Eosinophilic esophagitis: From pathophysiology to treatment (original) (raw)
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Eosinophilic esophagitis: latest insights from diagnosis to therapy
Annals of the New York Academy of Sciences, 2018
Eosinophilic esophagitis (EoE) represents a chronic, local immune-mediated esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Other systemic and local causes of esophageal eosinophilia should be excluded. Clinical manifestations or pathologic data should not be interpreted in isolation. EoE was first described as a distinct disease entity in 1993. Most patients are diagnosed with underlying food allergies. The first diagnostic and therapeutic guidelines were published in 2007 with a first update in 2011. In 2017, new international guidelines were published based on the GRADE methodology. These guidelines provide, among many other topics, insights on the role of proton pump inhibitor-responsive esophageal eosinophilia. Over the last two decades, considerable progress was made by stakeholders regarding the understanding of EoE's pathogenesis, genetic background, natural history, allergy workup, standardization of assessment of disease activity, evaluation of minimally invasive diagnostic tools, and new therapeutic approaches. This brief review provides further insights into latest diagnostic and therapeutic advances.
EOSINOPHILIC ESOPHAGITIS: A LITERATURE REVIEW (Atena Editora)
EOSINOPHILIC ESOPHAGITIS: A LITERATURE REVIEW (Atena Editora), 2024
A esophagitis eosinofílica (EoE) is a chronic esophageal condition with an immunological and allergic etiology, characterized by symptoms related to esophageal dysfunction and histological findings of inflammation predominantly involving eosinophils. The aim of this study was to analyze recent research on aspects related to EoE. Methodology involved a search of scientific articles indexed in PubMed and EBSCO databases between 2018 and 2023, yielding 161 articles. Inclusion criteria included articles published within the last 5 years, with full-text availability. Paid articles and those published more than 5 years ago were excluded, resulting in the selection of 25 articles. Results and Discussion: EoE is a globally distributed disease with increasing incidence. Its primary immunological mechanism involves Th2 cells. External factors stimulate Th2 cells to produce interleukins (IL) such as IL-4, IL-5, and IL-13, with the contribution of an IgE-mediated pathway and other mediators like eotaxin-3. Symptoms vary with age and can resemble those of GERD. In children up to preschool age, symptoms include food refusal or intolerance and poor weight gain, while school-aged children commonly experience vomiting, epigastric pain, heartburn, and regurgitation. Treatment of EoE aims to mitigate esophageal inflammation to alleviate symptoms, prevent complications such as esophageal remodeling and fibrosis, and improve patient quality of life. Therapeutic approaches include medications like Proton Pump Inhibitors (PPIs), swallowed topical corticosteroids (fluticasone and budesonide), dietary interventions, mechanical dilation, and biologic medications. Dupilumab 300 mg weekly is the first selective systemic immunomodulatory biologic therapy approved for EoE in patients aged 12 and older, showing clinically significant benefits with a favorable safety profile compared to non-selective systemic immunosuppressants. Conclusion: Diagnosis of EoE is based on clinical and pathological evidence, including symptoms of esophageal dysfunction, mucosal changes, eosinophilic infiltration, and inflammation observed during endoscopy and biopsy. Treatment focuses on reducing esophageal inflammation to alleviate symptoms, prevent complications, and improve patient quality of life.
Eosinophilic esophagitis: New insights in pathogenesis and therapy
World Journal of Gastrointestinal Pharmacology and Therapeutics, 2016
Eosinophilic esophagitis (EoE) is a clinico-pathological entity with esophageal symptoms and dense esophageal eosinophilic infiltration throughout the esophagus that may persist despite treatment with proton pump inhibitors. This eosinophilic infiltration is usually absent in the stomach, small intestine and colon, although there are a number of reports of patients with a multiorgan involvement. EoE is associated with abnormalities involving TH2-dependent immunity, with multiple environmental factors strongly contributing to disease expression. The layer of the esophagus affected by the eosinophilic infiltration causes the specific symptoms. Esophageal involvement results mostly in dysphagia for solids that can be severe enough to cause recurrent esophageal obstruction with typical endoscopic features suggesting esophageal remodeling and pathological changes of eosinophilic infiltration of the mucosa, sub-epithelial fibrosis and muscle hypertrophy. This disease is frequently associated with other allergic conditions such as allergic asthma, allergic dermatitis and eosinophilia. The treatment of patients with EoE depends on the severity of the symptoms and of the inflammatory process as well as to their response to a gradual step-up treatment. The first line of treatment consists of steroid containing local inhalers. If unresponsive they are then treated with oral steroids. Intravenous interleukin blockers seem to have a consistent positive therapeutic effect.
Eosinophilic Esophagitis: Review and Update
Frontiers in medicine, 2018
Eosinophilic esophagitis (EoE) was first described in the 1990s, showing an increasing incidence and prevalence since then, being the leading cause of food impaction and the major cause of dysphagia. Probably, in a few years, EoE may no longer be considered a rare disease. This article discusses new aspects of the pathogenesis, symptoms, diagnosis, and treatment of EoE according to the last published guidelines. The epidemiological studies indicate a multifactorial origin for EoE, where environmental and genetic factors take part. EoE affects both children and adults and it is frequently associated with atopic disease and IgE-mediated food allergies. In patients undergoing oral immunotherapy for desensitization from IgE-mediated food allergy the risk of developing EoE is 2.72%. Barrier dysfunction and T-helper 2 inflammation is considered to be pathogenetically important factors. There are different patterns of clinical presentation varying with age and can be masked by adaptation h...
Treatment of Eosinophilic Esophagitis
Journal of Clinical Gastroenterology, 2010
Eosinophilic esophagitis (EE) is a chronic clinicopathologic syndrome and is the latest inflammatory disease of the esophagus described in literature. It seems to have a multifactorial etiology. Its causes include exposure to food or airborne allergens that affect individuals who may be genetically predisposed and exposure to the acid could also modulate the inflammatory response at esophageal level. However, we currently do not know how each of these possible etiologic factors contribute to the development of the disease that is essential to define specific treatment. We have used 3 different therapeutic approaches that were effective in patients with EE: various antiinflammatory drugs that are useful in treating asthma, controlling the exposure to allergens, particularly with respect to dietary changes and dilation of the esophagus. Although none of these treatments have absolute advantages, they can efficiently control the symptoms and inflammation in a large number of patients. Each treatment option should be assessed on a case-by-case basis in accordance with the experience of each center, the patients' characteristics, their sensitivity to allergens and their preferences. This article provides the latest information on the different treatment options for patients with EE, analyzing the advantages and disadvantages of each pathology and it offers practical recommendations on how to manage these patients who are being more frequently diagnosed.
Annals of Allergy, Asthma & Immunology, 2020
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4e12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: antieinterleukin-5 therapy, antieinterleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
Emerging Therapeutic Strategies for Eosinophilic Esophagitis
Current Treatment Options in Gastroenterology, 2013
Eosinophilic esophagitis (EoE) has emerged as a common cause of dysphagia and food impaction in children and adults. A trial of proton pump inhibitor (PPI) therapy is a mandatory diagnostic first step, given that at least one third of patients with suspected EoE will have PPI-responsive esophageal eosinophilia. Once EoE is diagnosed, short-and long-term therapeutic decision making may rely on patient symptoms, phenotype (inflammatory vs fibrostenotic) and preferences. Currently, the most reliable therapeutic targets are mucosal healing and caliber abnormalities resolution. Topical steroids followed by endoscopic dilation are recommended in symptomatic narrow caliber esophagus/strictures, whereas either topical steroids or dietary therapy are good short-term options for mucosal inflammation. Maintenance anti-inflammatory therapy is necessary to prevent esophageal fibrotic remodeling and stricture formation.