Eosinophilic esophagitis in adults: An ear, nose, and throat perspective

OBJECTIVES/HYPOTHESIS

Eosinophilic esophagitis is a rather new disease entity diagnosed with increasing frequency. The main symptoms in adults are dysphagia and food impaction. The aim of this review is to summarize the present knowledge about adult eosinophilic esophagitis, and in particular to cast light on certain issues of concern for the ear, nose, and throat (ENT) specialist.

STUDY DESIGN

Scientific review.

METHODS

The biomedical literature on adult eosinophilic esophagitis was reviewed regarding epidemiology, etiology, subjective symptoms and objective signs, diagnosis, treatment, and prognosis with an emphasis on matters of interest for the ENT specialist. PubMed was used as the search engine.

RESULTS

Among the 393 papers on eosinophilic esophagitis published in PubMed, only 162 deal with adults. During the last few decades, the annual number of papers has been exponentially increasing. A high prevalence of eosinophilic esophagitis in combination with a diagnostic delay suggests the existence of an unacceptable number of undiagnosed cases. This calls for increased attention. Endoscopic examination, including proper biopsies, verifies the diagnosis. Untreated, the disease will lead to substantial distress and in some cases even strictures. Keeping the diagnosis in mind will avoid improper treatment and the risk of accidental perforation.

CONCLUSIONS

It is imperative that ENT specialists recognize patients with eosinophilic esophagitis.

Paediatric eosinophilic oesophagitis presenting to the otolaryngologist

Introduction:

The prevalence of eosinophilic oesophagitis is increasing. A Pubmed search for ‘eosinophilic oesophagitis’ and ‘eosinophilic esophagitis’ yielded 345 publications since 1976. Only seven were in otolaryngology journals.1–7Patients typically present with dysphagia, vomiting, dyspepsia or food impaction and are therefore usually referred to a paediatric gastroenterologist; otolaryngologists are not usually involved in management. A missed diagnosis may result in oesophageal stricture.

Methods:

Two patients, aged two and four years, were referred to the paediatric otolaryngology department with intermittent upper oesophageal food impaction. A paediatric gastroenterologist was involved in the investigation. Histological examination of oesophageal biopsies demonstrated changes consistent with eosinophilic oesophagitis.

Results:

Both patients were expediently diagnosed, investigated and managed.

Conclusion:

A diagnosis of eosinophilic oesophagitis must be considered in patients presenting with food bolus impaction. Early involvement of a paediatric gastroenterology team in the diagnosis is recommended in children presenting with oesophageal symptoms, in order to avoid delayed diagnosis.

Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review

BACKGROUND

Eosinophilic esophagitis (EoE) is an emerging clinicopathologic entity defined by abnormal esophageal eosinophilic infiltration. Our understanding of this disease is hampered by the lack of a uniform diagnostic standard. The aim of this systematic review was to determine the range of diagnostic strategies and histologic criteria in the EoE literature.

METHODS

The MEDLINE-indexed literature from 1950 through December 31, 2006 was independently searched by two investigators. To identify additional relevant studies, bibliographies were hand searched, as were the published proceedings of the 2000-2006 American College of Gastroenterology and American Gastroenterological Association national meetings. Data were extracted from all human EoE case reports, case series, cross-sectional and cohort studies, and clinical trials.

RESULTS

Of 318 publications initially identified, 116 original articles, 39 abstracts, and 69 reviews were included. We found 10 different histologic definitions of EoE, ranging from 5 to 30 eosinophils per high-powered field (hpf), though 41 (35%) of the original articles did not state their diagnostic criteria. In the 13 original articles (11%) reporting an hpf area, the eosinophil density per mm(2) varied 23-fold. There was also variation in esophageal biopsy protocols, but specific protocols were reported in just 45 (39%) original articles.

CONCLUSIONS

Significant variability in diagnostic criteria for eosinophilic esophagitis exists, and in a large proportion of studies, criteria are not reported. Because of this lack of a common disease definition, conclusions drawn from the cumulative EoE literature should be viewed with caution. A consensus research-quality standard for diagnosis of eosinophilic esophagitis is needed.

Esofagitis eosinofílica

Eosinophilic esophagitis is characterised for a dense infiltration of the esophagus by eosinophilic leukocytes. The disease's origin is a local reaction to different antigens of which the patient presents previous sensitization, acquired by digestive, inhaled or even epicutaneous exposure. The esophagus contains different cellular types resident in its structure, with capability to participate in the capture, processing and antigens' presentation to T lymphocytes, which could initiate a T helper 2-type immunological response mostly mediated by interleukin-5, with a possible T helper 1-type component. Local production of immunoglobulin E could also participate in the pathophysiology of eosinophilic esophagitis, and for this reason, this disease can be considered a mixed-humoural and cell-mediated immunological disturbance. Studies directed to identificate responsible allergens must consider test for determine immunoglobulin E-mediated reactions as well as cell-mediated hyper-responsiveness responses. Main symptom of eosinophilic esophagitis are dysphagia and esophageal food impactations, which are conditioned by endoscopic alterations and motor disturbances objectively demonstrated by manometric recorders. Eosinophil and mast cell's activation and degranulation against responsible antigens cause damage over esophageal epithelium and dynamic disturbances over neuromuscular components in esophageal wall. Therapies proposed for eosinophilic esophagitis include control of antigen exposition, endoscopic dilation of stenosis and drugs with antieosinophilic effect; in this group topical steroids can be outlined for the capacity of them to restore the histology and the esophageal motility in parallel to vanishment of inflammation.

Esofagitis eosinofílica. Revisión de los conceptos fisiopatológicos y clínicos actuales

Eosinophilc esophagitis (EE) is an emerging disease which is characterized by a dense infiltration of the esophagus by eosinophilic leukocytes. The main symptoms of this disease are dysphagia and frequent food impaction in esophagus, and they are due to a hypersentivity response to different foods or aeroallergens. Eosinophil accumulation in the esophageal epithelium is determined by local production of eosinophilotropic cytokines and chemokines, which have been well defined as a TH2-type hypersensitivity reaction in animal models of the disease. Esophageal epithelium, after T CD4+ lymphocytes stimulation, contains all the necessary cell types for the development of local immunoallergic responses. However, there is increasing data on the significant role that humoral immunity could play in the pathophysiology of EE, by means of the action of IgE over mast cells function. The high density of T CD8+ lymphocytes in inflammatory infiltrate suggests that a TH1-type reaction could also participate in the mechanism of the disease. Proteins contained in cytoplasmic granules of activated eosinophils and mast cells could act over neural and muscular components of the esophageal wall, triggering motor disturbances which can be measured by means of manometric recordings and justify the esophageal symptoms. This paper aims to review the newest clinical aspects of EE and the results of studies directed at investigating the pathophysiology of the disease. Furthermore, we carry out a critical review of available therapeutic options.