Eosinophilic Esophagitis. Another Reason Not to Swallow
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1 Eosinophilic Esophagitis Another Reason Not to Swallow
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3 Eosinophilic Esophagitis Overview Presentation Pathogenesis Differentiation from GERD Diagnosis Treatment
4 Case 30 yr old male doctor Very healthy with occ asthma and excema ER for food impaction 2 yrs ago spasm Periodic slow swallowing but passes Now chicken bolus that will not clear
5 Epidemiology First reported 1978 Rising incidence 0.35/100,000 in 1991 to 9.45/100,000 in 2001 Increasingly recognised More awareness or true escalation? Children and adults Especially Caucasian males
6 Eosinophilic Gastro Intestinal Disorders Primary E Esophagitis E gastritis E gastroenteritis E enteritis E colitis Hypereosinophilic syndrome Secondary GERD Food allergies GI infections IBD Connective tissue disease
7 New Patients Diagnosed with Eosinophilic Esophagitis Liacouras. Clin Gastro Hepatol 2005; 3: 1198
8 Trends in Endoscopy Volume and Diagnosis of EE Prasad. Clin Gastro Hepatol 2009; 7: 1055
9 Prevalence of EE 400 consecutive upper endoscopies 8 biopsies proximal and distal esophagus EE diagnosed if >20 eosinophils/hp field Prevalence EE 6.5% Veerappan. Clin Gastro Hep 2009; 7: / 100,000 Clin Gastro Hep 2014; 12: 589
10 Clinical Presentation EoE + EoE - Male 80% 48%* Asthma 32% 11%* Food Impactions 32% 9%* *P < Veerapppan. Clin Gastro Hep 2009; 7: 420
11 Seasonal Variation in Diagnosis of EE Prasad. Clin Gastro Hepatol 2009; 7: 1055
12 Socioeconomic Chartacteristics of EE White Male MHHI College education EE 83.6% 75.8% $68, % Census 73.0% 48.0% $49, % Franciosi. Clin Gastro Hepatol 2009; 7: 415
13 Clinical Manifestation Adult Dysphagia (average 4.5 yrs) Food impaction Children Feeding disorder (median age 2) Vomiting (median age 8) Dysphagia (median age 13) Atopy (52%)
14 Dysphagia Overview Transfer Dysphagia Oropharynx Neurogenic Myogenic Oropharyngeal tumor Esophageal Dysphagia Body of esophagus Mechanical Motility
15 Questions to ask Lump sensation (globus) Trouble chewing? What happens when you try to swallow? Difficulty initiating swallow Food sticks in chest Solids and liquids? Symptom duration, frequency, progression Associated symptoms
16 Test Options Modified barium study Barium esophagram Endoscopy Esophageal manometry
17 Esophageal Dysphagia Peptic stricture Esophageal webs and rings Cancer Achalasia Radiation damage Esophageal spasm Scleroderma Eosinophilic esophagitis
18 Etiology of Dysphagia A prospective Study of 376 Adults Reflux esophagitis 77 (20%) Eosinophilic Esophagitis 33 (9%) Schatzkis Ring 26 (7%) Esophageal Stricture 13 (3%) Other Achalasia, Fundoplication, Mass, Ulcer 43 (11%) Prasad. Am J Gastro 2007; 102: 2627
19 Independent Risk Factors for Finding EE in Patients with Dysphagia (n=220) Risk Factor Odds Ratio (95%CI) P value Age 0.94 ( ) 0.01 Food impaction > 5min Endoscopic features of EE Use of PPI for GERD 2.61 ( ) ( ) ( ) 0.01 Prasad. Am J Gastro 2007; 102: 2627
20 Endoscopic Findings Strictures Mucosal rings (often multiple) Linear furrowing White papules
21 6.5% Prevalence of EE in Routine UGI Endoscopy (n=400) Veerappan. Clin Gastro Hepatol 2009; 7: 420
22
23 Diagnosis Clinical Endoscopic Histologic Tissue eosinophilia (>15/hpf) 100% sensitivity with 5 biopsies Biopsies of upper and lower esophagus required for diagnosis
24 Eosinophilic Esophagitis Odze. Am J Gastro 2009; 104: 485
25 Accuracy of Different Eosinophil Cutoff Points for Diagnosis of EE Sensitivity % Specificity % PPV % PNV % >15 eo/hpf 100 (70-100) 0 (0-13) 26 (14-42) - >15 eo/hpf (peak count) >20 eo/hpf 100 (70-100) 35 (19-54) 35 (19-54) 100 (70-100) Eosinophlic microabscesses >24 eo/hpf 100 (70-100) 46 (29-65) 39 (22-59) 100 (76-100) >35 eo/hpf 100 (70-100) 65 (46-81) 50 (29-71) 100 (82-100) >50 eo/hpf 67 (35-88) 90 (74-96) 67 (35-88) 90 (74-96) Molina-Infante. Clin Gastro Hepatol 2011; 9: 110
26 Esophageal Eosinophilia Disease Associations GERD Drug induced (pill esophagitis) Infection Crohns Eosinophilic gastroenteritis Celiac Graft vs Host disease
27 Pathogenesis Recruitment of eosinophils by exposure to allergen (airborn or oral) Degranulation of eosinophils
28 Rothenberg. Gastro 2009; 137: 1238
29 Powell. Nat Rev Gastro Hepatol 2010; 7: 146
30 Mechanical Properties of the Esophagus in Eosinophilic Esophagitis Kwiatek. Gastro 2011; 140: 82-90
31 Treatment Consider adult vs child Consider presence of dominant stricture 3 D s Drugs Diet Dilation
32 Treatment Acid Suppression- PPI 40mg daily Esophageal dilation Steroids Systemic Topical Dietary
33 GERD Eosinophilic Esophagitis
34 Distinguishing GERD from EoE Nat Rev Gastro Hep 2015; 12: 379
35 Normal Esophageal Mucosa Mild GERD GERD is associated with 5-10 eos/hpf, in distal esophagus
36 Peak Esophageal Eosinophil Counts Pre and Post PPI Therapy 75% had full response to 2 mos of Rabeprazole 20mg bid Molina-Infante. Clin Gastro Hep 2011; 9: 110
37 Esophageal Dilation NB. Complications in 31% (Cohen. Clin Gastro Hep 2007; 5: 1149)
38 Steroids Fluticasone swallowed - 220ug 2-4 puffs twice daily for 6-12 weeks, followed by gentle rinse and no food for 30 mins. Budesonide respule (2mg) mixed with 10gm sucralose to make a slurry; 1-2mg twice daily (Prednisone 40mg daily and tapered over 6 weeks)
39 Dietary Treatment Elemental diet Directed elimination diet Based on allergy testing Non-directed elimination diet Empiric exclusion
40 Reduced Esophageal Eosinophil Count after 6 weeks of an Amino-Acid Based Formula in Children Kelly. Gastro 1995; 109: 1503
41 Milk and Wheat Most Common Food Triggers Am J Gastro 2016; doi
42 Elimination Diet in Eosinophilic Esophagitis Am J Gastro April 12, 2016
43 Pre and Post treatment eosinphil counts after six-food elimination diet (Cow milk, soy, wheat, egg, peanut, seafood) Kagalwalla. Clin Gastro Hep 2006; 4: 1097
44 Efficacy of Six Food Elimination in EoE Gastro 2014; 146: 1639
45 Response of EoE to Dietary Treatments Gastro Clin NA 2014; 43: 375
46 Prognosis Untreated Recurrent symptoms? Treated 25-40% relapse
47 Natural history of EE in 30 Adults for up to 11.5 years Straumann. Gastro 2003; 125: 1660
48 Risk of Strictures with Unrecognized EoE Gastro 2013; 145: 1230
49 An Approach to Eosinophilic Esophagitis Am J Gastro 2013; 108: 679
50 Therapy for Eosinophilic Esophagitis Postgrad Med J 2014; 90: 273
51 Summary Eosinophilic Esophagitis Increasingly recognized Presents as recurrent dysphagia Diagnosis by esophageal biopsies Treatment with PPI, topical steroids, dietary elimination
52 References ACG clinical guideline. Eosinophilic esophagitis. Am J Gastro 2013; 108: 679 Current Management of EoE. J Clin Gastroenterol 2016; 50: 99 The first two decades of EoE. Am J Gastro 2016 doi: /ajg Eosinophilic Esophagitis. NEJM 2015; 373: 1640 How I approach management of EoE. Am J Gastro 2017; 112: 197 Making dysphagia easier to swallow. Mayo Clin Proc 2017; 92: 965
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