The first French recommendations on eosinophilic esophagitis in adults will soon be available. The key points of this document, which was developed under the auspices of the French National Society of Gastroenterology, were presented at the French-speaking Days of Hepato-Gastroenterology and Digestive Oncology by one of the working group members, Frank Zerbib, MD, PhD, head of the Department of Hepato-Gastroenterology at the University Hospital of Bordeaux in Bordeaux, France.
Eosinophilic esophagitis is a relatively new and emerging chronic esophageal condition. It is of allergic and immunologic origin and is characterized by an eosinophilic inflammatory reaction. The main allergens responsible come from food, making it a unique model of non–immunoglobulin E (IgE)-mediated food allergy.
The incidence of eosinophilic esophagitis, which is on the rise, is estimated at 50 per 100,000 people. It is the leading cause of dysphagia in young adults due to its fibro-stenotic evolution. It also is responsible for potential food impactions. In adults, dysphagia with solid foods and food impaction are the most frequently reported symptoms, with respective frequencies of 70%-80% and 33%-54%.
Five Lesion Types
In addition to dysphagia or food impaction, eosinophilic esophagitis in adults is characterized by a count of eosinophil polynucleocytes of at least 15 per high-power field (60/mm2) in esophageal biopsies in the absence of other causes of esophageal eosinophilia.
Five elementary endoscopic lesions of eosinophilic esophagitis have been described, namely, circular rings (pseudo-tracheal appearance), longitudinal furrows, exudates, edema, and strictures. However, a normal endoscopic appearance of the esophagus is observed in approximately 17% of adults with eosinophilic esophagitis.
Differential diagnoses of esophageal eosinophilia include eosinophilic gastroenteritis, hypereosinophilic syndrome (which is characterized by elevated eosinophils in the blood and symptoms such as abdominal pain, diarrhea, or ascites), achalasia, Crohn's disease, parasitic infections, certain autoimmune diseases, and a hypersensitivity reaction to medication. These differential diagnoses should only be considered if suggestive clinical signs are present.
Systematic Biopsies
In cases of dysphagia or food impaction, esophageal biopsies should be performed systematically during esophagogastroduodenoscopy, regardless of the appearance of the esophageal mucosa, according to the recommendations. When this examination is performed urgently for food impaction, staged esophageal biopsies should be taken from healthy mucosa and on macroscopically abnormal areas.
Rescheduling an endoscopy entails several risks, such as delaying the confirmation of the diagnosis, delaying treatment initiation, and increasing the risk for loss to follow-up. There is a strong recommendation, backed by moderate evidence, for the performance of at least six esophageal biopsies taken from at least two sites of the esophagus for diagnosis and follow-up. Eosinophilic infiltration is uneven, hence the need for multiple biopsies along the esophagus.
It is preferable to stop proton pump inhibitors (PPIs) before performing esophageal biopsies to search for eosinophilic esophagitis. The drugs should be stopped about 3 weeks in advance, according to the few publications on this point.
In case of spontaneous resolution of a food impaction episode, a gastroenterology consultation and an esophagogastroduodenoscopy are advised.
Therapeutic Objectives
The initiation of treatment for eosinophilic esophagitis aims to achieve symptomatic relief (eg, of dysphagia), histological remission, and prevention of relapses. An endoscopy with biopsies is recommended at 6-12 weeks after the start of treatment because clinical response is not always correlated with histological response. The latter is defined by less than 15 eosinophils in the esophageal mucosa per high-power field (or 60/mm2).
The initial treatment, which lasts 6-12 weeks, is primarily based on PPIs, orodispersible budesonide, or an elimination diet. In patients whose eosinophilic esophagitis has been confirmed, PPIs effectively induce a clinical and histological response. They represent a first-line therapeutic treatment (off label) with 50%-60% effectiveness. They should be prescribed twice per day for a minimum of 8-12 weeks to achieve clinical and histological response, according to the recommendations.
If PPIs fail, then local corticosteroids (specifically, orodispersible budesonide) are effective in inducing a clinical and histological response. At 12 weeks, the efficacy of orodispersible budesonide reaches 85%.
As a third-line treatment, if orodispersible budesonide fails to establish a clinical or histological remission, dupilumab can be prescribed. This monoclonal antibody targets interleukin 4 and 13 receptors. It is effective in achieving both types of response and has European marketing authorization for this indication. In pivotal studies, dupilumab had an efficacy of approximately 80% at 24 weeks.
The elimination diet targets one to six food groups (dairy products, wheat, eggs, soy and legumes, nuts, and seafood and fish). It represents an alternative to drug treatment, although it is complex to implement. It should be supervised by an experienced dietitian, especially because it carries a risk for vitamin and nutritional deficiencies, weight loss, and eating disorders. Allergy tests (specific IgE levels in serum, skin prick tests, or patch tests) do not help guide this elimination or reintroduction diet. Instead, an endoscopy with biopsies should be performed after the reintroduction of each food group to quantify esophageal eosinophilia.
Finally, endoscopic dilation (with a balloon or bougie) is safe and effective in improving the symptoms of patients with a fibro-stenotic form of eosinophilic esophagitis. It should be combined with medical treatment with the intention of preventing relapses, according to the recommendations.
Systemic corticosteroid therapy is not recommended for eosinophilic esophagitis.
Therapeutic Management
Less than 10% of patients with eosinophilic esophagitis fail to respond to available treatments. In cases of refractory disease, it is advisable to refer the patient to an expert center.
According to retrospective studies, approximately 90% of patients relapse upon discontinuation of treatment with PPIs or local corticosteroids. Therefore, maintenance treatment is necessary, using the medical treatment that achieved clinical-histological remission, whatever it may be. During annual and long-term clinical follow-up, the gastroenterologist evaluates the evolution of symptoms, compliance with maintenance treatment, and the need for an endoscopy.
"Early diagnosis and treatment of eosinophilic esophagitis can prevent long-term fibro-stenotic complications," said Zerbib.
Zerbib received compensation from Sanofi, Dr. Falk Pharma, Bioprojet, BMS, and AstraZeneca.
This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.