EoE: NEW GUIDELINES

*first guidlines on EoE from American College of Gasteroenterology

*addressing controversies in diagnosis and management

*heterogenity in definitions and endpoints

*few recommendations with high levels of evidence.

ENDOSCOPIC FEATURES OF EoE

*Validated endoscopic features

*Major Criteria

– Mucosal pallor (edema, loss of vascularity)

-, 2mg Furrows

– Exudates

– Stricture

– fixed rings

*Minor Criteria

– “Crepe Paper” esophagus (friable)

– feline esophagus

– Narrow- caliber esophagus

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TREATMENT OF EoE: Steroids

*Swallowed steroids work well

* Fluticasone (children, 88-440 ug; adults, 800-1760ug)

*Budesonide (children, 1mg; adults 2mg)

*split daily doses

*systemic steroids for refractory patients

*maintenance therapy; limited data

*Endoscopic reassessment: < 15eos/hpf Page 4: TREATMENT OF EoE: Diet *if no response to steroids: dietary approach *test for food allergies; 13% of tests helpful *use selective withdrawal diet -remove common food allergens (wheat,soy, milk, nuts, eggs, seafood) -replace 1 food group every 4-6 weeks *rebiopsy or follow symptomatically *work with a dietician Page 5: OTHER TREATMENT CONSIDERATIONS *Esophageal dilation during diagnostic evaluation -presenting with food impaction -hydrostatic balloon preferred -stop if mucosal disruption occurs -warn patients of chest pain following dilation *Educate about chewing, swallowing, cutting foods, and foods to avoid *Consider maintenance therapy in rapid relapsers *Candidiasis risk with swallowed steroids Page 6: THERAPY AND EoE *many have PPI-responsive eosinophils in the esophagus *some GERD patients have esophageal eosinophils *trial of PPi therapy before EoE diagnosis *PPI for 8 weeks, once or twice daily *reassess endoscopically or symptomatically Page 7: MAKING THE DIAGNOSIS OF EoE *adult presentation: food impaction *children: failure to thrive, abdominal pain, vomiting *endoscopic confirmation: 15 eos/hpf *exclude other causes *need 4 biopsies from 2 separate areas *doing 6-9 biopsies increases sensitivity *do biopsy even if endoscopic appearance is normal