Eosinophilic esophagitis: A newly established cause of dysphagia

Table 1 Clinical features of eosinophilic esophagitis

	Adult	Pediatric
Common	Dysphagia	Abdominal pain
	Food impaction/foreign body	Failure to thrive
	Esophageal stricture	Nausea/vomitting
	Nausea/vomitting/regurgitation	Dysphagia
	Heartburn	Food allergy
	Food allergy	Heartburn
Uncommon	Hematemesis	Food impaction
	Globus
	Waterbrash
	Weight loss
	Chest pain
	Abdominal pain
Associated Conditions	History of atopy	Asthma
	Asthma	Allergic rhinitis
	Allergic rhinitis	Eczema
		Atopic dermatitis
		Strong family history of atopy

Table 2 Endoscopic features of eosinophilic esophagitis

Endoscopic feature	Description
Feline esophagus	Multiple concentric rings, may be fine in nature, web-like or thickened
(corrugated, ringed esophagus)
Small calibre esophagus	Narrow, fixed internal diameter
	Featureless, unchanging column
	Poor expansion on air insufflation
	Proximal and/or distal stenosis
Adherent white papules	White exudates 1-2 mm in diameter which do not wash off (similar to candidiasis)
	Speckled patches
	Vesicles
	Loss of vascular pattern
Esophageal furrows	Vertical esophageal lines
Crêpe paper mucosa	Fragile esophageal mucosa
	Delicate, inelastic
	Mucosal abrasions or tear with minimal contact

Table 3 Histopathology of eosinophilic esophagitis

	GERD	Eosinophilic esophagitis
Eosinophilic infiltration (squamous epithelium)	<10/hpf	>20/HPF
Other features	Esophagitis (usually distal)	Esophagitis (proximal and/ or distal, may be patchy or segmental)
	Intestinal metaplasia	Basal zone hyperplasia
		Increased papillary size
		Superficial eosinophilic layering or aggregates
		Microabscesses

GERD: Gastroesophageal reflux disease; HPF: high power field.

Table 4 Differential diagnosis [40]

Primary	Idiopathic eosinophilic esophagitis
	Familial eosinophilic esophagitis
	Atopic esophagitis
Secondary: Eosinophilic related	Eosinophilic gastroenteritis
	Hypereosinophilic syndromes
Secondary: Non – eosinophilic related	GERD
	Recurrent vomitting
	Infection (helminth, parasitic, fungal)
	Esophageal GI stromal tumor
	Myeloproliferative disorders
	Carcinomatosis
	Allergic vasculitis
	Scleroderma
	Drugs/Iatrogenic

Table 5 Treatment regimens for eosinophilic esophagitis

Treatment option	Protocol
Elimination Diet	Avoidance of allergen depending on results of food allergy testing
	Oligoantigenic diet: Eliminate large number of suspected foods and allow limited nutritionally balanced diet
	Elemental diet: Various formulas such as Neocate (free amino acids, corn syrup solids, medium chain triglycerides)
Topical corticosteroids: Mayo Clinic protocol	Fluticasone 220 μg puffer 4 puffs BID x 6 wk, swallowed, no spacer
	Rinse mouth with water and spit out
	No food or drink for 3 h after dose
Systemic (oral) corticosteroids	Methylprednisolone 1.5 mg/kg per day (or equivalent dose prednisone)
	Divide into bid dosing for 4 wk then taper over 6 wk
Montelukast	Initial dose: 10 mg po daily
	Titration: Dose up to 100 mg/d depending on symptoms and tolerance
	Maintenance: Once symptoms relieved titrate down to minimal dose to maintain remission (usually 20 - 40 mg/d)
Mepolizumab	10 mg/kg iv infusion q 4 wk x 3 doses

BID: twice daily; PO: oral; IV: intravenous.