Eosinophilic Oesophagitis (EoE) is estimated to affect about 1 in 100 adults in Australia1 and the number of cases are increasing.
Several factors could be contributing to this rise in EoE –
- More gastroscopy procedures are being performed and more biopsies being taken
- More early-life exposures to certain medications e.g.antibiotics
- Changes in the oesophageal microbiome due to diet and certain medications
Symptoms and Diagnosis of Eosinophilic Oesophagitis
This chronic condition involves immune-mediated responses primarily localised to the oesophagus, often categorised within the atopic disease spectrum. It’s characterised by an elevated presence of eosinophils triggered by food-related allergens (80%) or, less commonly, aeroallergens. This immune response leads to inflammatory changes, and over time can result in fibrosis and stricturing of the oesophagus.
Clinically, Eosinophilic Oesophagitis (EoE) manifests as motility issues, presenting with symptoms like dysphagia, food bolus obstruction, chest pains, and heartburn.
Diagnostic challenges can arise as initial gastroscopy may appear normal. However, more advanced cases may display fine exudate, granularity, and a tracheal-like appearance of the oesophagus. For accurate diagnosis, it’s essential to perform biopsies from the lower, middle, and upper oesophagus – a total of 12 biopsies. It’s important to note that one or two biopsies are insufficient for a definitive diagnosis of Eosinophilic Oesophagitis.
Therapeutic approaches to consider
1. Proton Pump Inhibitor (PPI) Trial: Initiate a PPI trial with doses as high as 40 mg bd to induce remission. After achieving remission, the dosage can be reduced to standard maintenance levels. Approximately 50% of patients respond positively to this approach. Long-term PPI use is an option for some patients.
2. Elimination Diet: Implement a food elimination diet, which could involve eliminating two, four, or six specific foods. Dairy is the most common allergen, followed by wheat, soy, eggs, and then nuts and fish. Beyond the main allergens, there are an additional 15-20 foods identified in international literature, including pork, beef, chickpeas, and carrots. The elimination diet requires multiple gastroscopies as patients cycle through food elimination and reintroduction. The sequence and reintroduction options can be discussed with a dietitian and gastroenterologist. Elemental diet can be used to determine if a food culprit is involved.
3. Orodispersible Budesonide (Jorveza): This option involves direct contact with the oesophageal mucosa. It requires an authority script and entails a higher induction dose. Long-term follow-up over five years is recommended, with no alarm signals. This approach has an 85% chance of achieving remission.
As we continue to advance our understanding and treatment of EoE, these therapeutic options provide valuable tools for managing this complex condition. Collaboration between clinicians, dietitians, and other specialists is crucial to tailor treatment plans to individual patient needs.
- Australasian Society of Clinical Immunology and Allergy. Eosinophilic Oesophagitis [Internet]. Sydney: ASCIA, 2014 [updated January 2014]. www.allergy.org.au/patients/food-other-adverse-reactions/eosinophilic-oesophagitis