Eosinophilic Esophagitis: An Overlooked Entity in Chronic Dysphagia

Brian M. Yan and Eldon A. Shaffer

Disclosures

Nat Clin Pract Gastroenterol Hepatol. 2006;3(5):285-289. 

In This Article

Treatment and Management

A number of different therapeutic regimens have been used with varying success in both pediatric and adult populations.[11,12,13,14,15,16,17,18,19] All of the published studies are case series, and there has been no rigorous testing of regimens with randomized controlled trials. Currently, there are no evidence-based guidelines for the management of eosinophilic esophagitis. Measures of the efficacy of treatment regimens for eosinophilic esophagitis are generally based on symptomatic improvement; few studies have assessed endoscopic or histologic improvement. It is undetermined whether goals of treatment should be aimed at symptomatic improvement, histologic improvement, or both. Food avoidance or use of an elemental diet can help to reduce the stimulation of allergic responses and has been reported to be effective in children. Skin testing (including both skin-prick and patch testing) for food allergies can help to identify causative factors.[12,13] Liacouras and colleagues retrospectively assessed 381 children with eosinophilic esophagitis over a 10-year period and found that 98% of children who received dietary therapy had a significant improvement in symptoms and histology.[12] Remission was maintained if patients remain on dietary restriction.[12] Whether this information can be extrapolated to adults is unknown. Compliance in adults would be a major issue. In addition, food allergies are more common in children and might be more readily identified than in adults.

Topical steroids have been the most effective treatment reported in adults to date. Arora and colleagues published a case series of 21 patients with eosinophilic esophagitis, treated with four puffs of 220 µg fluticasone, swallowed twice a day for 6 weeks (the dose given in this case with a positive response).[15] All patients experienced complete symptomatic relief; however, recurrence of symptoms at 1 year was approximately 50-60%.[15] Remedios and colleagues showed symptomatic and histologic improvement in patients treated with a 4-week course of swallowed fluticasone, but most patients had recurrence of symptoms 3 months after cessation of therapy.[16]

Topical steroids are not completely benign as oral and esophageal candidiasis has been reported in patients receiving this treatment for eosinophilic esophagitis.[12,16] Theoretically, the risk of adrenal suppression is low, owing to the minimal absorption of fluticasone from the gastrointestinal tract and rapid first-pass metabolism by the liver.[17] Nevertheless, there have been case reports of adrenal suppression in asthmatic patients.

The use of systemic steroids has only been reported in children; a 4-week regimen of 1.5 mg/kg per day methylprednisolone might be effective.[11,12] In children, both topical and systemic steroids have been shown to improve symptoms and histology after 4 weeks of treatment; however, virtually all children relapse symptomatically and histologically 6 months after cessation of therapy. Recurring symptoms might be treated with a repeat course of topical or systemic steroids.[11,15]

Other treatments that target eosinophil trafficking and activation have been assessed in pilot studies. The use of the leukotriene inhibitor, montelukast, 10 mg orally per day, has been reported in a small case series with good symptomatic response.[18] There was no histologic improvement, however, which might account for the rapid relapse rates following its discontinuation.[18] Cromolyn was not effective for symptomatic or histologic improvement in children.[12]Finally, mepolizumab, a humanized monoclonal antibody to IL-5, infused intravenously once a month for 3 months in one patient with eosinophilic esophagitis produced symptomatic, endoscopic, and histologic improvement.[19]

In the adult population, eosinophilic esophagitis tends to be chronic, but stable, with no significant effect on morbidity or mortality. Straumann and colleagues documented the natural history of eosinophilic esophagitis in 30 adult patients who received no dietary or medical therapy.[20] Only those with severe and frequent attacks were treated with dilatation. No patients died during the study and all were in 'good health'; however, 96.7% had dysphagia over the 7.2 years of follow-up. Little effect on socioprofessional activities was reported. No increased risk of malignancy was found and no eosinophilic gastroenteritis was documented. Whether a persistent inflammatory state will affect motility, mechanical obstruction, inflammatory bowel disease, malignancy, or mortality in the long term has yet to be seen.

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