Eosinophilic Esophagitis
Purpose of review To present the clinical, endoscopic, and histologic features of eosinophilic esophagitis (EoE), review the current diagnostic guidelines for EoE, and present an approach for diagnosis of EoE. It will also highlight selected techniques that are under development that may be useful in the future for diagnosis of EoE.
Recent findings Recently updated guidelines emphasize that EoE is a clinicopathologic condition. Specifically, three criteria must be met to diagnose EoE: clinical symptoms of esophageal dysfunction; an esophageal biopsy with a maximum eosinophil count of at least 15 eosinophils per high-power microscopy field, with few exceptions; and exclusion of other possible causes of esophageal eosinophilia, including proton-pump inhibitor responsive esophageal eosinophilia (PPI-REE). A PPI trial is typically required both to assess for PPI-REE and to evaluate for the presence of concomitant gastroesophageal reflux disease.
Summary EoE is a chronic, immune-mediated disorder. Because no single symptom, endoscopic finding, or histopathologic feature is pathognomonic, diagnosis can be challenging. In the future, symptom scores, tissue or serum biomarkers, and genetic testing may play a role in diagnosis, but these methods have yet to be validated and are not yet recommended for routine clinical use.
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus characterized by symptoms of esophageal dysfunction and an esophageal epithelial eosinophilic infiltrate. It was first described in 1978 and initially felt to be rare. Over the past 10 years, however, the condition has been increasingly recognized, first in children and then in adults, and now EoE is a frequently encountered cause of dysphagia and food impaction. Estimates suggest that EoE is found in 6–15% of patients undergoing endoscopy, depending on the indication, and that it is the cause of food impaction in approximately half of cases [9–14]. In addition to increasing recognition by gastroenterologists, the incidence and prevalence of EoE appear to be rising rapidly as well, though the reasons for this are not well understood.
The pathogenesis of EoE is felt to be immune mediated. In response to antigen stimuli, either from food or environmental allergies, a Th2 inflammatory response is triggered and factors such as interleukin 4 (IL-4), IL-5, and IL-13 stimulate eotaxin-3, a potent chemokine, to traffic eosinophils to the esophageal mucosa. When activated, the eosinophils cause local tissue damage and recruit other effector cells such as mast cells and fibroblasts, which play a role in esophageal remodeling. Recent work has identified potential loci of genetic susceptibility in patients with EoE.
Although knowledge about EoE has been increasing rapidly, diagnosis of EoE can be challenging because the symptoms and histopathologic findings are not specific. The purpose of this paper is to present the clinical, endoscopic, and histologic features of EoE, review the current diagnostic guidelines for EoE, and present an approach for diagnosis of EoE. It will also highlight selected techniques that are under development and that may be useful in the future for diagnosis of EoE.
Abstract and Introduction
Abstract
Purpose of review To present the clinical, endoscopic, and histologic features of eosinophilic esophagitis (EoE), review the current diagnostic guidelines for EoE, and present an approach for diagnosis of EoE. It will also highlight selected techniques that are under development that may be useful in the future for diagnosis of EoE.
Recent findings Recently updated guidelines emphasize that EoE is a clinicopathologic condition. Specifically, three criteria must be met to diagnose EoE: clinical symptoms of esophageal dysfunction; an esophageal biopsy with a maximum eosinophil count of at least 15 eosinophils per high-power microscopy field, with few exceptions; and exclusion of other possible causes of esophageal eosinophilia, including proton-pump inhibitor responsive esophageal eosinophilia (PPI-REE). A PPI trial is typically required both to assess for PPI-REE and to evaluate for the presence of concomitant gastroesophageal reflux disease.
Summary EoE is a chronic, immune-mediated disorder. Because no single symptom, endoscopic finding, or histopathologic feature is pathognomonic, diagnosis can be challenging. In the future, symptom scores, tissue or serum biomarkers, and genetic testing may play a role in diagnosis, but these methods have yet to be validated and are not yet recommended for routine clinical use.
Introduction
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus characterized by symptoms of esophageal dysfunction and an esophageal epithelial eosinophilic infiltrate. It was first described in 1978 and initially felt to be rare. Over the past 10 years, however, the condition has been increasingly recognized, first in children and then in adults, and now EoE is a frequently encountered cause of dysphagia and food impaction. Estimates suggest that EoE is found in 6–15% of patients undergoing endoscopy, depending on the indication, and that it is the cause of food impaction in approximately half of cases [9–14]. In addition to increasing recognition by gastroenterologists, the incidence and prevalence of EoE appear to be rising rapidly as well, though the reasons for this are not well understood.
The pathogenesis of EoE is felt to be immune mediated. In response to antigen stimuli, either from food or environmental allergies, a Th2 inflammatory response is triggered and factors such as interleukin 4 (IL-4), IL-5, and IL-13 stimulate eotaxin-3, a potent chemokine, to traffic eosinophils to the esophageal mucosa. When activated, the eosinophils cause local tissue damage and recruit other effector cells such as mast cells and fibroblasts, which play a role in esophageal remodeling. Recent work has identified potential loci of genetic susceptibility in patients with EoE.
Although knowledge about EoE has been increasing rapidly, diagnosis of EoE can be challenging because the symptoms and histopathologic findings are not specific. The purpose of this paper is to present the clinical, endoscopic, and histologic features of EoE, review the current diagnostic guidelines for EoE, and present an approach for diagnosis of EoE. It will also highlight selected techniques that are under development and that may be useful in the future for diagnosis of EoE.
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