The British Medical Journal (BMJ):

British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines

Eosinophilic oesophagitis is a condition characterised by symptoms of dysphagia and/or food impaction in adults, and feeding problems, abdominal pain and/or vomiting in children, with oesophageal histology showing a peak eosinophil count of ≥15 eosinophils/high power field (or ≥15 eosinophils/0.3 mm² or >60 eosinophils/mm², in the absence of other causes of oesophageal eosinophilia.

Eosinophilic oesophagitis is increasing in prevalence in both adults and children. There is seasonal variation in the symptoms of eosinophilic oesophagitis in many patients, which seems to be associated with higher pollen counts.

Eosinophilic oesophagitis is more common in men than women. Having an affected first-degree relative increases the risk of eosinophilic oesophagitis. The incidence rises during adolescence and peaks in early adulthood.

Clinical presentation

1. In adults, food bolus obstruction and dysphagia are strongly associated with a diagnosis of eosinophilic oesophagitis.
2. In children, symptoms associated with a diagnosis of eosinophilic oesophagitis may be non-specific and vary with the age of the child.
3. All adults undergoing endoscopy should have oesophageal biopsies taken if they have endoscopic signs associated with eosinophilic oesophagitis, or symptoms of dysphagia or food bolus obstruction, with a normal looking oesophagus.
4. All children undergoing endoscopy for upper gastrointestinal symptoms should have oesophageal biopsies taken to diagnose eosinophilic oesophagitis.
5. Endoscopy and biopsy to exclude eosinophilic oesophagitis should be undertaken in children with typical gastro-oesophageal reflux disease symptoms refractory to treatment with proton pump inhibitors.
6. Endoscopy and biopsies to exclude eosinophilic oesophagitis in adult patients with typical gastro-oesophageal reflux disease symptoms refractory to proton pump inhibitors is usually not indicated, given the low prevalence of eosinophilic oesophagitis in such patients, in the absence of clinical features associated with eosinophilic oesophagitis (eg, dysphagia or atopy).
7. In patients with food bolus obstruction, urgent referral to gastroenterology and an endoscopy on the next available endoscopy list, or as an immediate emergency is recommended, depending on clinical presentation.
8. Oesophageal biopsies should be taken at index endoscopy in patients with food bolus obstruction to diagnose eosinophilic oesophagitis.
9. After spontaneous resolution of food bolus obstruction, patients should be booked for an endoscopy and outpatient review.
10. Maintenance therapy with topical steroid reduces the risk of recurrent food bolus obstruction.

11. For an accurate diagnosis of eosinophilic oesophagitis, proton pump inhibitors should be withdrawn for at least 3 weeks prior to endoscopy and biopsy.
12. In patients where a high index of suspicion exists for a diagnosis of eosinophilic oesophagitis but whose initial histology was not diagnostic, repeat endoscopy with adequate biopsies should be considered, if there were suggestive endoscopic features or typical symptoms of eosinophilic oesophagitis.
13. Diagnosing and treating eosinophilic oesophagitis effectively early in its natural history may prevent long-term complications of fibrosis and strictures requiring subsequent endoscopic intervention.
14. Eosinophilic oesophagitis that responds clinically and histologically to a proton pump inhibitor is the same disease as eosinophilic oesophagitis that fails to respond to a proton pump inhibitor.
15. Eosinophilic oesophagitis and gastro-oesophageal reflux disease are not mutually exclusive and can coexist in the same patient.
16. Formal transition of care from paediatric to adult services may improve symptom control, concordance with therapy and reduce emergency presentations in eosinophilic oesophagitis.

Investigation

1. At least six biopsies should be taken from different anatomical sites within the oesophagus for diagnosis and follow-up of eosinophilic oesophagitis.
2. Eosinophil density should be expressed as eosinophil counts per 0.3 mm² (this equates to a conventional optical high power field) and the cut-off for a diagnosis should be ≥15 eosinophils per 0.3 mm² in any biopsy specimen.
3. Mucosal eosinophilia should be accompanied by other histological features of eosinophilic oesophagitis. These may include the presence of basal cell hyperplasia, oedema (spongiosis), eosinophil microabscesses, eosinophil layering, eosinophil degranulation and subepithelial sclerosis.
4. In treated eosinophilic oesophagitis, histological response should be classified according to the eosinophil density. Remission is defined for clinical purposes as a maximum eosinophil count <15 eosinophils/0.3 mm².
5. Oesophageal physiological testing should be considered in patients with eosinophilic oesophagitis who have ongoing dysphagia, despite histological remission and the absence of fibrostenotic disease at endoscopy.

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