Eosinophilic esophagitis (EoE) used to be recognized only as a pediatric disease. Its prevalence in adults who present with dysphagia and, often, food bolus obstruction has become better known (JW Gastroenterol Mar 28 2006). Esophageal dilation is necessary in the majority of affected patients.

Researchers now present long-term treatment data from 16 consecutive adult patients (age range, 20–58; 75% men) who met diagnostic criteria for EoE, had detailed histories taken, and underwent baseline upper gastrointestinal endoscopy with multiple esophageal biopsies. Of these patients, 15 were receiving proton-pump inhibitor therapy, 13 underwent initial esophageal dilation, 1 was treated with a restrictive diet, and 1 received topical (swallowed) fluticasone.

Follow-up data (mean, 22 months) were available for 10 patients, 9 of whom had initially undergone esophageal dilation. None experienced food impaction, and only one required further esophageal dilation. Surprisingly, only two patients experienced intermittent dysphagia; eight were asymptomatic at follow-up. The average dysphagia score decreased significantly, from 2.1 to 0.3 (P<0.002). No significant change from baseline to follow-up was evident in the mean number of eosinophils per high-power field, either proximally or distally. The esophageal mucosa normalized in one patient; gross endoscopy findings were unchanged in the other patients. Eight patients were tested for allergens: Six were positive for food allergens, and five were positive for aeroallergens.

Comment: Clearly, esophageal dilation does not influence the underlying inflammatory process in EoE. Symptom improvement despite persistence of eosinophilic inflammation suggests that tissue remodeling contributes substantially to symptom generation. In my experience, providing detailed, specific dietary instructions is extremely helpful to patients with EoE. I advise them to cut all food into small pieces before ingesting it and to avoid tough meat, doughy bread or pasta, hard uncooked foods (e.g., fruit and raw vegetables), and anything with a skin (e.g., potatoes and fresh fruit). We obviously still need more data on the natural history of EoE to identify optimal long-term care strategies for this increasingly prevalent disease. In the end, adults with EoE might require less therapeutic intervention than initially reported for pediatric patients.

Published in Journal Watch Gastroenterology September 3, 2010