Causes, symptoms and treatment of eosinophilic esophagitis (EoE)

Eosinophilic esophagitis (EoE) is still a little-known but increasingly diagnosed chronic inflammatory disease of the esophagus that is often not recognized at an early stage. EoE can lead to reflux-like symptoms, difficulty swallowing and a feeling of food entrapment. This article provides an up-to-date overview of the background, history, epidemiology, pathogenesis, diagnosis, clinical symptoms and therapeutic options of this disease.

Background: EoE is a chronic inflammatory disease of the esophagus associated with atopic diseases. It is sometimes referred to as the "asthma of the esophagus". Although originally considered a rare disease, the incidence is increasing significantly. There is a high rate of non-recognition, with GPs and specialists from other disciplines being consulted in addition to gastroenterologists.

History: EoE is a comparatively young disease. It was only described in the 1990s by Stephen Attwood (England) and Alex Straumann (Olten, Switzerland).

Epidemiology and pathogenesis: The incidence and prevalence of EoE are increasing in industrialized countries, with higher prevalence in urban areas. Men in the third and fourth decades of life are most frequently affected. There is a link to atopic diseases, especially IgE-mediated food allergies in children and allergic respiratory diseases in adults.

Diagnosis: The diagnosis is based on three criteria: esophageal biopsies, typical endoscopic findings (severity grading using EREFS score) and exclusion of other causes. Visible changes during endoscopy may be stacked circular rings, furrows or strictures, but often there are no external signs, so biopsies are crucial. Investigations for eosinophilic infiltration in the stomach and duodenum and differentiation from gastroesophageal reflux disease (GERD) are important.

Clinic, symptoms and complaints: Symptoms vary with age. In adults, dysphagia is in the foreground, while children show reflux-like symptoms. Patients adjust their eating habits, which requires a detailed medical history. Delay in diagnosis can lead to serious complications, so a thorough medical history with specific questions is crucial for patients:

Discomfort when eating dry food
rapid swallowing due to time pressure
Necessity to drink at night
Stress when eating in company
Avoidance of certain foods
family history of swallowing difficulties or bolus obstruction.

Treatment options: There are three main treatment goals: Symptom control, inflammation control and prevention of complications. Three pillars form the basis: medication (mainly topical corticosteroids), diet (elemental diet, empirical or allergy test-based elimination diets) and dilation for strictures. Long-term therapy is necessary as EoE cannot be cured

Proton pump inhibitors (PPI): In adults, the first medical intervention is often the administration of PPIs, while in children PPIs are usually used after unsuccessful dietary changes.

Topical corticosteroids: If PPIs are not sufficient, topical corticosteroids such as fluticasone or budesonide may be prescribed. These are usually administered over a period of at least 8 weeks with subsequent dose reduction as part of the maintenance treatment of EoE.

Exclusion diet: The six-food elimination diet is a common recommendation in which potentially triggering foods such as milk, egg, soy, wheat, peanuts/tree nuts and fish/shellfish are sequentially eliminated from the diet.

esophageal dilation: Patients with significant stenosis may require cautious esophageal dilation to restore food passage.

New approaches: Recent experimental studies are using treatments with monoclonal antibodies against interleukin-13 (IL-13) and IL-5, which show promise.

Long-term care and patient compliance: Eosinophilic esophagitis (EoE) remains resistant to complete cure by medication or diet. If the anti-inflammatory therapies are discontinued, there is unfortunately a tendency for the inflammation to recur after a short time and for the associated symptoms to return. After successful induction therapy, it is therefore essential to initiate long-term maintenance treatment. Unfortunately, there is little correlation between symptoms and histologic/endoscopic activity, which is why even asymptomatic EoE patients require regular endoscopic surveillance. After a proven remission, it is recommended to perform an endoscopic control every one to two years. It is important to emphasize that treatment must be individualized and regular gastroenterological monitoring is necessary to prevent complications and progression of eosinophilic esophagitis in time.

What is important for your health: Even significant swallowing difficulties can initially go unnoticed due to avoidance strategies (such as avoiding certain foods, drinking more while eating and chewing longer) and gradual habituation.also look out for the presence of EoE in the case of unexplained retrosternal symptoms (such as cramps, pressure, pain, burning), which usually occur in connection with eating and occasionally also at rest, especially in atopic individuals.

Endoscopic findings can be subtle and therefore easily overlooked! Ask your doctor if esophageal biopsies have been taken during previous gastroscopies. If clinical suspicion persists, plan a repeat endoscopy with your GP with specific questions about eosinophilic esophagitis (EoE).patients with a characteristic history of dysphagia, but without histologic evidence of eosinophilia or other organic causes of swallowing difficulties, should be further evaluated for esophageal motility disorders (such as achalasia) and non-erosive reflux disease(24-hour impedance pH metry).

Can eosinophilic esophagitis be cured?

Eosinophilic esophagitis is a chronic disease with no definitive cure to date. It is triggered by various allergens that are ingested with food, and the complete elimination of all triggers is often not possible. Nevertheless, it is important to emphasize that eosinophilic esophagitis is extremely treatable and therefore requires appropriate therapy.

What is the aim of the treatment?

The treatment goals of eosinophilic esophagitis include two main aspects:

Control inflammatory activity: A major focus is to control inflammatory activity in order to control or prevent potential sequelae of eosinophilic esophagitis.

Improving quality of life: An equally important focus is on improving the patient's quality of life. The symptoms of dysphagia can have a major impact on daily life, both when eating and in social settings. The restrictions associated with the feeling of food blockage and regurgitation are a considerable burden for many patients. Therefore, treatment aims to restore a normal social life, including activities such as eating out.

How can the therapy change my symptoms?

As part of the therapy, there is hope and the possibility that the symptoms will be positively influenced. This means that swallowing difficulties will decrease and the tolerance of foods that may have been consumed before the onset of symptoms will increase.

It is important to try different foods during the course of the disease and during treatment to see if there is a noticeable improvement. In particular, one should actively move away from avoidant behaviors that many patients have developed over time.

However, it should be noted that side effects can also occur during treatment. These occasionally include a fungal infection of the esophagus, which can lead to a burning sensation in the esophagus or oral cavity. Although extremely rare, study reports have also noted weight gain, food cravings or insomnia due to systemic cortisone effects in very few patients. Careful monitoring of these aspects is advisable.

What consequences of eosinophilic esophagitis can be avoided by treatment?

Eosinophilic esophagitis can have serious consequences, including the formation of strictures, i.e. narrowing of the esophagus due to scarring. The inflammatory process leads to the deposition of connective tissue in the mucous membrane and underlying layers, which hardens the esophagus and causes strictures. These must be avoided at all costs.

In the worst case, bolus events can occur in which food gets completely stuck in the oesophagus. This means that neither water nor other food can be ingested. This carries the risk of aspiration, where liquid or saliva enters the lungs and causes inflammation. This is a real emergency and requires immediate action in the emergency room, including endoscopy.

Effective treatment of eosinophilic esophagitis is crucial, as long-term therapy can control and prevent both bolus impaction and fibrosis.

What are the treatment options for eosinophilic esophagitis?

The treatment of eosinophilic oesophagitis is based on the three Ds:

Drugs: Specific drugs are used to control the inflammatory activity. Although the disease cannot be completely cured, these drugs provide effective treatment and symptom relief.

Dilatations: In some cases, it may be necessary to perform dilatations due to narrowing of the esophagus. This process dilates the narrowed areas to facilitate the normal passage of food.

Diet: Dietary choices and adjustments play a crucial role in treatment. Dietary measures can help to identify and avoid potential triggers, which can help to reduce inflammation. The most common triggers of eosinophilic oesophagitis are:

Cow's milk
Wheat
Soy and legumes
Fish and seafood
Eggs
Nuts

The use of these three Ds makes it possible to treat eosinophilic esophagitis, thereby improving the quality of life of those affected.

What is local cortisone and why does it help with eosinophilic oesophagitis?

A local cortisone represents a specific drug formulation that targets the mucosa of the esophagus. This specific formulation allows the drug to act exclusively on the affected area without entering the systemic circulation and thus causing systemic side effects.

The effectiveness of this approach is based on the fact that inflammatory processes triggered by allergens are specifically downregulated. This strategy tricks the immune system to a certain extent by reducing the allergic reaction and displacing the eosinophils from the mucous membrane.

The targeted use of local cortisone in the treatment of eosinophilic oesophagitis is therefore an effective method of controlling inflammation and sustainably improving the quality of life of those affected.

What side effects can local cortisone have and what can I do about them?

The main side effect of local cortisone therapy is thrush esophagitis, a fungal infection of the esophagus. By suppressing the immune system, a ubiquitous fungus found in food can attach itself more easily to the esophageal mucosa and grow. This may manifest as a burning sensation in the mouth or esophagus, especially after initial improvement of symptoms.

To minimize the risk of this side effect, you can take action yourself:

Timing of intake: be sure to wait about 30 minutes to 1 hour after applying topical cortisone before consuming liquids or food. This will help to rinse off the cortisone film and make it more difficult for the fungus to colonize.

Regular monitoring: Discuss any signs of side effects with your doctor regularly. Continuous medical supervision enables the treatment to be adjusted in good time.

Hygiene: Good oral hygiene, including regular tooth brushing and the use of mouthwashes, can help minimize the risk of fungal infections.

Conscious use: Be careful not to inadvertently get the cortisone into your airways to avoid hoarseness.

By taking these measures, you can actively help to reduce the incidence of thrush and maintain the effectiveness of your treatment. If you have any questions or concerns, it is always advisable to discuss them directly with your doctor.

What is Jorveza and how is it taken for EoE?

Jorveza, a medication used to treat eosinophilic esophagitis (EoE), is taken according to doctor's instructions and may vary depending on individual needs. Here are general guidelines for taking Jorveza:

Taking the orodispersible tablet: Jorveza orodispersible tablet should be taken after a meal. Place the tablet on the tip of the tongue and gently press it against the roof of the mouth; the disintegration time is at least two minutes, but can take up to 20 minutes. The effervescent properties stimulate saliva production and the budesonide-containing saliva should be swallowed during disintegration. The melting tablet should not be taken with liquid or food.
After ingestion: At least 30 minutes should elapse before eating, drinking or performing oral hygiene and the melting tablet should not be chewed or swallowed undissolved to ensure optimal exposure of the esophageal mucosa to the active substance.
Prevention of fungal infections (thrush esophagitis): For people with an increased risk or with an existing fungal infection of the oral cavity, there are recommendations for prevention
- Usea soft toothbrush: This is gentle on the gums.
- Clean between the teeth: Dental plaque and food debris are removed in the process. It is important to proceed carefully and avoid damaging the mucous membrane.
- Mouthwash: Many sufferers rinse their mouth with antiseptic solutions.