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Importance of Early Recognition and Treatment of Eosinophilic Esophagitis
Importance of Early Recognition and Treatment of Eosinophilic Esophagitis

Released: September 07, 2022

Expiration: September 06, 2023

Ikuo Hirano
Ikuo Hirano, MD
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Key Takeaways:

  • The prevalence of eosinophilic esophagitis is increasing, affecting both children and adults.
  • Multiple factors contribute to a several-year diagnostic delay in eosinophilic esophagitis, including failed recognition of the signs and symptoms of the disease.
  • Starting treatment early in the course of the disease can prevent long-term complications of esophageal remodeling.

The prevalence of eosinophilic esophagitis (EoE) is currently 1 case per 1500 persons in the United States, according to the most recent estimates. Furthermore, the prevalence continues to increase. Most patients who develop EoE are 30-40 years of age, but it can affect individuals at any age, including infants and older adults. EoE is a male-predominant disease, affecting 2- to 3-fold more men than women. EoE is hypothesized to be an allergic disease, and most patients with EoE also have a comorbid atopic condition, such as allergic rhinitis, asthma, atopic dermatitis, or an immunoglobulin E–mediated food allergy.

Importance of Early Diagnosis

Multiple studies conducted worldwide have shown that the remodeling consequences of EoE increase over time. Indeed, the longer patients have unrecognized or untreated EoE, the higher the likelihood of developing an esophageal stricture. Strictures in EoE are associated with ER visits for food impactions, as well as the need for esophageal dilation. Many patients will try to alleviate the symptoms of EoE by adaptive eating behaviors (eg, avoiding hard-texture foods, careful mastication, prolonged mealtimes).

The diagnosis of EoE requires the identification of both clinical and pathologic features. Adults are more likely to present with dysphagia and food impaction, whereas the symptoms observed in children are much less specific and include food refusal, failure to thrive, abdominal or chest pain, nausea, and vomiting. To fulfill the pathologic criteria for EoE, patients must undergo endoscopic biopsies demonstrating ≥15 eosinophils/high-powered field. The final step in the diagnosis of EoE is to rule out any secondary causes.

A reason for the several-year delay in the diagnosis of EoE is multifactorial. First, only in the past 2 decades has quantification of esophageal eosinophil density become routine for pathologists. Second, because EoE is a progressive disease, the symptoms may start as relatively mild, and patients may not seek healthcare until they get more burdensome. In addition, many patients develop modified eating behaviors to minimize symptoms. Finally, nonspecific symptom presentations and a lack of awareness by healthcare professionals are responsible for a delay in diagnosis for many patients. Indeed, patients and/or healthcare professionals may believe their symptoms are consistent with another disease, such as acid reflux, and initiate acid suppressant therapy in lieu of an upper endoscopy. Alternatively, for children, parents and/or pediatricians may believe the child is simply a fussy eater or eating too quickly, delaying appropriate investigation for several years.

Available Treatments

Treatment is warranted for EoE to both alleviate the immediate symptoms and prevent future progression of fibrostenotic complications. Currently available treatments include dietary elimination and drug treatment with proton pump inhibitors, swallowed topical corticosteroids, or dupilumab, which recently became the first FDA-approved agent to treat EoE.

Elimination diets involve the removal of common food triggers (milk, wheat, soy, egg), followed by reintroduction to identify the specific culprit food group(s). Alternatively, a patient may opt for pharmacologic management of their EoE if removing foods from their diet is unsuccessful or unacceptable. Esophageal dilation is an important adjunctive therapy that addresses strictures commonly identified in adolescents and adults with long-standing disease. Shared decision-making is important when determining the best treatment plan for each patient to ensure long-lasting success.

Learn more by joining me and my colleagues for an upcoming live CME dinner series on EoE starting October 6 in Phoenix, Arizona, and coming to a city near you. The series also will be available as a simulcast. To view all dates and locations, visit here.

Your Thoughts?

What do you perceive to be the main challenges in diagnosing or treating EoE? Join the discussion by posting a comment.