For individuals with severe dysphagia, strictures, and narrow-caliber esophagus, endoscopic dilation should be performed (Table 2).2 Esophageal dilation is either done by guidewire or balloon technique.3 It is important to be cautious with esophageal dilation; patients with EoE are at increased risk for esophageal tearing and perforation.2,3 In spite of the risks, esophageal dilation has shown immediate symptomatic improvement in an estimated 83% of patients with EoE.3 It has been reported that recurring symptoms after esophageal dilation can be found in only 20% of patients with EoE.3

TABLE 2. Managing eosinophilic esophagitis


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Medication
  • Swallowed aerosolized corticosteroids
  • PPIs
  • Systemic steroids
Dietary
  • Targeted elimination diets
  • Elemental diets
Procedures Endoscopic dilation

PPI therapy in patients with EoE is poorly understood but is thought to have an anti-inflammatory mechanism that acts directly on cytokines involved in the recruitment of eosinophils.10 Some experts believe that PPIs may help heal disrupted epithelial barriers and therefore decrease immune activation.10 In addition, PPI therapy has been shown to block the release of eotaxin-3, which plays a critical role in the development of EoE.10

Disease outlook and the primary care provider


The role of the primary care provider (PCP) in the successful treatment of EoE cannot be overemphasized (Table 3). It is imperative to recognize and manage EoE symptoms early, and it is the responsibility of the PCP to identify patients with EoE, refer patients to specialists, and aid in long-term medication management. If a patient presents with persistent esophageal dysfunction and acid blockade is ineffective at relieving symptoms, referral to a gastroenterologist is appropriate.4 Once an esophageal biopsy is analyzed, patients newly diagnosed with EoE should be referred to an allergy/immunology specialist for further antigenic investigation.4

TABLE 3. Role of the primary care provider

Recognition of disease
Referral to specialist
Patient education
Emphasizing importance of compliance for symptom resolution
Medication management

The long-term outcome of EoE is still unclear; symptoms frequently subside and then recur when treatment is stopped.9 Some evidence in adults suggests that EoE may progress to a fibrostenotic stage if it is not controlled. Many other chronic immune-mediated inflammatory diseases of the gastrointestinal tract harbor an increased risk of malignant development as a result of recurrent injury and regeneration. Thus, a chronic immune-mediated inflammatory disorder such as EoE could increase the risk of developing esophageal cancer.11 Furthermore, patients with chronic eosinophilic disorders may be at risk for lymphoproliferative disorders as a result of abnormal T-cell clones.11 With the development of strictures, rings, furrows, and fibrostenosis in EoE, the risk of esophageal neoplasia is a real concern.9

Since 1989, data on patients in Switzerland with a clinically, histologically, and endoscopically confirmed diagnosis of eosinophilic esophagitis have been collected in a registry.12 Straumann et al took that population and winnowed the subject pool by requiring all patients to have a history of acute and recurrent dysphagia, consistent endoscopic abnormalities, and eosinophil infiltration of the esophagus (>24 eos/400 hpf). The researchers also controlled for GERD by excluding patients who had an abnormal 24-hour pH probe-monitoring test. The patients who were identified participated in a surveillance study for a mean of 7.2 years. 


Under histological and endoscopic evaluation, the researchers found no malignant tumors, dysplasias, or cells in the esophagus. Flow cytometric analysis was completed on peripheral lymphocytes, with no signs of abnormal T-cell clones or mature lymphoproliferative diseases.11

Based on the research of Straumann et al, the risk of developing malignancies from EoE is low. There is no known literature that has reported a case of esophageal malignancy as a result of EoE.11 It appears that having EoE does not influence the risk of developing esophageal cancer. 


To ensure the successful management of EoE, it is essential that the patient understand his or her newly diagnosed condition. It is the PCP’s role to educate and emphasize the importance of patient compliance with long-term treatment to achieve symptom resolution.

Matthew I. Giddens, MPH, PA-S, is a student at Georgia Regents University, and Kathy H. Dexter, MLS, MHA, MPA, PA-C, is an associate professor at Georgia Regents University in Augusta, Ga.



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References


  1. Roman S, Savarino E, Savarino V, Mion F. Eosinophilic oesophagitis: from physiopathology to treatment. Dig Liver Dis. 2013;45:871-878.

  2. McQuaid KR. Gastrointestinal disorders: eosinophilic esophagitis. In Papadakis MA, ed. Current Medical Diagnosis & Treatment. San Francisco, CA: McGraw-Hill Education; 2014:581-582.

  3. Nonevski IT, Downs-Kelly E, Falk GW. Eosinophilic esophagitis: an increasingly recognized cause of dysphagia, food impaction, and refractory heartburn. Cleve Clin J Med. 2008;75:623-633. 

  4. Nationwide Children’s Hospital. Eosinophilic esophagitis in children. Columbus, OH: Nationwide Children’s Hospital; 2014.

  5. Jenson ET, Hoffman K, Shaheen NJ, et al. Esophageal eosinophilia is increased in rural areas with low population density: results from a national pathology database. Am J Gastroenterol. 2014;109:668-675. 

  6. Dellon ES, Gonsalves N, Hirano I, et al. ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis. Am J Gastroenterol. 2013;108:679-692. 

  7. McCormick SE, Kozarek RA. Endoscopic evaluation of esophageal motility disorders. GI Motility Online. Available from: http://www.nature.com/gimo/contents/pt1/full/gimo29.html 2006.

  8. Mulder DJ, Hurlbut DJ, Noble AJ, Justinich CJ. Clinical features distinguish eosinophilic and reflux-induced esophagitis. J Pediatr Gastroenterol Nutr. 2013;56:263-270. 

  9. Bonis PA, Furuta GT. Clinical manifestations and diagnosis of eosinophilic esophagitis. Uptodate. Available from: http://www.uptodate.com/contents/pathogenesis-clinical-manifestations-and-diagnosis-of-eosinophilic-esophagitis?source=search_result&search=eosinophilic+esophagitis&selectedTitle=1~75#H1 

  10. Moawad FJ, Veerappan GR, Dias JA, et al. Randomized controlled trial comparing aerosolized swallowed fluticasone to esomeprazole for esophageal eosinophilia. Am J Gastroenterol. 2013;108:366-372. 

  11. Straumann A, Spichtin H, Grize L, et al. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology. 2003;125:1660-1669.


All electronic documents accessed on September 8, 2015.



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