eosinophilic esophagitis (EoE) :
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| Esinophilic oesophagitis ( Dr E Said) |
The esophageal rings in this patient with eosinophilic esophagitis (EoE) represent more esophageal fibrosis with remodeling than inflammation.
Remember that endoscopy in EoE is unreliable and often confusing. A history of dysphagia is a clear indication for biopsy sampling even in the absence of evident abnormalities.
Represent a chronic, immune mediated eosophageal disease characterised clinically by symptoms related to oesophageal dysfunction and histologically by an eosinophilic predominent inflammation.
EoE is food related disease that persumed to result from eosionphilic activation to deitary antigen which is limited to the oesophagus.
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Symptoms:
Adults:
1-Dysphagia for solids 100%
2-Long lasting food impaction 35%
3-Non swallowing related retro sternal pain 50%
Children:
1-Food refusal
2-Failure to thrive
3-Vomiting, regurgitation
4-Chest pain/ abdominal pain
5-Diarrhea
Histology:
> 15 eso/ hpf
eosinophils micro abscesses
surface laying of eosinophils
Its a patchy disease, so several Bx should be taken from proximal and distal oesophagus.
Treatment:
1-Diet:
elemental/ elemination diet
6 food diet elimination ( caw milk, wheat, eggs, soy, nuts,seafood, shellfish )
2-Drugs:
topical corticosteroids
3-Dilatation:
post procedure pain, risk of deep ulceration/ perforation
Recent data indicates that dysphagia symptoms and esophageal eosinophilic infiltration may respond to twice daily proton pump inhibitor treatment for 2 months.
ReplyDeleteIf this approach is unsuccessful, then swallowed fluticasone may be tried, followed by oral systemic steroid pills in refractory cases.
A 60-year-old man undergoes upper endoscopy for a suspected food impaction, which you remove. You suspect eosinophilic esophagitis as a contributing underlying cause. In order to optimize the diagnostic yield, which of the following approaches should be applied?
ReplyDeleteA. One biopsy because of the trauma from foreign body removal
B. Five biopsies of distal esophagus
C. Five biopsies spread among distal, middle and proximal esophagus
D. Empiric treatment is fine after a dilation.
Explanation
Multiple studies have attempted to determine the optimal biopsy protocol for diagnosis of eosinophilic esophagitis. There is not complete agreement on the endoscopic findings and some studies have suggested that a patient may even have a normal endoscopy so multiple biopsies have been recommended as the standard diagnostic test. A single study, a retrospective analysis of 341 biopsy specimens from 66 adults with EOE found that one biopsy had a sensitivity of 55% while five biopsies had a sensitivity of 100%. This has led to a recommendation that a minimum of five biopsies be obtained and expert recommendations suggest that the biopsies be from multiple parts of the esophagus, hence the suggestion of proximal, middle, and distal. The dominant consensus statement suggests that the biopsies be fixed in formalin. The consensus recommendation further suggests that biopsies be obtained from the stomach and duodenum to rule out other diseases associated with mucosal eosinophilia. No definite consensus exists on the role and/or technique in biopsy after foreign body removal.
The patient in the previous question is on no treatment of any type. Management of this patient would include:
ReplyDeleteA. Proton pump inhibitors given twice daily as initial treatment
B. Esophageal dilation immediately
C. Topical corticosteroids started at the same time as PPI trial
D. He should have a liquid diet.
Explanation
Treatment of patients with suspected eosinophilic esophagitis in part assumes that the patient fulfills all of the diagnostic criteria for the disease. Expert consensus suggests that the diagnosis be made in the appropriate clinical setting, the finding of greater than or equal to 15 eosinophils in one high powered field and the lack of responsiveness to high dose proton pump inhibition or normal pH monitoring of the distal esophagus. As such, it is recommended that all patients be given a PPI trial of some length to both establish the diagnosis and be certain that reflux is not part of the picture. Esophageal dilatation has been shown in observational studies to be effective in relieving dysphagia but because of a reportedly higher risk of perforation, it is recommended by most that where possible, either topical corticosteroids and/or proton pump inhibitor therapy be given first prior to attempting a dilatation. Current recommendations suggest the major usefulness of dilatation to be in patients with fixed strictures due to rings. Topical steroids should not generally be started until the diagnosis is confirmed. He can eat as tolerated for now.
topial corticosteroids treatment;
ReplyDeletefluticasone 220 microgm/puff, two puffs BID. This is a therapeutic course and should be understood as not a cure as almost 70% will be back on steroids within three years, 28% will have food impactions and 22% will need further dilations. Indefinite use is not a current recommendation. Esophageal candidiasis has been reported as a relatively frequent complication of this therapy. For rare intermittent choking with no history of aspiration, dilation may not be advised at this time, although it may be effective for fixed rings with more frequent food obstruction as there is thought to be a component of fibrosis that will not respond to therapy with anti-inflammatory agents.