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)
Furrows
Exudates
Stricture
fixed rings
Minor Criteria
“Crepe Paper” esophagus (friable)
feline esophagus
Narrow- caliber esophagus
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
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
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
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
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
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