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