Eosinophilic Esophagitis

Educational Objectives

The goal of this program is to improve the diagnosis and management of eosinophilic esophagitis. After hearing and assimilating this program, the clinician will be better able to:

1. Recommend the most appropriate treatment option (medical, dietary, or endoscopy) for eosinophilic esophagitis.
2. Identify common triggers of eosinophilic esophagitis.

Summary

Eosinophilic esophagitis (EoE): endoscopic and pathologic diagnosis; represents chronic immune antigen-mediated esophageal disease, characterized by symptoms related to esophageal dysfunction and histologically by eosinophilic-predominant inflammation; demographics — incidence increasing; not limited to young individuals; unlike Barrett esophagus, more common in younger individuals; endoscopic appearance — “classic 3” (ringed esophagus, furrowed esophagus, and granular or exudative esophagitis)

Biopsy: use separate bottles for specimens from mid and distal esophagus; speaker believes biopsy of distal esophagus has limited utility and mid-esophageal biopsy most important; >15 eosinophils per high-power field required for diagnosis; infiltration and microabscesses also typical

Determining etiology: disappearance of eosinophils following initiation of proton pump inhibitor (PPI) does not establish presence of pathologic acid exposure (ie, PPIs have anti-inflammatory as well as acid suppressing effects); pH test necessary

PPI-naive EoE: initiate trial of twice-daily PPI for 8 wk, followed by repeat endoscopy with biopsies; if eosinophilia persistent, condition not acid-related; if eosinophilia absent, condition caused by gastroesophageal reflux disease (GERD; likely associated with, eg, heartburn, chest pain) or PPI-responsive eosinophilia (typical dysphagia patient)

Pathogenesis of EoE: develops through combined effects of genetic abnormalities and antigens (food, and probably aeroantigens); Mayo Clinic has data supporting seasonality of eosinophilic infiltration in esophagus; seasonality appears to differ with location (correlates with times during which aeroantigen load highest); if resulting inflammation chronic, tissue becomes fibrotic

Treatment: after trial of PPI, options include diet, topical steroids, and esophageal dilation

Dietary therapy: milk, soy, eggs, wheat, nuts, and shellfish most commonly associated with EoE; study — in small cohort, found EoE could be reduced through elimination of common food triggers (wheat and milk most common)

Medical therapy: steroid-based therapy (eg, fluticasone inhaler [220 µg suggested dose for most patients]); randomized controlled trial in children showed symptomatic and histologic improvement produced by steroid superior to that with placebo; relatively inexpensive; budesonide — different compounding options possible; costly; 2 mg twice daily can increase response rate to ≤90%; most of drug stays in gastrointestinal tract, while lungs receive majority of fluticasone; decreases endoscopic, clinical, and histologic relapse rates if given long term; however, study found that 43% of children on standard budesonide had some evidence of adrenal axis suppression

Esophageal dilation: produces improvement in 75% of patients; perforation uncommon (1 in 100 cases; many patients have pain after procedure); speaker now uses esophageal balloon; for long stricture, dilator bougie recommended; ensure that all areas adequately dilated; administration of fentanyl after or during procedure may prevent chest pain; increase by 2 mm with each dilation

Questions and answers: duration of treatment — 2 to 3 mo (then, stop treatment and determine whether symptoms recur); patient refractory to diet, PPI, and topical steroids — options include trial of immunomodulators or systemic steroids, elemental diet, and periodic dilation

Readings

González-Cervera J, Lucendo AJ: Eosinophilic esophagitis: an evidence-based approach to therapy. J Investig Allergol Clin Immunol, 2016;26(1):8-18; quiz 2p following 18; O’Shea KM et al: Pathophysiology of eosinophilic esophagitis. Gastroenterology, 2018 Jan;154(2):333-345; Reed CC et al: Food elimination diets are effective for long-term treatment of adults with eosinophilic oesophagitis. Aliment Pharmacol Ther, 2017 Nov;46(9):836-844; Runge TM et al: Control of inflammation decreases the need for subsequent esophageal dilation in patients with eosinophilic esophagitis. Dis Esophagus, 2017 Jul 1;30(7):1-7; Whitson MJ et al: Lack of proton pump inhibitor trial prior to commencing therapy for eosinophilic esophagitis is common in the community. Dis Esophagus, 2018 May 1;31(5).

Disclosures

For this program, the members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. DevVault was recorded at the 41st Annual New York Course: Precision Endoscopy: The Scope of the Future, held December 14-15, 2017, in New York, NY, and presented by the Albert Einstein College of Medicine and the New York Society for Gastrointestinal Endoscopy. For information about upcoming CME activities from these sponsors, please visit www.Einstein.edu and www.nysge.org. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GE330401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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