Eosophagus

Question 1

What is the likely diagnosis for an infant with excessive secretions and choking episodes in whom a nasogastric tube cannot be passed into the stomach?

Answer 1

Esophageal atresia with tracheoesophageal fistula.

Question 2

What underlying diagnoses should be considered in a patient who presents with a meat impaction in the esophagus?

Answer 2

• Eosinophilic esophagitis
• Achalasia
• Esophageal stricture, congenital or acquired
• Prior esophageal surgery

Question 3

How is EoE diagnosed?

Answer 3

The diagnosis of EoE requires upper endoscopy . According to the most recent EoE guidelines, EoE is a defined clinicopathologic diagnosis that consists of isolated esophageal dysfunction and esophageal biopsies with greater than 15 eosinophils per high power field. Other causes of an isolated esophageal eosinophilia must be excluded, specifically GER and proton pump inhibitor responsive esophageal eosinophilia. Patients must be on an adequate dosage proton pump inhibitor for a period of 8 weeks before any biopsy.

Question 4

What are common endoscopic findings in EoE?

Answer 4

• Esophageal furrowing and edema
• Esophageal rings or “trachealization
• White plaques
• Esophageal strictures
• Mucosal tearing

Question 5

What causes esophageal eosinophilia in EoE?

Answer 5

EoE is an antigen-driven immune-mediated disease. Although aeroallergens have been implicated, specifically in mouse models, the ingestion of food antigens is responsible for greater than 98% of the disease. A pathological response induces a chronic inflammatory infiltrate in the esophagus with hyperplasia of the epithelia and muscular layers and fibrosis of the lamina propria.

Question 6

What are the symptoms of EoE?

Answer 6

• Infants/toddlers : FTT, feeding issues, irritability, vomiting, regurgitation
• Children : epigastric abdominal pain, vomiting, regurgitation, heartburn, and other gastroesophageal reflux disease (GERD) symptoms, and dysphagia
• Adolescents : GERD symptoms, heartburn, dysphagia, and food impaction

Question 7

What are the therapies for EoE?

Answer 7

• Oral steroids are used when severe symptoms are present and can promote immediate histologic and symptomatic recovery; however, they are not used long-term for maintenance therapy.
• Topical swallowed steroids are the most common pharmacologic medications used to treat EoE. These medications are used for both the initial treatment and for maintenance therapy.
• Dietary restriction involves the removal of the offending food antigen(s).
• Elemental formula is greater than 98% effective at inducing and maintaining disease remission; however, poor palatability and cost provide some limitations.
• A six-food elimination diet (removing dairy, wheat, eggs, soy, nuts, fish/shellfish) has been shown to improve symptoms and esophageal histology in 65% to 75% of patients.
• An allergy-directed diet using skin prick tests and atopy patch tests to determine offending foods has been shown to improve symptoms and esophageal histology in 60% to 70% of patients.