Highlighter is on. Drag to highlight text. Click a highlight to remove it.
ALL / Gastroenterology

Eosinophilic oesophagitis

Eosinophilic oesophagitis

Eosinophilic oesophagitis is characterised by an allergic inflammation of the oesophagus. An oesophageal biopsy will show dense infiltrate of eosinophils in the epithelium. Although this disease is relatively poorly understood, it is thought to be caused by an allergic reaction to ingested food. The resulting oesophageal inflammation results in pain and dysphagia, amongst other symptoms.

Epidemiology:
  • 3:1 male:female ratio
  • Average age at diagnosis is 30-50 years old

Risk factors for developing eosinophilic oesophagitis:
  • Allergies/ asthma: suffering from food/ environmental allergies or atopic dermatitis and asthma increases the risk of diagnosis
  • Male sex
  • Family history of eosinophilic oesophagitis or allergies
  • Caucasian race
  • Age between 30-50
  • Coexisting autoimmune disease e.g. coeliac disease

Patients typically present with a subacute onset of:
  • In children, disease presents with failure to thrive due to food refusal
  • Adults often experience dysphagia, strictures/ fibrosis (56%), food impaction (55%), regurgitation/ vomiting, anorexia

Signs:
  • Signs are minimal and suspicion of this diagnosis relies mainly on the reported symptoms, past medical history and exclusion of other differential diagnoses e.g. GORD
  • Weight loss

Investigations:
  • Endoscopy: diagnosis can only be made on the histological analysis of an oesophageal biopsy. There must be more than 15 eosinophils per high power microscopy field to diagnose the condition. Other findings on endoscopy include reduced vasculature, thick mucosa, mucosal furrows, strictures and laryngeal oedema. Histologically, the diagnosis is made more likely in the presence of epithelial desquamation, eosinophilic microabscesses, and abnormally long papillae

Management: the 3 'D's'

Drugs
  • Proton pump inhibitor (PPI) therapy
    • First-line
    • Omeprazole or lansoprazole (standard or high dose) for 8 weeks.
    • Some patients have 'PPI-responsive oesophageal eosinophilia'
  • Topical corticosteroids (swallowed, not inhaled) if symptoms or histology persist:
    • Budesonide or fluticasone swallowed after actuation or as viscous slurry.
    • Continue for 6–12 weeks; long-term maintenance may be needed.
    • Rinse mouth after use to avoid oral thrush.

Diet
  • Elimination diet – particularly useful in children or when drug therapy fails.
    • Six-food elimination diet (excludes milk, wheat, eggs, soy, nuts, seafood).
    • Step-down or targeted versions can also be used based on allergy testing or stepwise reintroduction.

Dilatation
  • Consider if there is fibrotic stricture or narrowing causing persistent dysphagia.
  • Performed endoscopically with careful technique; ideally after inflammation has been controlled.

Complications:
  • Strictures of the oesophagus (56%)
  • Impaction: 55% of patients experience this, and 38% of these require endoscopic removal of the impaction
  • Mallory-Weiss tears
+PassMedicine Notes

Eosinophilic oesophagitis is characterised by an allergic inflammation of the oesophagus. An oesophageal biopsy will show dense infiltrate of eosinophils in the epithelium. Although this disease is relatively poorly understood, it is thought to be caused by an allergic reaction to ingested food. The resulting oesophageal inflammation results in pain and dysphagia, amongst other symptoms.

Epidemiology:
  • 3:1 male:female ratio
  • Average age at diagnosis is 30-50 years old
Risk factors for developing eosinophilic oesophagitis:
  • Allergies/ asthma: suffering from food/ environmental allergies or atopic dermatitis and asthma increases the risk of diagnosis
  • Male sex
  • Family history of eosinophilic oesophagitis or allergies
  • Caucasian race
  • Age between 30-50
  • Coexisting autoimmune disease e.g. coeliac disease
Patients typically present with a subacute onset of:
  • In children, disease presents with failure to thrive due to food refusal
  • Adults often experience dysphagia, strictures/ fibrosis (56%), food impaction (55%), regurgitation/ vomiting, anorexia
Signs:
  • Signs are minimal and suspicion of this diagnosis relies mainly on the reported symptoms, past medical history and exclusion of other differential diagnoses e.g. GORD
  • Weight loss
Investigations:
  • Endoscopy: diagnosis can only be made on the histological analysis of an oesophageal biopsy. There must be more than 15 eosinophils per high power microscopy field to diagnose the condition. Other findings on endoscopy include reduced vasculature, thick mucosa, mucosal furrows, strictures and laryngeal oedema. Histologically, the diagnosis is made more likely in the presence of epithelial desquamation, eosinophilic microabscesses, and abnormally long papillae

Management: the 3 'D's'

Drugs
  • Proton pump inhibitor (PPI) therapy
    • First-line
    • Omeprazole or lansoprazole (standard or high dose) for 8 weeks.
    • Some patients have 'PPI-responsive oesophageal eosinophilia'
  • Topical corticosteroids (swallowed, not inhaled) if symptoms or histology persist:
    • Budesonide or fluticasone swallowed after actuation or as viscous slurry.
    • Continue for 6–12 weeks; long-term maintenance may be needed.
    • Rinse mouth after use to avoid oral thrush.
Diet
  • Elimination diet – particularly useful in children or when drug therapy fails.
    • Six-food elimination diet (excludes milk, wheat, eggs, soy, nuts, seafood).
    • Step-down or targeted versions can also be used based on allergy testing or stepwise reintroduction.
Dilatation
  • Consider if there is fibrotic stricture or narrowing causing persistent dysphagia.
  • Performed endoscopically with careful technique; ideally after inflammation has been controlled.
Complications:
  • Strictures of the oesophagus (56%)
  • Impaction: 55% of patients experience this, and 38% of these require endoscopic removal of the impaction
  • Mallory-Weiss tears


Saved ✓

MEDIA