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Eosinophilic Esophagitis (EoE) is a chronic inflammatory condition of the esophagus that is characterized by the presence of eosinophils, a type of white blood cell. The pathophysiology of EoE involves the release of Th2 cytokines, such as Thymic Stromal Lymphopoietin (TSLP), IL-4, IL-5, and IL-13, which promote eosinophilic inflammation, mast cell activation, and tissue remodeling.<br /><br />The goals of therapy in EoE are to eliminate symptoms, reduce mucosal inflammation, correct disease consequences, and prevent complications. Treatment options include dietary modifications, proton pump inhibitors (PPIs), topical corticosteroids, esophageal dilation, and biologic agents.<br /><br />Dietary treatment involves the elimination of allergenic foods, such as cow's milk, wheat, egg, soy, peanut/tree nut, and fish/seafood. Studies have shown that elimination diets can lead to histologic remission in a significant percentage of patients.<br /><br />PPI therapy has also been shown to be effective in reducing esophageal eosinophilia, with a response rate of 42%. However, long-term use of PPIs may have potential adverse consequences.<br /><br />Topical corticosteroids, such as budesonide and fluticasone, are commonly used for the treatment of EoE. They have been shown to induce histologic remission in a majority of patients.<br /><br />Esophageal dilation is recommended for patients with strictures or narrowing of the esophagus. It can improve dysphagia symptoms, but the effects are usually temporary and multiple dilation sessions may be required.<br /><br />Novel treatment options for EoE include new formulations of topical corticosteroids, such as budesonide orally dispersible tablets and fluticasone orally disintegrating tablets, as well as biologic agents, such as dupilumab, AK-002, benralizumab, and cendakimab. These agents target specific pathways involved in the pathogenesis of EoE.<br /><br />Refractory EoE refers to cases where patients do not respond to initial therapy. Factors to consider in these cases include compliance, inadequate dosing, inappropriate administration of medications, fibrostenosis, and esophageal hypervigilance.<br /><br />In summary, the current understanding of EoE pathophysiology involves Th2 cytokines and eosinophilic inflammation. The goals of therapy are to control symptoms, reduce inflammation, and prevent complications. Treatment options include dietary modifications, medications, dilation, and biologic agents. Ongoing research is focused on developing new treatment options for EoE, especially for refractory cases.

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Rishi Naik, MD, MSCI

Keywords

Eosinophilic Esophagitis

Chronic inflammatory condition

Th2 cytokines

Dietary modifications

Proton pump inhibitors

Topical corticosteroids

Esophageal dilation

Biologic agents

Refractory EoE

Histologic remission