reviewed. The importance of utilizing endoscopy, biopsies, and barium esophagram to help define the 2 phenotypes (inflammatory, fibrostenosis) of EoE will be highlighted. The controversy about PPI-responsive esophageal eosinophilia will be discussed and contrasted with idiopathic EoE. Finally, the 3 treatment options for EoE (drugs, diet, dilation) will be reviewed in detail and a useful clinical management algorithm presented.

Eosinophilic esophagitis: between reflux and allergy

Eosinophilic esophagitis (EoE) is a chronic/recurrent inflammatory disease of the esophagus characterized by the association between symptoms of esophageal dysfunction and a prominent eosinophilic infiltrate (>15/HPF) of the esophageal epithelium [1]. This condition mostly affects males and is increasingly being reported in all age groups, with a prevalence currently estimated at around 1:1000 in the Western world. Many experimental and clinical observations suggest that EoE is indeed an allergic condition with a strong genetic predisposition [2]. The natural history is unknown, but several studies suggest the potential progression of untreated disease, such as escalation of symptoms from feeding difficulties in infants to strictures and food impaction in teenagers [2,3]. This evolutionary pattern is somehow similar to that of gastroesophageal reflux disease (GERD), and could be related to a histological remodeling of the esophageal wall characterized by increasing fibrosis [1,2]. Furthermore, cow's milk protein allergy often causes GERD-like symptoms, and both GERD and cow's milk allergy cause an increase eosinophil count in the esophageal mucosa of infants. Topical steroids as well as elemental or selective exclusion diet have proven effective in inducing clinical and histologic remission in EoE, but the long-term management of EoE is not yet defined [3,4]. In most pediatric studies, the only mechanism of outgrowing EoE appears to be the long-term avoidance of sensitizing food(s) rather than spontaneous remission [3]. An alternative explanation is that there are different phenotypes of EoE, including a proton pump inhibitor (PPI)-sensitive variant for which long-term PPI therapy may be indicated [5].

Meta-Analysis-Based Guidance for Dietary Management in Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is a prevalent chronic esophageal disorder, triggered and maintained by immunologically mediated responses against dietary antigens. EoE represents the most recent form of food allergy, and its control by avoiding offending foods has increasingly appeared as a therapeutic alternative to achieve and maintain remission. Dietary therapies have proved equally effective in pediatric and adult EoE patients, among whom various types of interventions to eliminate or reduce food antigens exposure have been evaluated. A recent meta-analysis showed elemental diet as the most effective option to induce disease remission, but with a limited application in clinical practice. Inconsistency and wide variability in results from skin allergy testing-directed food restriction contributed to dissatisfaction with implementation of this option, which subsequently was displaced by empiric elimination of common food allergens. Such empiric elimination of common food allergens is now recognized as the best alternative for dietary treatment, with moderate-to-high efficiency and reproducible results. This review provides evidence-based insights into the dietary management of EoE.

PTH-182 Atopic history and ige levels – are they a useful adjunct in diagnosing eosinophilic oesophagitis? – a study of investigations and treatment response in the adult population of a district general hospital: Abstract PTH-182 Table 1

<h3>Introduction</h3> Eosinophilic Oesophagitis (EoE) is an increasingly common cause of dysphagia. Most reported series are from specialist centres. We present a series of adult patients with EoE from a typical UK district general hospital, describing their demographics, investigations and treatment response. We also highlight the role of Total IgE measurement in supporting the diagnosis. <h3>Method</h3> Patients were selected retrospectively by reviewing biopsies from endoscopies performed over a 4 year period (2009–2012). Diagnosis of EoE was confirmed by having oesophageal symptoms, 15 or more eosinophils per high powered field and absence of an alternative diagnosis. <h3>Results</h3> 73 cases were identified, 52 were male and 21 female. Average age at presentation was 51 years. Presenting symptoms included dysphagia (n = 58), bolus obstruction (n = 34) and reflux (n = 19). We estimate EoE is responsible for 3% of cases of dysphagia presenting to our hospital. 49 patients were asked about atopy history. 37 (76%) had a positive history for at least one condition; hay fever (n = 19), asthma (n = 18), eczema (n = 8), urticarial (n = 4) and/or dermatitis (n = 1). Total IgE was measured in 31/65 (48%) patients who had blood tests. 30 (97%) had either a strongly positive (n = 27) or positive (n = 3) total IgE reading, defined as total IgE &gt; 0.35 kU/L. Levels ranged from 5–520 kU/L. 23/31 (74%) of these cases had history of atopy. Food mix allergy testing was done in 29/73 with a positive result in 16. First line treatments prescribed were documented in 62 cases as shown: Those not responsive to combination therapy of PPI and swallowed steroid as first line agents had antihistamines, domperidone or cromoglycate added. <h3>Conclusion</h3> EoE is a common and treatable cause of dysphagia. This study supports that adult EoE patients have atopic coexistence, more often reported in paediatric studies. Total IgE measurement may be useful in supporting a diagnosis. Only 3 previous studies have reported total IgE levels in EoE patients. Food specific radioallergosorbent testing (RAST) may have a role in management of EoE with dietary exclusion a treatment option. This is well described in the paediatric population but less so in adults – only one adult study has described use of food specific RAST in adult EoE patients. Given the variability in treatment approach to EoE there is a clear need for guidelines to standardise the care of EoE. <h3>Disclosure of interest</h3> None Declared.

Distinguishing GERD from eosinophilic oesophagitis: concepts and controversies.

Over the past three decades, the detection of oesophageal mucosal eosinophils has transitioned from a biomarker of GERD to a diagnostic criterion for eosinophilic oesophagitis (EoE). In GERD, oesophageal eosinophils are considered part of the chronic inflammatory response to acid reflux, whereas the marked eosinophilia in EoE is viewed as a central feature of the immune response to ingested food and/or environmental antigen stimulation. Descriptions of a considerable subset of patients with symptomatic, endoscopic and histological findings of EoE that resolve with PPI therapy has led to confusion and controversy regarding the distinction of EoE from GERD. Study findings indicate that PPI-responsive oesophageal eosinophilia (PPI-REE) more closely resembles EoE than GERD, both from a clinical and immunological aspect. Although responsiveness to PPI therapy should not be utilized to exclude EoE, PPI therapy is effective at reducing oesophageal eosinophilia in ∼40% of patients, and PPI therapy is both a safe and practical initial step in the management of patients with oesophageal eosinophilia. Ongoing studies elucidating the mechanism behind PPI-REE will improve our understanding and management of EoE. In this Review, the mechanisms and evidence that underlie the controversy in the distinction between GERD and EoE are evaluated.

Treatment outcomes for eosinophilic esophagitis in children with esophageal atresia

Eosinophilic esophagitis (EoE) has been reported to be more prevalent in patients with esophageal atresia/tracheoesophageal fistula (EA-TEF). To date, there is limited data on the management of EoE in this group of patients. The aim of this study is to evaluate the treatment outcomes of EoE in children with EA-TEF. A retrospective chart review was performed on all EA-TEF children who were diagnosed with and treated for EoE between January 2000 and September 2013 at the Sydney Children's Hospital. Data collected included details of the patient's treatment, post-treatment endoscopy, symptoms and nutrition. Twenty patients were included in the study. Median age at diagnosis was 26 months (8-103 months), and median time from diagnosis to last follow-up was 23 months (2-132 months). Patients were treated with budesonide slurry, swallowed fluticasone, elimination diet alone or in combination. All patients were on proton pump inhibitors at time of diagnosis of EoE which was continued. Six out of seven patients who had furrowing/exudate in endoscopy at diagnosis had complete resolution at a median follow-up period of 26 months (P = 0.031). Median peak intraepithelial eosinophil count reduced significantly from 30/high-powered field (HPF) (19-80/HPF) to 8/HPF (0-85/HPF) (median time for improvement = 24 months) (P = 0.015). There was a significant reduction in symptoms of dysphagia and reflux post-treatment (P < 0.001). Prevalence of strictures significantly decreased (P = 0.016), as did need for dilatations (P = 0.004). In four out of six patients with gastrostomies at baseline, the feeding improved on treatment of EoE and the gastrostomy could be closed. There was also a nonsignificant trend towards improvement in weight and height 'z scores' of the patients. Treatment of EoE in children with EA-TEF was found to significantly reduce intraepithelial eosinophil count, symptoms, strictures and need for dilatations.

Utility of a Noninvasive Serum Biomarker Panel for Diagnosis and Monitoring of Eosinophilic Esophagitis: A Prospective Study.

Noninvasive biomarkers would be valuable for diagnosis and monitoring of eosinophilic esophagitis (EoE). The aim of this study was to determine the utility of a panel of serum biomarkers for the diagnosis and management of EoE. We conducted a prospective cohort study of consecutive adults undergoing outpatient esophagogastroduodenoscopy. Incident cases of EoE were diagnosed per consensus guidelines; controls had gastroesophageal reflux disease (GERD) or dysphagia and did not meet the EoE criteria. EoE cases were treated with topical steroids and had repeat endoscopy. Pre- and post-treatment serum samples were analyzed in a blinded manner for interleukin (IL)-4, IL-5, IL-6, IL-9, IL-13, transforming growth factor (TGF)-α, TGF-β, tumor necrosis factor-α, eotaxin-1, -2, and -3, thymic stromal lymphopoietin (TSLP), major basic protein, and eosinophil-derived neurotoxin. Cases and controls were compared at baseline, and pre- and post-treatment assays were compared in cases. A total of 61 incident EoE cases and 87 controls were enrolled; 51 EoE cases had post-treatment serum analyzed. There were no significant differences in any of the biomarkers between EoE cases and controls at baseline. IL-13 and eotaxin-3 for cases and controls were 85 ± 160 vs. 43 ± 161 pg/ml (P=0.12) and 41 ± 159 vs. 21 ± 73 (P=0.30). There were no significant differences in assay values among cases before and after treatment. There were also no differences after stratification by atopic status or treatment response. A panel of inflammatory factors known to be associated with EoE pathogenesis were not increased in the serum, nor were they responsive to therapy. None of these biomarkers are likely candidates for a serum test for EoE. Histologic analysis for diagnosis and management of EoE continues to be necessary, and novel, less invasive, biomarkers are needed.

Food Allergy and Eosinophilic Esophagitis: What Do We Do?

Eosinophilic esophagitis (EoE) is an inflammatory disease of the esophagus triggered by foods and possibly environmental allergens. Common conditions that mimic EoE include gastroesophageal reflux disease and proton pump inhibitor-responsive esophageal eosinophilia. These need to be excluded before confirming the diagnosis of EoE. Identification of food triggers for EoE using standard allergy tests remains challenging. Dietary therapy for EoE so far consists of test-directed elimination of foods, empiric elimination of common food allergens, or exclusive feeding of amino acid-based formulas, with variable success. No FDA-approved medications yet exist for EoE. Topical corticosteroids to the esophagus are being used. EoE is a chronic disease; therefore, long-term therapy seems to be necessary to avoid potential long-term complications such as esophageal remodeling and strictures. Optimal long-term therapies and follow-ups are still not established; therefore, discussion with patients and families regarding the choice of therapy is important to ensure the best possible outcomes from a medical and social standpoint. In this article, we discuss all the above issues in detail by using a hypothetical case; highlighting in a stepwise manner what is known with respect to diagnosis, work-up, and management of EoE; and discussing gaps in knowledge that need to be addressed in the future.

A review of the evidence linking eosinophilic esophagitis and food allergy.

Eosinophilic esophagitis (EoE) is a chronic inflammation of the esophagus that has been considered an allergic phenomenon based on its similarities to other allergic conditions. More specifically, EoE has been considered a form of food allergy because of patient sensitizations to foods and improvements in symptoms and inflammation after food eliminations. This article presents the currently available evidence regarding the classification of EoE as an allergic condition, the involvement of foods in disease pathogenesis, and the value of different types of allergy testing and elimination diets in management of EoE. Using the search engines PubMed and Ovid, English literature in the past 10 years was reviewed with the use of the following key words: eosinophilic esophagitis, EoE epidemiology, EoE pathophysiology, food allergy, eosinophils, skin-prick testing, atopy patch testing, elemental diet, test directed elimination diet, six food elimination diet. Studies of EoE epidemiology and pathophysiology support the link between EoE and allergy in general, and studies of food allergy testing and elimination diets have supported a link between EoE and food allergy. Although food elimination diets cause resolution of symptoms and pathology in pediatric EoE, the results of testing and diet elimination studies are not as clear in adults, and aeroallergen sensitizations may play a larger role in adult EoE pathophysiology. Although several studies in children and adults support considering EoE a form of food allergy, the usefulness of skin-prick testing and atopy patch testing for food allergies and the optimal elimination diet for disease management are still uncertain.

Recent advances in the recognition and management of eosinophilic esophagitis.

The incidence and recognition of eosinophilic esophagitis is increasing. Pathophysiological understanding of eosinophilic esophagitis is improving and an immunological reaction to ingested food is likely to play a significant role. Patients present with dysphagia and food bolus obstruction. Both histological and endoscopic criteria have been developed and validated. Dietary therapy, topical steroid therapy, proton pump inhibitors and endoscopic dilation are the main approaches to therapy; however, novel targeted therapies are being developed. Among the food items commonly implicated are wheat, dairy, nuts, soy, shellfish and eggs. A multidisciplinary approach to management in dedicated clinics may yield the best results.

Eosinophilic oesophagitis.

Eosinophilic oesophagitis (EoE) is an antigen-driven pan-oesophagitis that is defined by the presence of at least 15 eosinophils per high power field on oesophageal histology in conjunction with upper gastrointestinal symptoms. EoE is closely associated with atopic disorders, in particular with food allergy, and as for other atopic diseases in childhood, there is a strong preponderance of male patients who have this disorder. The mechanisms leading to EoE have been characterised at the molecular level. Eotaxin-3, interleukin-5 and interleukin-13 are the key effector molecules in EoE pathogenesis. EoE presents with a diverse range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or feeding refusal in infancy, as well as heartburn, dysphagia and food bolus impaction in older children and adults. The diagnosis may also be ascertained as an incidental finding in patients undergoing gastroscopy for other suspected conditions, including coeliac disease. EoE is different from gastro-oesophageal reflux disease and does not improve in response to proton pump inhibitors. Therefore, EoE needs to be distinguished from so-called PPI-responsive oesophageal eosinophilia. The long-term prognosis of EoE remains poorly defined, and complications mainly relate to subepithelial remodelling and fibrosis that may result in dysmotility, dysphagia and oesophageal strictures. The treatment of EoE involves elimination diets and topical swallowed aerosolised corticosteroids, while biological therapies targeting molecular mechanisms have so far been unsuccessful. In children, elemental diets have proved highly effective, but multiple food elimination diets are more sustainable in the long term. Further randomised, controlled trials on dietary or pharmacological interventions are needed to inform the optimal long-term management of EoE.

Underutilization of Esophageal Biopsies and Endoscopic Follow-up in Patient Populations at Higher Risk for Eosinophilic Esophagitis

Introduction: Despite advancements in the diagnosis and management of eosinophilic esophagitis (EoE), the variation in both clinical symptoms and the suggestive, yet not specific, endoscopic findings complicate the diagnostic process. Nonetheless, common presentations include dysphagia and food impaction, implying that these presentations warrant further consideration and work-up for EoE. To further evaluate the clinical utilization of esophageal biopsies in EoE diagnosis, this study sought to examine whether or not patients with dysphagia and concurrent stricture or food impaction are appropriately screened with esophageal biopsies. Methods: A retrospective chart review from 2001-2012 in a tertiary care, university-affiliated hospital. Included patients were referred for EGD for either food impaction or dysphagia with documented stricture. Esophageal biopsies at the time of index endoscopy, rate of esophageal biopsies on subsequent EGD, and the number of patients with follow-up EGDs were examined. Patients with esophageal malignancy, radiation history, or esophageal dysmotility disorders were excluded. Results: Of the 91 patients with food impaction, 13 (14%) were biopsied initially, while 54 (58%) did not have a follow-up EGD. Of the 85 stricture patients, 33 (39%) were biopsied initially and 29 (34%) were never biopsied on repeat EGD. EoE was diagnosed in 13 (14%) of the food impaction group and 17 (20%) of the stricture group, both considerably higher compared to general population prevalence estimates of 0.05-6.5%. Conclusion: These results emphasize the underutilization of esophageal biopsies in current practice by demonstrating sub-optimal screening and follow-up in at risk populations. The higher prevalence in this study reiterates the necessity of esophageal biopsies to aid accurate diagnosis and guide appropriate treatment. Without changes in the current use of biopsies, delays in diagnosis will likely persist, resulting in progression of disease. Although strides have been made, if we do not adequately capture the most at risk populations for EoE by implementing a standardized practice approach, we will continue to miss crucial opportunities to intervene.Figure 1: Use of biopsies on index and follow-up EGD in patients with food impaction.

A Case of Eosinophilic Esophagitis With Achalasia Requiring Myotomy

Introduction: Eosinophilic esophagitis (EoE) is a clinicopathological disorder defined by esophageal dysfunction and eosinophilic infiltration of the esophagus with more than 15 eosinophils per high power field (hpf) on microscopy after ruling out other causes of eosinophilia. Dysphagia is the most common symptom first described in a 1978 case report. Esophageal dysmotility on esophageal manometry has been described in EoE patients. Only one case report documented successful management of EoE with concomitant achalasia via Heller’s myotomy. Our patient demonstrates EoE in the presence achalasia with persistent symptoms despite medical management requiring Heller myotomy for symptomatic improvement. A 48-year-old female presented to clinic with difficult, painful swallowing and food regurgitation. She was diagnosed with EoE one year prior and treated with PPI followed by swallowed fluticasone, but did not achieve reduction in eosinophil count until she started a six food elimination diet. Despite histologic improvement, her symptoms persisted. She underwent upper endoscopy at our institution revealing a narrow-caliber esophagus that was subsequently dilated. Mucosal features were consistent with EoE. Biopsies showed up to 18 intraepithelial eosinophils per hpf from the proximal esophagus. She subsequently underwent high resolution esophageal manometry (EM) revealing achalasia. The esophagus exhibited failed peristalsis without relaxation of the lower esophageal sphincter (LES). The patient underwent laparoscopic Heller myotomy with Nissen fundoplication providing nearly complete resolution of symptoms. There are few reports of achalasia in the setting of EoE since the 1978 case. One case series reported most patients with EoE have abnormalities on EM. Only one patient had achalasia, which resolved with inhaled fluticasone. Another case series identified that 4 of 512 cases of achalasia had concomitant EoE. Two patients were treated for achalasia with Heller myotomy, but symptoms recurred. A recent study evaluating EoE with high resolution EM shows that esophageal body motility abnormalities, namely weak or failed peristalsis, are most common. It is unclear if our patient has type 1 or type 2 achalasia as stratified by the Chicago Classification since panesophageal pressurization may be seen in EoE alone. EoE with achalasia may be resistant to medical management and require myotomy for symptom improvement. EoE patients may benefit from early EM studies to identity concurrent esophageal motility abnormalities.

Accuracy, Safety, and Tolerability of Tissue Collection by Cytosponge vs Endoscopy for Evaluation of Eosinophilic Esophagitis

Management of eosinophilic esophagitis (EoE) requires repeated endoscopic collection of mucosal samples to assess disease activity and response to therapy. An easier and less expensive means of monitoring of EoE is required. We compared the accuracy, safety, and tolerability of sample collection via Cytosponge (an ingestible gelatin capsule comprising compressed mesh attached to a string) with those of endoscopy for assessment of EoE. Esophageal tissues were collected from 20 patients with EoE (all with dysphagia, 15 with stricture, 13 with active EoE) via Cytosponge and then by endoscopy. Number of eosinophils/high-power field and levels of eosinophil-derived neurotoxin were determined; hematoxylin-eosin staining was performed. We compared the adequacy, diagnostic accuracy, safety, and patient preference for sample collection via Cytosponge vs endoscopy procedures. All 20 samples collected by Cytosponge were adequate for analysis. By using a cutoff value of 15 eosinophils/high power field, analysis of samples collected by Cytosponge identified 11 of the 13 individuals with active EoE (83%); additional features such as abscesses were also identified. Numbers of eosinophils in samples collected by Cytosponge correlated with those in samples collected by endoscopy (r = 0.50, P = .025). Analysis of tissues collected by Cytosponge identified 4 of the 7 patients without active EoE (57% specificity), as well as 3 cases of active EoE not identified by analysis of endoscopy samples. Including information on level of eosinophil-derived neurotoxin did not increase the accuracy of diagnosis. No complications occurred during the Cytosponge procedure, which was preferred by all patients, compared with endoscopy. In a feasibility study, the Cytosponge is a safe and well-tolerated method for collecting near mucosal specimens. Analysis of numbers of eosinophils/high-power field identified patients with active EoE with 83% sensitivity. Larger studies are needed to establish the efficacy and safety of this method of esophageal tissue collection. ClinicalTrials.gov number: NCT01585103.

Recent advances in the pathophysiology and management of eosinophilic oesophagitis

Eosinophilic oesophagitis is an increasingly recognized allergic gastrointestinal disease, which is becoming more common. Although the average age at diagnosis is 30-50years, it often affects very young children and carries significant long-term morbidity. While our understanding of its pathophysiology is accumulating, the precise pathways by which the disease arises remain unclear. There are inconsistencies in its diagnosis and definition, and a drive towards international standardization is underway. Current methods for diagnosis and monitoring are relatively invasive, and controversies surround their interpretation. Management strategies are imperfect and involve burdensome long-term dietary exclusions, or drug treatments with uncertain efficacy or serious side-effects. It is the focus of a rapidly increasing body of research, the latest insights from which are systematically presented in this review.

Elimination diets in the management of eosinophilic esophagitis.

Eosinophilic esophagitis, an increasingly recognized chronic inflammatory disorder isolated to the esophagus, is triggered by an abnormal allergic response to dietary antigens. Current treatment includes swallowed topical steroids and dietary modification, which aim to resolve symptoms and prevent long-term complications such as formation of strictures. The dietary approach has become more widely accepted because long-term steroid therapy is associated with potential risks. Dietary treatment includes elemental and elimination diets. An exclusive elemental diet, which requires replacement of all intact protein with amino acid-based formula, offers the best response of all available therapies, with remission in up to 96% of subjects proving it to be superior to all other available therapies including topical steroids. However, compliance with this approach is challenging because of poor taste and monotony. The high cost of formula and the associated psychosocial problems are additional drawbacks of this approach. Empiric and allergy test-directed elimination diets have gained popularity given that elimination of a limited number of foods is much easier and as such is more readily acceptable. There is a growing body of literature supporting this type of therapy in both children and adults. This paper reviews the evidence for all types of dietary therapy in eosinophilic esophagitis.

Non-IgE Medicated Food Allergy: Eosinophilic Esophagitis Update on the Pathogenesis, Clinical Features, and Management of Eosinophilic Esophagitis in Children

Eosinophilic esophagitis (EoE) is a chronic allergic disorder of increasing worldwide prevalence. Diagnosis and management require upper gastrointestinal endoscopy with biopsy. Therapeutic strategies in children and adults include empiric and testing-based elimination diets as well as topical esophageal corticosteroids. The last 12 months have provided a number of insights including updated diagnostic/management guidelines, the role of PPI therapy, and an understanding that EoE disease mechanisms rely on basophils and mast cells in addition to eosinophils. Novel diagnostic techniques have been described and include the esophageal string test and a molecular gene array panel. In addition, new techniques for assessing esophageal rigidity have been reported. In this review, we summarize the most impactful findings in EoE over the last 12–15 months.

Dietary Management of Patients with Eosinophilic Esophagitis

Twenty years after it was first described, eosinophilic esophagitis (EoE) is now recognized as a prevalent disorder, representing the second most common cause of chronic esophagitis (after gastroesophageal reflux) and constituting the main cause of esophageal symptoms in young patients. In most cases the disease is triggered and maintained by exposure to food antigens, thus representing a novel form of food allergy. While topical steroids still constitute the prevailing therapeutic option, there is increased interest in dietary therapy as a treatment alternative capable of inducing and maintaining drug-free remission of the disease. First assessed in a pediatric series, more recent studies have demonstrated that dietary therapy is equally effective for adult sufferers of EoE. Indeed, various types of dietary interventions that either eliminate or reduce food antigens from the diet have been shown to induce remission of esophageal inflammation and its derived symptoms in a high proportion of patients. After remission has been achieved, food reintroduction is an essential part of the dietary management of EoE and should always be considered once esophageal biopsies are normal. Food reintroduction consists of a food allergy challenge that facilitates the identification of specific food triggers for the disease. This allows patients to follow as normal a diet as possible, thus improving the acceptance of and adherence to specific dietary restrictions.The dietary management of EoE is a challenging therapy that should be considered for every patient with the disease. Its major limitations arise from the necessity of repeated endoscopies with biopsies during the food reintroduction protocol, as well as from the absence of noninvasive subrogated markers of disease activity. For these reasons, the use of dietary therapy has been limited to highly motivated patients who are reluctant to utilize drug-based therapies on a chronic basis, as well as to highly motivated health-care providers.Ongoing research on less restrictive dietary options should facilitate the spread of dietary interventions, making this type of therapy more available for extended use.

Eosinophilic Esophagitis- Clinical Management in Adults

Eosinophilic esophagitis (EoE) represents a chronic, immune-mediated esophageal disease, characterized clinically by symptoms related to esophageal dysfunction, histologically by eosinophilic infiltration of esophageal mucosa and endoscopically by a range of abnormalities. EoE is increasing in prevalence and predominantly affects children and young males, with a racial predilection of the patients being Caucasian. The relationship between EoE and gastroesophageal reflux disease (GERD) can be complex, since their clinical and pathologic features may overlap. Furthermore, an entity that can be considered a subtype of GERD or EoE is the proton pump inhibitorresponsive esophageal eosinophilia (PPI-REE). PPI-REE emerged from the observation that some patients who appeared to have EoE would have a clinical and histologic response to PPI treatment. Currently, upper endoscopy with esophageal biopsies is the only way to diagnose EoE. Fifteen eosinophils//high-power field (hpf) are considered a minimum threshold for the diagnosis of EoE, since the disease is isolated to the esophagus and other causes of esophageal eosinophilia are excluded. Patients commonly have concurrent allergic diatheses, especially to food. The therapeutic options of EoE include: chronic elimination diet, topical corticosteroids and esophageal dilation. We review the latest approach to clinical diagnosis and management of EoE.

Emerging Therapeutic Strategies for Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is recognized as an increasingly common cause of chronic and recurrent esophageal symptoms that significantly impact quality of life and may occasionally result in severe complications in both pediatric and adult patients. The disease is triggered and maintained by exposure to food antigens in most patients, with an additional role proposed for airborne allergens. Different diet-based approaches focused on restricting potentially offending foods have proven to be effective long-term therapies for EoE. Dietary therapy is thus an attractive, yet challenging treatment option that should be considered for all pediatric and adult EoE patients. However, limitations related to food restriction, patient willingness to undergo repeated endoscopies and biopsies, and the variable results of allergy testing imply that dietary management is for the most part currently restricted to highly motivated healthcare providers treating highly motivated patients reluctant to utilize drug-based therapy on a chronic basis. Pharmacological therapies for EoE mainly comprise swallowed topical steroids, especially fluticasone propionate and budesonide, which were originally developed to treat bronchial asthma and are now extensively used "off label" in EoE patients. In fact, topical steroids currently constitute the prevailing therapeutic option and will probably continue to do so in the near future; indeed, several randomized clinical trials are currently underway to test these drugs for approval as the first pharmacological agents for EoE patients. Immunomodulators and several anti-allergic agents must be further assessed as therapeutic alternatives for refractory cases or patients with complications. Endoscopic dilation represents the third pillar in the therapeutic management of EoE patients, since they frequently present reductions in the esophageal caliber as a result of collagen deposition and a progressive fibrous remodeling process promoted by chronic eosinophilic infiltration. Dilation provides at least temporary symptom relief with similar complication rates to esophageal strictures from a different origin. However, although repeated endoscopic dilation has sometimes been used as the sole therapy for EoE, it best constitutes an adjuvant therapy along with dietary or pharmacological-based interventions, especially since dilation has no effect on the underlying esophageal inflammation. Current therapeutic management of EoE varies widely, with physician experience being a major explanatory factor. New evidence from ongoing research on EoE should thus seek to define a common treatment algorithm to optimize EoE patient management.