Eosinophilic Oesophagitis: Rapidly emerging disorder.
Eosinophilic Oesophagitis (EoE), first described in the early 1990’s, has rapidly evolved as distinctive chronic inflammatory oesophageal disease. The diagnosis is based clinically by the presence of symptoms related to an oesophageal dysfunction and histologically by an eosinophil-predominant inflammation once other conditions leading to oesophageal eosinophilia are excluded. This striking male-prevalent disease has an increasing incidence and prevalence in the westernised countries. Currently, EoE represents the main cause of dysphagia and bolus impaction in adult patients.
Related to allergenic profile
EoE is an allergy-based disorder. It presents commonly in adults as long standing dysphagia, sometimes with food impaction.
Topical corticosteroids lead to a rapid improvement of active EoE clinically and histologically; they are therefore regarded as first-line drug therapy. Elimination diets have similar efficacy as topical corticosteroids, but their long-term use is limited by compliance issues. Resolving the altered mucosal immune loss of tolerance offers a tantalising opportunity for natural resolution.
EoE, increasingly recognised in both adults and children, is characterised especially by oesophageal symptoms of dysphagia with impaction (a feeling of food being stuck at the lower end of the oesophagus) and biopsy evidence of significant eosinophil accumulation in the oesophageal epithelium.
Data collected so far suggest a multi-step allergy process starting with an atopic skin response that later primes the oesophagus on further allergen exposure – known as the ‘allergic march’, and which may be linked to thymic stromal lymphopoietin (TSLP). Diagnosis of EoE is suggested by food impaction in a young adult with a personal and family history of allergy.
|Table 2: Diagnostic criteria of Eosinophilic Oesophagitis.|
|Clinical manifestations||Symptoms of oesophageal dysfunction|
|Histologic manifestations||Number of eosinophils >15 in at least one hpf|
|Exclusion criteria||Exclusion of GERD, clinically, endoscopically, histologically and if necessary by functional studies (e.g., pH-monitoring/impedance)
Exclusion of other conditions that cause oesophageal eosinophilia
|Adapted from Liacouras CA, et al. J Allergy Clin Immunol. 2011;128:3–20.|
With respect to dietary counselling, the pearls that I would give you here are: when you talk to a patient with EoE, one thing that I use is the cardinal dysphasia diet. Explain the benefits of avoidance of anything that’s cut into anything other than a miniscule piece. The reduction of food mass especially food groups that are particularly notorious for catching in the oesophagus with a structural lesion such as EoE. Tough meat, doughy bread products, pasta — sometimes it will glom up and become very much of a bolus, rice, anything with a skin, like a potato skin, a fresh fruit or vegetable that’s raw and hard, those things are particularly likely to catch, so I just tell them, if you want a fresh fruit or vegetable, make sure it’s soft, cooked, and you cut it well. Those are dietary recommendations that I use routinely in all my EoE patients.
Next an exclusionary diet, or at least the exclusion of any recognised food allergens ahead of any clinical testing is worth undertaking as the benefits will be felt soon. Then, using digestive enzymes to aid in stomach and small intestinal degradation of antigens offers increased reduction in irritation.
TSLP inhibition through the inclusion of natural agent demonstrated in in-vitro studies to contribute to the suppression of the TSLP related allergic march are also worth exploring. These will include selenium, green tea, pineapple juice and berberine.,,,
 Attwood SE, Smyrk TC, Demeester TR, Jones JB. Esophageal eosinophilia with dysphagia, a distinct clinicopathologic syndrome. Dig Dis Sci. 1993;38:109–16. View Abstract
 Hruz P, Straumann A, Bussmann C, Heer P, Simon HU, Zwahlen M, et al. Escalating incidence of eosinophilic esophagitis: A 20 year prospective, population-based study in Olten County Switzerland. J Allergy Clin Immunol. 2011;128:1349–50. View Abstract
 Sherrill JD, Gao PS, Stucke EM, Blanchard C, Collins MH, Putnam PE, Franciosi JP, Kushner JP, Abonia JP, Assa’ad AH, Kovacic MB, Biagini Myers JM, Bochner BS, He H, Hershey GK, Martin LJ, Rothenberg ME. Variants of thymic stromal lymphopoietin and its receptor associate with eosinophilic esophagitis. J Allergy Clin Immunol. 2010 Jul;126(1):160-5.e3. View Abstract
 Moon PD, Choi IH, Kim HM. Epigallocatechin-3-O-gallate inhibits the production of thymic stromal lymphopoietin by the blockade of caspase-1/NF-κB pathway in mast cells. Amino Acids. 2011 Aug 11. View Abstract
 Moon PD, Choi IH, Kim HM. Naringenin suppresses the production of thymic stromal lymphopoietin through the blockade of RIP2 and caspase-1 signal cascade in mast cells. Eur J Pharmacol. 2011 Dec 5;671(1-3):128-32. Epub 2011 Sep 24. View Abstract
 Moon PD, Choi IH, Kim HM. Berberine inhibits the production of thymic stromal lymphopoietin by the blockade of caspase-1/NF-κB pathway in mast cells. Int Immunopharmacol. 2011 Nov;11(11):1954-9. Epub 2011 Aug 19. View Abstract
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