A 34-year-old man was referred by his GP under the 2-week wait suspected cancer pathway with symptoms of dysphagia. On further questioning he gave a 15-year history of swallowing problems and occasional heartburn. He described intermittent dysphagia to solid foods, and occasional odynophagia after drinking orange juice. His weight is stable. He has had a previous endoscopy 8 years ago which have been reported as normal. He has tried PPIs over the years, but never found these to be particularly helpful.
References and recommended further reading about EoE
Attwood, S., Smyrk, T., Demeester, T., Eosophageal asthma – episodic dysphagia and eosinophilic infiltrates. Gut, 30 (10)
Attwood, S.E., 2019. Overview of eosinophilic oesophagitis. British Journal of Hospital Medicine, 80(3), pp.132-138.
Chen, J.W. and Kao, J.Y., 2017. Eosinophilic esophagitis: update on management and controversies. BMJ, 359.
Dhar, A., Haboubi, H.N., Attwood, S.E., Auth, M.K., Dunn, J.M., Sweis, R., Morris, D., Epstein, J., Novelli, M.R., Hunter, H. and Cordell, A., 2022. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut.
Philpott, H., Nandurkar, S., Royce, S.G., Thien, F. and Gibson, P.R., 2016. A prospective open clinical trial of a proton pump inhibitor, elimination diet and/or budesonide for eosinophilic oesophagitis. Alimentary Pharmacology & Therapeutics, 43(9), pp.985-993.
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You arrange an urgent endoscopy and follow-up once this is completed. Below is the image from the endoscopy report:
Picture credit : http://www.endoscopy-campus.com/en/klassifikationen/klassifikationen-eosinophile-oesophagitis/
What is the most likely diagnosis, based on the history and endoscopic appearance?CorrectIncorrect
Eosinophilic oesophagitis (EoE) is a chronic allergen driven immune mediated disease, which was first described in the late 1980s by Professor Attwood, and prevalence has increased significantly over the last 2 decades (Attwood et al. 1989). The prevalence is variable globally, however in Europe and the US the prevalence is estimated to be between 0.4-1% of the population and tends to affect younger male adults (Chen and Kao 2017).
The classic symptoms of EoE in adults are dysphagia, food impaction, chest pain and heartburn.
The BSG has recently (2022) published guidelines for the diagnosis and management of this condition. This case study will guide you through the guidelines, and as you progress through the case study I would recommend that you familiarise yourself with the relevant section of the guidance, as well as some of the additional resources highlighted in the materials associated with this virtual clinic.
Which of the following would support a diagnosis of EoE (tick all that apply)?CorrectIncorrect
50-80% of people with EoE have concurrent atopy (including food allergy, seasonal allergic rhinitis, atopic dermatitis, or asthma).
In those with longstanding EoE, obstructive features such as intermittent food bolus obstruction. Left untreated, EoE can lead to oesophageal strictures in 10% of sufferers (Attwood, 2019).
Some people with EoE will respond at least partially to a trial of PPI therapy, whereas other will not. PPIs play a role as first-line treatment in those with EoE (BSG guidance, 2022) however response to PPIs is not recommended as a diagnostic test for EoE. Response to PPIs lacks both sensitivity and specificity for the diagnosis of EoE. For example, a lack of response does not rule out EoE, for the reasons outlined above, whilst a good response to PPIs can be more suggestive of more common conditions such as GORD.
H Pylori infection appears to have a protective effect against EoE. Presence of H Pylori infection would therefore reduce the likelihood of EoE (Chen and Kao 2017).
Which of the following is the gold standard for confirming the diagnosis of EoE:CorrectIncorrect
At your follow-up appointment, the patient confirms that he has a history of seasonal rhinitis and eczema. You check the clinical reporting system, and the histology report states that there are >15 eosinophils/HPF. You explain to the patient about EoE and move on to discussion of management of the condition.
Which of the following are recognised treatments of EoE (tick all that apply):CorrectIncorrect
The BSG guidelines on the management of EoE includes all of the above treatments, and a link to the document can be found here: https://gut.bmj.com/content/gutjnl/71/8/1459.full.pdf.
Several diets have been proposed and evaluated for the treatment of EoE. The six-food exclusion diet (SFED), which consists of excluding the 6 commonest food allergens (cows milk, soy, peanut/tree nut, wheat, egg and fish/seafood), is the most commonly advised. In a recent meta-analysis, histological remission rates were found to be 72%, however compliance can be a significant issue and can limit the usefulness of the SFED. The BSG recommends the assistance of a dietician for patients considering the SFED to treat their EoE (Dhar et al. 2022). This is to not only help with compliance with the diet, but also to ensure that the patient does not develop nutritional deificiency (eg. calcium/vitamin D deficiency). The BSG does not advise allergy testing (sking prick, RAST) to identify a causative allergen (Dhar et al. 2022).
Given that PPIs at a dose of 40mg daily can induce histological and symptomatic remission, albeit only in 30-40% of patients, the BSG guidance recommends the use of drug in EoE (Attwood 2019; Dhar et al. 2022). The mechanism of action of PPIs in EoE is unclear, but it is thought that in some patients it may have a beneficial effect on oesophageal lumen inflammation (Dhar et al. 2022).
Topical steroids, such as orodispersible budesonide (eg. Jorveza) has been shown to be highly effective, inducing symptomatic and histological remission at 12 weeks in up to 85% of people (Attwood 2019). The dose of Jorveza is 1mg twice daily, for up to 12 weeks. There is a 5% risk of oral candida, and so this should be monitored for and treated with Nystatin suspension if identified.
Oesophageal dilation is indicated in those who have failed pharmacological therapy, or who have a tight oesophageal stricture at presentation which is causing significant symptoms.
Having outlined the options available and having considered previous failure with high dose PPIs, you decide to start the patient on topical Budesonide. He does not feel he will be able to stick to the SFED. He asks if he will need further endoscopic examination, will he need further imaging, and if so, when?CorrectIncorrect