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The Penn Esophageal and Swallowing Disorders Program: Eosinophic Esophagitis

Image of a stricture in the esophagus caused by eosinophilic eosinophilia

The Esophageal and Swallowing Disorders Program at Penn Gastroenterology and Hepatology has the mission of diagnosing and treating disorders of the upper gastrointestinal tract, including cancers and pre-cancerous conditions, hypersecretory disorders and such rare disease states as eosinophilic esophagitis (EoE), the focus of this report.

 

What is Eosinophilic Esophagitis?

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus characterized by dysmotility, dysphagia to solids, chest pain, recurrent food impaction, aperistalsis and gastroesophageal reflux.

Histologically, the condition presents as dense infiltration of the esophageal squamous epithelium by inflammatory eosinophils. The role of eosinophil infiltration in EOE is complex. Eosinophils are known to alter smooth muscle contractility, and may contribute to tissue remodeling and fibrosis in the esophagus.

Diagnosis of EoE

To distinguish EoE from conditions with similar symptoms (i.e., gastroesophageal reflux), biopsies of esophageal tissue are obtained throughout the esophagus and reviewed by microscopy.

The finding of pronounced esophageal eosinophilia (peak value of ≥15 eosinophils per high-power field) suggests an abnormality warranting investigation. Diagnosis is further supported by persistence of eosinophilia following an 8-week trial of acid-suppression therapy (typically, a proton pump inhibiter) and bloodwork to define elevations in serum eosinophil count.

Barium swallow is a useful determinant of stricture in patients experiencing dysphagia, food impaction and retrosternal pain upon swallowing.

Individualized Treatment Plans for EoE at Penn Medicine

Confirmation of EoE at Penn Gastroenterology spurs the development of individualized treatment plans for each patient by gastroenterologists, in collaboration with an allergist, if appropriate. The immediate goal of EoE treatment is symptom relief and the resolution of esophageal eosinophilia.

The long-term goal of management is to avoid the risk of esophageal remodeling and stricture formation.Treatment of EoE is typically initiated at Penn with swallowed topical steroid therapy (i.e., budesonide, fluticasone), which has been shown to control inflammation and suppress eosinophilic infiltration in the majority of patients.

The standard timeframe for EoE steroid therapy is 2 to 8 weeks; some patients with EoE may require long-term steroid treatment, however. Food allergy is a known component of the EoE etiology, and identification of a provoking allergen via skin-prick or patch testing and targeted dietary management may also be part of the treatment algorithm at Penn.

The six food elimination diet, for example, excludes food groups commonly associated with food allergies (dairy, eggs, nuts, wheat, fish and soy). Over time, each food may be slowly reintroduced in an attempt to discover which ones are causing the allergic reaction. Repeat biopsies and endoscopic examinations are necessary to gauge histologic remission.

The Esophageal and Swallowing Disorders Program at Penn Gastroenterology and Hepatology is led by Drs. Kristle Lee Lynch, David Metz and Gary W. Falk.

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The Penn Physician Blog is a resource for health care professionals featuring Penn Medicine physicians and their research, innovations, programs and events. 

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