Eosinophilic esophagitis: what is it, symptoms, treatment, causes

general information

Eosinophilic esophagitis is a chronic inflammatory disease of the esophagus.

The inflammatory process is supported immune-mediated response, in which a large number of eosinophils, special type leukocytes.

The causes of eosinophilic esophagitis are still unknown, but inflammation can be influenced by a combination of genetic and environmental factors. This condition is often associated with allergic syndromes, caused by food antigens. Eosinophilic esophagitis can occur in both children and adults, mainly in men.

People with eosinophilic esophagitis are most likely to have dysphagia, food bolus occlusion, gastroesophageal reflux, and retrosternal burning and pain (heartburn). Over time, inflammation of the esophagus can lead to chronic narrowing (stenosis) of the esophagus.

The diagnosis of eosinophilic esophagitis is based on endoscopy of the upper digestive tract, in combination with biopsy taken from the mucous membrane of the esophagus.

For most patients, corticosteroid therapy, removal of food antigens from the diet, and possible endoscopic enlargement of the esophagus can effectively control symptoms.

What is eosinophilic esophagitis?

Eosinophilic esophagitis is chronic illness, which can affect the esophageal mucosa at any age.

The underlying inflammation is immune-mediated (that is, caused by the immune system in accordance with the mechanism of autoimmune diseases).

Symptoms of eosinophilic esophagitis may include pain or difficulty swallowing (dysphagia), reflux, heartburn, and vomiting. In some patients, the esophagus may narrow to a point, blocking the passage of food.

Causes and risk factors

The exact causes of eosinophilic esophagitis are still not entirely clear. However, the connection between inflammation of the esophagus and allergic and / or atopic pathologies known (in about 70% of cases, eosinophilic esophagitis appears in combination with allergic rhinitis, bronchial asthma or atopic dermatitis).

People with genetic predisposition eosinophilic esophagitis is mainly caused by the intake of certain food antigens (such as milk, eggs, soy, etc.), but the reaction can also be caused by environmental allergens.

Physiopathological mechanisms

Eosinophilic esophagitis is associated with esophageal dysfunction resulting from predominantly eosinophilic inflammation.

With regard to the maintenance of the inflammatory process, overexpression of some mediators plays a significant role. (including interleukins and chemokines), which "resemble" eosinophils (through chemotaxis) and regulate them activation. This explains the high density of these immune cells at targeted tissue levels and the associated injury.

Eosinophilic exophagitis: what are eosinophils?

Eosinophilic esophagitis owes its name to the fact that the disease is characterized by a strong accumulation of eosinophils (also called eosinophilic granulocytes) in the squamous epithelium of the esophagus; these cells are usually involved in immune responses to allergens or parasitic invasions.

In the case of eosinophilic esophagitis, a large number of eosinophils penetrate the epithelial tissue of the esophagus, causing various gastrointestinal symptoms such as reflux, frequent vomiting, difficulty swallowing, and pain in stomach.

Who is most at risk

• Eosinophilic esophagitis can occur at any time, but it mainly occurs during the period between infancy and adulthood. Only in a few cases does the disease first appear in older people.
• The disease is more common in men. The prevalence in men compared to women is 3: 1.
• Eosinophilic esophagitis is often associated with allergic syndromes. This disease is most common in people with bronchial asthma and food allergy.
• A high incidence of eosinophilic esophagitis is observed in patients with family history this disease, which confirms the hypothesis of a genetic basis.

Symptoms and complications

Eosinophilic esophagitis is characterized by alternating periods of remission and activity.

Symptoms of eosinophilic esophagitis change with age and may include pain or difficulty swallowing (dysphagia), reflux, heartburn, and vomiting. In some patients, the esophagus may narrow to the point that it can obstruct or block the passage of a food bolus.

Adults

In adults, the most common symptom of eosinophilic esophagitis is difficulty swallowing (dysphagia), especially if solid food is swallowed.

Less commonly, the disease may show signs of other esophageal disorders, such as gastroesophageal reflux disease, and manifest such signs as heartburn (feeling burning and chest pain). These manifestations usually do not respond to proton pump inhibitor drugs.

Eosinophilic esophagitis can also present with symptoms:

• retrosternal, epigastric and / or abdominal pain;
• vomiting;
• anorexia and early satiety.

Over time, inflammation also includes stopping the digestive tract and narrowing of the esophagus (or stenosis).

Sometimes it may not be present eating disorders, such as diarrhearecurrent or chronic laryngitis, recurrent asthma attacks, and bronchopneumonia.

Children

In childhood, eosinophilic esophagitis is manifested mainly by typical reflux disorders that do not respond to conventional therapy, such as heartburn and food regurgitation.

Inflammation of the esophagus can also be associated with less specific symptoms, such as:

• vomiting with frequent mucus;
• lack of appetite;
• excitement and crying while eating;
• belching;
• hiccups;
• pain in the abdomen or chest;
• intolerance to certain foods;
• weight loss;
• burning in the chest;
• epigastric or abdominal pain.

Associated complications and diseases

• Untreated chronic inflammation can lead to narrowing of the esophagus (stenosis).
• People with eosinophilic esophagitis may have manifestations of allergies or other atopic conditions (such as asthma, allergic rhinitis, eczema, etc.).

Diagnostics

Eosinophilic esophagitis is considered by a doctor if episodic dysphagia occurs, intestinal obstruction or noncardiac chest pain. Diagnosis is by biopsy-supported upper gastrointestinal endoscopy.

Complete medical history

As a rule, the first symptoms appear in young people (20 to 30-35 years old), but the age at diagnosis can be very different (1-89 years old). The doctor may also suspect the disease if gastroesophageal reflux does not respond to acid suppression therapy with proton pump inhibitors (even at high doses).

Upper digestive tract endoscopy

The diagnosis of eosinophilic esophagitis is confirmed after endoscopy of the upper digestive tract using a flexible probe (esophagogastroduodenoscopy, EGDS).

Endoscopic features often associated with eosinophilic esophagitis include:

• longitudinal narrowing of the esophagus or isolated stenosis (proximal or distal);
• longitudinal ruptures of the mucous membrane along the entire course of the esophagus;
• exudative or diffuse whitish spots of the mucous membrane;
• widespread nodularity and / or graininess;
• multiple rings of the esophagus, not completely smoothed by insufflation (feline folds or feline esophagus);
• pseudodiverticulosis.

When passing through an endoscope esophageal mucosa due to frequent fragility may bleed or crack.

As an additional endoscopic examination, a radiological examination. In addition to confirming a decrease in the size of the esophagus, this examination provides information about the distension of the walls.

Esophageal biopsy

During the endoscopy, the doctor takes fabric samples for analysis under microscope (biopsy). Bioptical examination shows the presence of significant eosinophilic infiltration (more than 15 eosinophils / for high field microscopic magnification) at the level of the squamous epithelium of the esophagus. Biopsy samples are necessary for the diagnosis of eosinophilic esophagitis, since the appearance of the esophageal mucosa may be normal for endoscopic vision.

In a patient with concomitant gastrointestinal disorders (eg, diarrhea and abdominal pain) with biopsy examination of the esophagus, it is necessary to add the removal of tissue from the stomach and duodenum intestines; this allows checking the involvement of eosinophilic infiltration and excluding other comorbidities.

Eosinophil count and differential diagnosis

The presence of an eosinophilic infiltrate in the squamous epithelium of the esophagus is common to several pathological conditions, including: gastroesophageal reflux disease, parasitosis, Crohn's diseaseand lymphoma. The "distinguishing" element is quantity: in eosinophilic esophagitis, eosinophils outnumber these conditions.

For this reason, it is important that the pathologist quantify the density of eosinophils using a microscopic field. Usually, to diagnose eosinophilic esophagitis, it is necessary to find a number equal to or greater than 15 eosinophils for HPF (strong field, that is, an increase of x400), in combination with other signs of eosinophilic infiltration.

Allergy test

To determine possible factors associated with eosinophilic esophagitis, the doctor may expose the patient to food and respiratory allergy testswhich may include skin testing (allergy tests) or radioallergosorbent test (RAST).

Summing Up: Diagnostic Criteria for Eosinophilic Esophagitis

The criteria for the diagnosis of eosinophilic esophagitis are:

• Availability majorsymptoms (dysphagia, food bolus occlusion, heartburn and reflux);
• ≥ 15 eosinophils / HPF with histological analysis of a biopsy sample;
• Lack of clinical response on full dose proton pump inhibitors.

Treatment

Treatment options for eosinophilic esophagitis include various interventions. In most cases, topical corticosteroid therapy, elimination of dietary antigens from the diet, and any endoscopic dilation will provide good symptom control.

Dietary changes

• If food allergy strongly suspected based on the patient's medical history and detected by objective allergy tests, the doctor may prescribe a targeted diet to eliminate allergies.
• In the absence of specific food sensitization, the diet of a patient with eosinophilic esophagitis may include empirical elimination of major allergens (milk, eggs, wheat, soy, peanuts and fish) for about 8-12 weeks.
• However, for patients with multiple allergies, the doctor may prescribe elementary (amino acid) dietexcluding all whole proteins.

The decision to adopt a specific dietary approach is more appropriate for children than for adults.

Treatment of eosinophilic esophagitis in childhood.

In children, initial therapy for eosinophilic esophagitis may:

• Include deprivation diet based on special allergy tests;
• Include elimination the most common allergenic products.

Overall, the results of this intervention are satisfactory and in many cases limit the need for corticosteroid therapy.

Corticosteroids

The most useful medications for controlling the symptoms of local esophagitis are corticosteroids (such as propionate fluticasone and budesonide).

The preferred method is the administration of reusable oral inhalers (considering the absence of side effects after systemic therapy and high local anti-inflammatory efficacy). In the case of eosinophilic esophagitis, it is possible to spray the drug in the mouth and swallow it: thus, the drug covers the esophagus and does not enter the lungs. Alternatively, before swallowing budesonide can be mixed with sugar substitute.

After taking the drug, the patient should rinse the mouth with water (to avoid a fungal infection such as candidiasis) and not drink and do not eat for at least 30 minutes (for maximum local anti-inflammatory effect at the mucosal level esophagus).

Corticosteroids for eosinophilic esophagitis are usually given 6 to 8 weeks, 30 minutes before breakfast and 30 minutes before lunch. This therapy should be repeated if symptoms reappear.

Endoscopic therapy

When subjects have recurrent episodes of dysphagia and significant stenosis, the physician may resort to using hydrostatic cylinder or solid esophageal dilator. Endoscopic esophageal dilation is performed by experienced endoscopists with extreme caution to prevent rupture and perforation of the esophagus.

In case of food bolus occlusion endoscopic dilation provides a quick dissection of the esophagus.

Forecast

Complications of untreated eosinophilic esophagitis include fibrosis of the lamina propria and the formation of constrictions, which increase the risk food obstruction and perforation of the esophagus.

Correct and timely treatment of pathology allows the patient to maintain a good quality of life.