Adult Eosinophilic Esophagitis

Burden of Disease

The global prevalence of EoE is estimated to be 50-100 per 100,000 people. The growing global prevalence of EoE and the burden that patients experience highlights the increased need for awareness and identification of patients with EoE.^1,2

Patient Burden in Eosinophilic Esophagitis

Watch this short video to learn about the burden patients with eosinophilic esophagitis experience, including physiological, psychiatric, and social impact on quality of life.

Symptoms of EoE Impact Quality of Life for Patients

Dysphagia and food impaction negatively impact quality of life and patients with EoE may develop compensatory eating behaviors to cope. Compensatory eating behavior leads to delay in seeking medical attention and proper diagnosis of EoE. Symptoms of EoE impact patients differently depending on patient age and the progression of disease (FIGURE 1).^1,3-7

FIGURE 1. Impacts of EoE on Patient Quality of Life.^1,3-7
*Responses from semi-structured interviews with adults diagnosed with EoE.
EoE, eosinophilic esophagitis; QoL, quality of life.

Coexisting Type 2 Diseases Add to Patient Burden

Type 2 inflammatory diseases commonly coexist in patients with EoE. Atopic comorbidities (asthma, atopic dermatitis, food allergy) should increase clinical suspicion of EoE (FIGURE 2).^2,4,8-10

FIGURE 2. Prevalence of Coexisting Type 2 Inflammatory Diseases in EoE Patients.^2,4,8-10
EoE, eosinophilic esophagitis.

Pathophysiology

Type 2 inflammation underlies the esophageal dysfunction, barrier disruption, and disease progression behind the signs and symptoms of eosinophilic esophagitis.^5,10-29

Eosinophilic Esophagitis: Understanding the Pathophysiology of Type 2 Inflammation and Disease Burden

Watch this short video to learn about the pathophysiology of eosinophilic esophagitis, the various cell types involved, and the role of type 2 inflammation in this chronic, progressive disease.

Type 2 Inflammation in EoE

Underlying type 2 inflammation is the main driver of EoE pathophysiology (FIGURE 3).^11-29

FIGURE 3. IL-4 and IL-13 Are Key and Central Drivers of Type 2 Inflammation That Mediate Pathophysiology of EoE.^11-29
EoE, eosinophilic esophagitis; IL, interleukin; Th2, T helper type 2.

Pathophysiology and Progressive Remodeling of the Esophagus

Persistent type 2 inflammation results in progressive remodeling and fibrosis when EoE is left untreated
(FIGURE 4).^{1,5,13,17,27,30,31}

FIGURE 4. Inflammatory and Fibrostenotic Progression of EoE Over Time.^{1,5,13,17,27,30,31}
*Endoscopic images of the esophagus (left to right): First and second provided by U. von Arnim, last image from Hirano I, et al.³¹
Reproduced from Hirano I, et al.³¹ with permission from BMJ Publishing.
EoE, eosinophilic esophagitis; ILC2, type 2 innate lymphoid cell; Th2, T helper type 2.

Identification and Diagnosis

Early identification of EoE is vital, as delayed diagnosis in EoE is associated with increased risk of esophageal remodeling and reduced quality of life.^5,30

EoE diagnosis requires a comprehensive assessment of clinical symptoms, histologic and endoscopic findings, and exclusion of non-EoE disorders (FIGURE 5).^5,10

FIGURE 5. Diagnostic Algorithm for EoE.^5,10
*Esophagogastroduodenoscopy (EGD).
^†Non-EoE disorders that cause or potentially contribute to esophageal eosinophilia include hypereosinophilic syndrome, non-EoE eosinophilic gastrointestinal disorders, GERD, achalasia, Crohn’s disease, infections, connective tissue disorders, and drug hypersensitivity reactions.¹⁰
AGREE, A Working Group on PPI-REE; EoE, eosinophilic esophagitis; GERD, gastroesophageal reflux disease; PPI, proton-pump inhibitor; PPI-REE, PPI-responsive esophageal eosinophilia.

Food Bolus Impaction: An Opportunity to Diagnose EoE

Hear Dr. Evan Dellon highlight how resolution of food impactions can be an opportunity to diagnose EoE.

Endoscopic and Histologic Attributes of EoE

EoE diagnosis is facilitated by endoscopic findings and confirmed with histologic evaluation of multiple biopsies (FIGURE 6,7).^5,10,31-33

FIGURE 6. Endoscopic Findings in EoE.^5,10,31-33
Reproduced from Hirano I, et al.³¹ with permission from BMJ Publishing.

EoE-HSS is more strongly associated with disease status in EoE than peak eosinophil count alone (FIGURE 7).³⁴

FIGURE 7. Histological Findings in EoE.³⁴
Reprinted from Collins MH, et al.³⁴ with permission from Oxford University Press.
EoE, eosinophilic esophagitis; eos/hpf, eosinophils per high-power field.

Clinical Management

Discussing individual therapy choices with the patient can lead to optimal outcomes, and maintenance therapy avoids relapse of disease due to chronic, progressive nature of EoE.^5,35

Guidelines From European and American Medical Societies for the Treatment of EoE

Treating EoE can involve dietary intervention, PPIs, STCs, or other options such as biologics (FIGURE 8, FIGURE 9); treatment guidelines and approval status for therapeutics may vary by region.^5,35,36

FIGURE 8. UEG/EAACI/ESPGHAN/EUREOS Treatment Guidelines for EoE (European Guidelines).^5,35
Republished from Lucendo AJ, et al.⁵ with permission from Elsevier.
*In patients with persistent symptoms under anti-inflammatory therapy, endoscopic dilation should be considered.^5
†Refer the patient to an EoE center.⁵
EAACI, European Academy of Allergy and Clinical Immunology; EoE, eosinophilic esophagitis; ESPGHAN, European Society of Pediatric Gastroenterology, Hepatology and Nutrition; EUREOS, European Society of Eosinophilic Oesophagitis; PPI, proton pump inhibitor; STC, swallowed topical corticosteroid; UEG, United European Gastroenterology.

FIGURE 9. AGA/JTF Clinical Guidelines for EoE (USA Guidelines).^35,36
Reprinted from American Gastroenterological Association.³⁶ with permission from Elsevier.
AGA, American Gastroenterological Association; EoE, eosinophilic esophagitis; JTF, Joint Task Force on Allergy-Immunology Practice Parameters; PPIs, proton pump inhibitors.

With any treatment, the ideal is for a patient to show symptom resolution, healthy esophageal biopsies, and normal endoscopic findings (FIGURE 10).^6,31,37

FIGURE 10. EoE Treatment Response Framework.^6,31,37
EEsAI, EoE Symptom Activity Index (score range: 0 to 100, higher score indicates more active EoE⁶); EoE, eosinophilic esophagitis; eos/hpf, eosinophils per high-power field; EREFS, Endoscopic Reference Score (total score range: 0 to 9, higher score indicates more severe endoscopic findings³¹).

The Importance of Maintenance Therapy for EoE

Maintenance therapy is necessary to avoid progression of disease in EoE patients (FIGURE 11).^5,38-43

FIGURE 11. Key Takeaways Supporting the Need for Maintenance Therapy.^5,38-43
EoE, eosinophilic esophagitis; TCS, topical corticosteroids.

2021: EoE Year In Review

Watch this video to learn more about the key scientific advances of 2021 EoE pathophysiology and therapeutics. Drs. Bredenoord and Dellon review key scientific advances in EoE from major gastroenterology congresses and peer-reviewed publications in 2021, then discuss the clinical implications of these advances for practicing clinicians in EoE.