EOSINOPHILIC ESOPHAGITIS

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EOSINOPHILIC ESOPHAGITIS

• ATILLA ERTAN, MD, FACP, AGAF, MACG

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Disclamer

• Grant/Research Support from Centocor, Abbott
  Labs, Elan-Biogen, UCB Salix Sucampo
  Pharmaceuticals, Genentech, Axcan Barrx Inc.
• Scientific Advisory Board Member for Centocor,
  UCB Pharmaceuticals Inc, Abbott Laboratories
  Prometheus Labs.

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Learning Objectives for EoE

• Recognize differential diagnosis
• Understand its pathogenesis
• Identify diagnostic criteria
• Recognize management difficulties different
  therapeutic approaches

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Eosinophilic Esophagitis (EoE)

• 12 adults over 2 yr period with gt20 IEE
• Dysphagia predominant complaint
• Unremarkable EGD
• pH monitoring normal in 11
• Attwood SE et al, Dig Dis Sci 38 109, 1993

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D.W.S. 1740111-8

• A 37 y/o male with a 5 yrs h/o intermittent
  food dysphagia food impactions who had related
  ER visits. During one of these episodes, he came
  to TMH ER.
• MED None
• ALL Penn, shellfish
• PMH/PSH Hay fever
• SH Married, lawyer, denied T, ETOH IVDA
• FH Noncontributory
• ROS/PE Unremarkable
• Emergent EGD biopsy findings

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D.W.S. 1740111-8
Post food impaction 3-20-2003
Food impaction 3-20-2003
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D.W.S. 1740111-8Linear furrowing, vertical
lines white specks
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EOSINOPHILIC ESOPHAGITIS EoE

• EoE is a chronic and recurrent inflammatory
  disease with increase prevalence woldwide and
  characterized by
• Dysphagia, food impaction, GERD less commonly
  chest pain in predominantly white males (75-82)
• 15 intraepithelial eosinophils/HPF leads to
  fibrosis and angiogenesis, with mural thickening,
  loss of elasticity of the esophageal wall and
  stricture formation.
• Exclusion of other disorders associated with
  similar clinical, histological, or endoscopic
  features
• ____________________________________________
• Gastroenterol 133 1342-63, 2007, Gastroenterol
  134 204-14, 2008
• Gastroenterol 140 82-90, 2011.

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PATHOGENESIS OF EoE

• EoE is associated with an allergic response to
  environmental antigens that lead to cytokine
  mediators associated esophageal eosinophilia.
• IL-5, IL-13 , IL-15 and other cytokines may play
  a major role in eosinophilic recruitment by
  response to certain food proteins.
• There is a clear disarray between circular
  longitudinal muscle contractions during the
  peristalsis.
• Esophageal distansibility was significantly
  reduced compared with controls by using a
  functional luminal imaging probe EndoFLIP.
• __________________________________________________
  __________________________________________________
  __________________________
• J Allergy Clin Immunol 120 1292-300, 2007
• Gut 59 12-20, 2010
• Gastroentrol 138 275-284, 2010 139 182, 2010
  140 82-90,2011

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ENDOSCOPIC FEATURES OF EoE

• ______________________________________
• Unremarkable endoscopic mucosa lumen.
• Circular rings, transient or fixed, feline
  esophagus
• Linear furrowing, vertical lines of the mucosa
• Linear shearing/crepe paper mucosa with passage
  of endoscope or dilator
• White exudates/specks, nodules or granularity
• Stricture/rings proximal, middle, or distal.
• ______________________________________
• Gastroenterol, 133 1342, 2007 (modified).
• None of the features are specific for EoE.

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J.M.H. 2096026-6Linear shearing
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A.E. 2096036-5Circular rings, feline
esophagus
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I.E. 3659813-1Barretts islands EoE with
transient circular rings
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EGD biopsy for patients with EoE

• More than 5-6 biopsies had a sensitivity of 100
  even in an unremarkable mucosa.
• Due to scaterred histologic distribution,
  proximal, mid distal esophagus should be
  biopsied.
• Mucosal eosinophilia may show a seasonal
  variation, possibly related to allergies.
• Gastrointest Endosc, 64 313, 2006
• Am J Gastroenterol, 104 716, 2009
  

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Differential Diagnosis of EoE

• _______________________________________
• Crohns disease
• Connective tissue disorders
• Hypereosinophilic syndrome
• Infections herpes candida
• Drug sensitivity response
• Eosinophilic gastroenteritis
• _______________________________________
• These diseases may have intraepithelial
  eosinophilia but less than
• 15/HPF in one or more biopsy specimens.

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EoE BARRETTS ESOPHAGUS BE

• BE or BD has not been reported in patients with
  EoE (1,2).
• EoE is not a disease characterized by mucosal
  ulceration or destruction. Therefore, it seems
  likely that the pathologic process of EoE is
  different from that of GERD and that adenoca or
  squamous ca of the esophagus are not the spectrum
  of EoE (2).
• Recent studies and our experience showed that
  this relation is not uncommon.
• 1. Am J Gastroenterol, 101 1900, 2006.
• 2. Gastroenterology, 133 1342, 2007.

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A.P. 01911497-4

• A 47 y/o male with a 9-10 yrs h/o GERD who had
  recent dysphagia few episodes of food
  impaction. He diagnosed as having L.S. Barretts
  with HGD/LGD EoE.
• MED Zegerid 40 mg BID
• PMH/PSH FH Unremarkable.
• SH Married, IT executive, no tobacco, ETOH or
  IVDA.
• ROS Gained 40 lbs within last 10 yrs.
• PE Essentially unremarkable except moderate
  obesity.
• LAB Unremarkable CBC-diff, SMA-6 other
  blood tests. Chest/abd CT scan
• EUS

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Case AP

• Previous history of food impactions

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A.P. 01911497-4L.S. BE with MF/HGD EoE with
transient circular rings
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Case AP

• Pathology

Basal zone hyperplasia, increased
eosinophils Intraepithelial eosinophils of
eosinophils
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EUS
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A.P. 019114974 L.S. Barretts with HGD EoE
, S/P RFA
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ALLERGY EVALUATION IN PATIENTS WITH EoE

• The majority of patients with EoE is atopic based
  on the coexistence of atophic dermatitis,
  allergic rhinitis, and/or bronchial asthma with
  antigen skin sensitization abnormal plasma
  antigen-specific IgE.
• 10-50 of adults had peripheral eosinophilia.
• Most patients improve on allergen-free diets.
• Allergist consultation may be recommended.
• __________________________________________________
  ________
• Clin Gastroenterol Hepatol 31198-206, 2005.
• J Pediatr Gastroenterol Nutr 4222-6, 2006.

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Medical Management 1

• Removal of allergenic foods diary, eggs, wheat,
  soy, peanuts, fish/shellfish- with unpredictive
  allergy testing in adults-, may be effective. The
  elemental diet may be helpful in severe cases (1)
• Endoscopic dilatation is useful in pts with fixed
  strictures/rings. The risk of mucosal tearing
  and perforation are relatively higher (2,3).
• __________________________________________________
  ___________________
• 1. Clin Gastroenterol Hepatol 4 1097-102, 2006.
• 2 3. Gastroenterology 127 364-5, 2004
  1331342-6, 2007.

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MEDICAL MANAGEMENT 2

• 16 to 50 of pts showed improvement with PPI
  treatment (1,2)
• Topical rarely systemic corticosteroids resolve
  symptoms. Fluticasone 440 mcg BID for 6-8 weeks
  may be effective for an induction therapy (3)
• A pilot trials with anti-IL-5Mepolizumab,
  leukotriene D4 receptor ab Montelukast
  Infliximab showed improvement in pts with severe
  EoE.
• Budesonide suspension (0.25 mg/ml) inhalation BID
  (4) for 50-wks.
  
• __________________________________________________
  _
• 1 2. J Gastroenterol 101 1666-70, 2006 Clin
  Gastroenterol Hepatol 9 110-7, 2011
• 3. Gastrointest Endosc 633-12, 2006 Clin
  Gastroenterol Hepatol 9 400-9, 2011