Eosinophilic oesophagitis

Introduction:

Eosionophlic oesophagitis ¹ is a relatively new disease entity. It is characterised by chronic / intermittent dysphagia, reflux like symptoms and intermittent oesophageal food impaction.

This condition was first reported by Landres in 1978 ². In 1993 Attwood and DeMeester reported 12 cases of dysphagia with no evidence of anatomic obstruction. They also reported dense eosinophilic infiltrates in the oesophagus. Attwood hence applied the criteria of presence of more than 20 eosinophils / high power field as histological criteria for diagnosing this condition ³.

Incidence:

True incidence of this disorder is still uncertain ⁴. Review of literature puts this figure as high as 1% ⁵. It is more common in men than in women. Male : female ratio is 3:1. Age of presentation may vary between 2nd – 4th decades.

Conditions associated with oesophageal eosinophilia:⁶

1. Eosinophlic oesophagitis

2. GERD

3. Collagen vascular disorders

4. Parasitic infections

5. Eosinophlic gastroenteritis

Pathophysiology of eosinophlic oesophagitis:

This is a primary disorder involving oesophagus

Biopsy of oesophageal mucosa should contain atleast 50 eosinophils / high power field.

There should not be associated eosinophlic infiltration of stomach / intestine.

Eosinophlic microabscess can be see in the oesophagus extending up to its lumen

The caliber of oesophageal lumen is drastically reduced.

Asthma / atopia +

Peripheral eosinophilia common

Endoscopic features:

Linear furrowing of oesophageal mucosa.

Presence of white plaques / exudates

Presence of concentric rings / strictures of oesophageal mucosa.

Appearance of crepe paper mucosa is diagnostic.

Multiple biopsies should be studied before a categorical diagnosis of this condition could be made. Multiple biopsy specimen increases the accuracy of diagnosis.

Diagnosis of eosinophlic oesophagitis should not be made until GERD has been categorically ruled out by performing ambulatory pH testing or performing repeat biopsy after a 8 week trial course of proton pump inhibitor.

Clinical features:

1. Abdominal pain

2. Chest burns

3. Dysphagia

4. These patients are very slow eaters

Classification of eosinophlic oesophagitis:

Vasilopoulous ⁷ proposed the first classitication of eosinophilic oesophagitis.

Type I : Early small caliber oesophagus

Type II: Advanced small caliber oesophagus

Type III: Ringed oesophagus

Management:

1. Avoidance of food allergen

2. Topical steroids

3. Oral steroids

4. Leukotriene inhibitors

5. Oesophageal dilatation is reserve for patients with extreme dysphagia

References:

1. Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology.

2007;133:1342-1363.

2. Landres RT, Kuster GGR, Strum WB. Eosinophilic esophagitis in a patient with vigorous achalasia. Gastroenterology 1978;74:1298-1301.

3. Attwood SEA, Smyrk TC, DeMeester TR, et al. Esophageal eosinophilia with dysphagia: a distinct clinicopathological syndrome. Dig Dis Sciences 1993;38:109-116.

4. Ronkainen J, Talley NJ, Aro P, et al. Prevalence of oesophagealeosinophils and eosinophilic oesophagitis in adults: the population-based Kalixanda study. Gut. 2007;56:615-620.

5. Arora AS, Yamazaki K. Eosinophilic esophagitis: asthma of the esophagus? Clin Gastroenterol Hepatol 2004;2:523-530.

6. Rodrigo S, Abboud G, Oh D, et al. High intraepithelial Eosinophil counts in esophageal squamous epithelium are not specific for eosinophilic esophagitis in adults Am J Gastroenterol 2008;103:435- 442.

7. Vasilipoulos S, Shaker R. Defiant dysphagia: small-caliber esophagus and refractory benign esophageal strictures. Current Gastroenterology Reports 2001;3:225-230.