Diagnosis and Management of Esophageal Eosinophilia and Eosinophilic Esophagitis
Publication Date: May 1, 2013
Last Updated: March 14, 2022
Recommendations
DIAGNOSIS
Definition and causes of esophageal eosinophilia
Esophageal eosinophilia, the finding of eosinophils in the squamous epithelium of the esophagus, is abnormal and the underlying cause should be identified. (Strong “We recommend”, Moderate)
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Definition of eosinophilic esophagitis (EoE) and diagnostic criteria
EoE is clinicopathologic disorder diagnosed by clinicians taking into consideration both clinical and pathologic information without either of these
parameters interpreted in isolation, and defined by the following criteria:
parameters interpreted in isolation, and defined by the following criteria:
- Symptoms related to esophageal dysfunction
- Eosinophil-predominant inflammation on esophageal biopsy, characteristically consisting of a peak value of ≥15 eosinophils per high-power field (eos/hpf)
- Mucosal eosinophilia is isolated to the esophagus and persists after a PPI trial
- Secondary causes of esophageal eosinophilia excluded
- A response to treatment (dietary elimination; topical corticosteroids) supports, but is not required for, diagnosis.
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Esophageal biopsies are required to diagnose EoE. 2 – 4 biopsies should be obtained from both the proximal and distal esophagus to maximize the likelihood of detecting esophageal eosinophilia in all patients in whom EoE is being considered. (Strong “We recommend”, Low)
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At the time of initial diagnosis, biopsies should be obtained from the antrum and/or duodenum to rule out other causes of esophageal eosinophilia in all children and in adults with gastric or small intestinal symptoms or endoscopic abnormalities. (Strong “We recommend”, Low)
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Diagnostic challenges: PPI-responsive esophageal eosinophilia and GERD
Proton-pump inhibitor esophageal eosinophilia (PPI-REE) should be diagnosed when patients have esophageal symptoms and histologic findings of esophageal eosinophilia but demonstrate symptomatic and histologic response to proton-pump inhibition. At this time, the entity is considered distinct from EoE, but not necessarily a manifestation of GERD. (Conditional (weak) “We suggest”, Low)
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To exclude PPI-REE, patients with suspected EoE should be given a 2-month course of a PPI followed by endoscopy with biopsies. (Strong “We recommend”, Low)
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A clinical, endoscopic and/or histologic response to a PPI does not establish gastroesophageal reflux as the cause of esophageal eosinophilia. To determine whether reflux is contributing to esophageal eosinophilia, additional evaluation for GERD, as per standard clinical practice, is recommended. This may include ambulatory pH testing in selected cases. (Conditional (weak) “We suggest”, Low)
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TREATMENT
Endpoints of treatment in EoE
The endpoints of therapy of EoE include improvements in clinical symptoms and esophageal eosinophilic inflammation. While complete resolution of symptoms and pathology is an ideal endpoint, acceptance of a range of reductions in symptoms and histology is a more realistic and practical goal in clinical practice. (Conditional (weak) “We suggest”, Low)
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Symptoms are an important parameter of response in EoE, but cannot be used alone as a reliable determinant of disease activity and response to therapy, given that compensatory dietary and lifestyle factors can mask symptoms. (Conditional (weak) “We suggest”, Moderate)
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Pharmacologic treatments
Topical steroids (i.e., fluticasone or budesonide, swallowed rather than inhaled, for an initial duration of 8 weeks) are a first-line pharmacologic therapy for treatment of EoE. (Strong “We recommend”, High)
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Prednisone may be useful to treat EoE if topical steroids are not effective or in patients who require rapid improvement in symptoms. (Conditional (weak) “We suggest”, Low)
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Patients without symptomatic and histologic improvement after topical steroids might benefit from a longer course of topical steroids, higher doses of topical steroids, systemic steroids, elimination diet, or esophageal dilation. (Conditional (weak) “We suggest”, Low)
There are few data to support the use of mast cell stabilizers or leukotriene inhibitors, and biologic therapies remain experimental at this time.
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Dietary treatments
Dietary elimination can be considered as an initial therapy in the treatment of EoE in both children and adults. (Strong “We recommend”, Moderate)
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The decision to use a specific dietary approach (elemental, empiric, or targeted elimination diet) should be tailored to individual patient needs and available resources. (Conditional (weak) “We suggest”, Moderate)
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Clinical improvement and endoscopy with esophageal biopsy should be used to assess response to dietary treatment when food antigens are either being withdrawn from or reintroduced to the patient. (Conditional (weak) “We suggest”, Low)
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Gastroenterologists should consider consultation with an allergist to identify and treat extraesophageal atopic conditions, assist with treatment of EoE, and to help guide elemental and elimination diets. (Conditional (weak) “We suggest”, Low)
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Endoscopic treatment
Esophageal dilation, approached conservatively, may be used as an effective therapy in symptomatic patients with strictures that persist in spite of medical or dietary therapy. (Conditional (weak) “We suggest”, Moderate)
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Patients should be well informed of the risks of esophageal dilation in EoE including post-dilation chest pain, which occurs in up to 75 % of patients, bleeding, and esophageal perforation. (Conditional (weak) “We suggest”, Moderate)
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OUTCOMES
Natural history of EoE
While knowledge of the natural history of EoE is limited, patients should be counseled about the high likelihood of symptom recurrence after discontinuing treatment due to the chronic nature of this disease. (Strong “We recommend”, Moderate)
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Maintenance therapy
The overall goal of maintenance therapy is to minimize symptoms and prevent complications of EoE, preserve quality of life, with minimal long-term adverse effects of treatments. (Conditional (weak) “We suggest”, Low)
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Maintenance therapy with topical steroids and / or dietary restriction should be considered for all patients, but particularly in those with severe dysphagia or food impaction, high-grade esophageal stricture and rapid symptomatic/histologic relapse following initial therapy. (Conditional (weak) “We suggest”, Low)
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Recommendation Grading
Overview
Title
Diagnosis and Management of Esophageal Eosinophilia and Eosinophilic Esophagitis
Authoring Organization
American College of Gastroenterology
Publication Month/Year
May 1, 2013
Last Updated Month/Year
January 9, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
In this evidence-based review, recommendations developed by adult and pediatric gastroenterologists are provided for the evaluation and management of Esophageal eosinophilia and eosinophilic esophagitis patients
Target Patient Population
Patients with esophageal eosinophilia and eosinophilic esophagitis patients
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D004802 - Eosinophilia, D004941 - Esophagitis, D057765 - Eosinophilic Esophagitis
Keywords
eosinophilic esophagitis, eosinophilic gastroenteritis
Source Citation
American Journal of Gastroenterology: May 2013 - Volume 108 - Issue 5 - p 679-692
doi: 10.1038/ajg.2013.71