Eosinophilic Esophagitis - Practical Gastroenterology

Eosinophilic Esophagitis
GERD IN THE 21ST CENTURY, SERIES #14
rences after short treatment periods we have tended to
taper the dose from 2 puffs bid to 1 puff bid after 6
months then 1 puff daily for a while. There is no
proven best way.
Systemic corticosteroids have been used with success,
usually in resistant patients; however, long term
use is not advised due to potential side effects including
stunted growth in children and candidiasis.
Other treatments include disodium cromoglycate,
a mast cell stabilizer, and leukotriene inhibitors such as
montelukast. We have seen one patient who was
unable to take inhaled steroids who took oral disodium
cromoglycate. She has remained asymptomatic for
several months and her esophageal eosinophilia is
gone. There are rare patients who must be placed on
immunomodulators such as azathioprine. Straumann
has rarely had to treat chronic patients with EE with
azathioprine alone (Straumann A., personal communication).
A pilot study has been conducted with
mepolizumab, a humanized monoclonal antibody
against IL-5 which suggests improvement in the
degree of eosinophilia in the tissue but these results
need to be further investigated (16).
TREATMENT (ESOPHAGEAL DILATION)
Straumann first described the “crepe paper” mucosa as
fragile with loss of elasticity thought to be pathognomonic
for EE, causing large lacerations after passing
the endoscope despite a lack of narrowing or resistance
(17).
Langdon suggested dilation for strictures from EE
should be done cautiously because of the risk of tear
and perforation due to the delicate nature of the
mucosa and recommended inspection of the esophagus
after each dilator has been passed (18).
Kaplan, et al recommended a minimum of 8 weeks
of medical therapy with proton pump inhibitors, histamine
antagonists, or immunosuppresants before
attempting dilation as patients with EE are more prone
to developing mucosal rents, even with passage of the
endoscope and perforation after dilation (3). We
encourage careful dilation, waiting several weeks after
steroids have been introduced, if possible. Often the
steroids will render the patient’s dysphagia asymptomatic
and dilation need not be performed.
CONCLUSION
Eosinophilic esophagitis is now better recognized by
both gastroenterologists and pathologists. Hopefully
through more expeditious and accurate diagnosis of
this specific disease entity, more information can be
obtained to improve patient care and the relief of their
symptoms with medical therapy and minimizing the
development of strictures. ■
References
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PRACTICAL GASTROENTEROLOGY • SEPTEMBER 2005