Eosinophilic esophagitis

Eosinophilic esophagitis is a chronic inflammatory disease of the esophagus.

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The phlogistic process is supported by an immune-mediated reaction , in which a high number of eosinophils , a particular type of white blood cell, intervenes .

The causes of eosinophilic esophagitis are still unknown, but the inflammation could depend on a combination of genetic and environmental factors. Often, this condition is associated with food antigen- induced allergy syndromes . Eosinophilic esophagitis can occur in both children and adults, predominantly males.

People who suffer from eosinophilic esophagitis more commonly experience dysphagia, food bolus impaction , gastroesophageal reflux , and heartburn ( heartburn ). Over time, inflammation of the esophagus can lead to chronic narrowing ( stenosis ) of the esophagus.

The diagnosis of eosinophilic esophagitis is based on endoscopy of the upper digestive tract associated with biopsy of the esophageal mucosa .

In most patients, corticosteroid therapy , elimination of food antigens from the diet and possible endoscopic dilation of the esophagus allow good control of symptoms.

Things

Eosinophilic esophagitis is a chronic disease that can affect the esophageal mucosa at any age.

The inflammation underlying the disorder is immune-mediated (i.e. caused by the immune system , according to the mechanism of autoimmune diseases ).

Symptoms of eosinophilic esophagitis may include: pain or difficulty swallowing (dysphagia), reflux, heartburn, and vomiting . In some patients, the esophagus may narrow to the point that it blocks the passage of food.

Causes

The exact causes of eosinophilic esophagitis are not yet fully understood. However, the association of inflammation of the esophagus with allergic and/or atopic pathologies is known (in approximately 70% of cases, eosinophilic esophagitis is concomitant with allergic rhinitis , bronchial asthma or atopic dermatitis ).

In people with a genetic predisposition , eosinophilic esophagitis is mainly induced by the ingestion of particular food antigens (e.g. milk , eggs , soy , etc.), but the reaction can also be triggered by environmental allergens .

Pathophysiological mechanisms

Eosinophilic esophagitis is associated with dysfunction of the esophagus resulting from predominantly eosinophilic inflammation.

As regards the maintenance of the phlogistic process, a significant role is played by the overexpression of some mediators (including interleukins and chemokines), which “recall” eosinophils (via chemotaxis) and regulate their activation. This explains the high density of these immune cells at target tissue levels and the resulting lesions.

Eosinophilic esophagitis: what are eosinophils?

Eosinophilic esophagitis owes its name to the fact that the disease is characterized by a strong accumulation of eosinophils (also called eosinophilic granulocytes ) in the squamous epithelium of the esophagus; these cells are usually involved in immune responses against allergens or parasitic infestations .

In the case of eosinophilic esophagitis, large numbers of eosinophils infiltrate the epithelial tissue of the esophagus, causing a variety of gastrointestinal symptoms such as reflux, frequent vomiting, difficulty swallowing , and abdominal pain .

Who is most at risk

• Eosinophilic esophagitis can begin at any time, but occurs mainly in the period between childhood and adulthood. Only on a few occasions does the disease appear for the first time in older people.
• Eosinophilic esophagitis is more common in males. The prevalence in men compared to women is 3:1.
• Eosinophilic esophagitis is often associated with allergic syndromes. The condition is more likely to occur in people with bronchial asthmaand food allergies .
• A higher frequency of eosinophilic esophagitis is observed in patients with close family relationships, supporting the hypothesis of a genetic basis.

Symptoms and Complications

Eosinophilic esophagitis is characterized by alternating periods of remission and activity .

Symptoms of eosinophilic esophagitis vary with age and may include pain or difficulty swallowing (dysphagia), reflux, heartburn , and vomiting. In some patients, the esophagus may narrow to the point that it impedes or blocks the passage of the food bolus.

Adults

In adults, the most common presenting symptom of eosinophilic esophagitis is difficulty swallowing ( dysphagia ), especially for solid foods.

Less frequently, eosinophilic esophagitis may be associated with other esophageal disorders, similar to those of gastroesophageal reflux disease , such as heartburn , heartburn (burning sensation behind the sternum), and chest pain . These latter manifestations do not usually respond to proton pump inhibitor drugs .

Eosinophilic esophagitis can also manifest itself with:

• Retrosternal, epigastricand/or abdominal pain ;
• Vomit;
• Anorexiaand early sense of satiety.

Over time, inflammation also leads to the stopping of the food bolus and the narrowing of the esophageal caliber (or stricture).

Sometimes, non-esophageal disorders may be present, such as diarrhea , recurrent or chronic laryngitis , relapsing asthma attacks and aspiration bronchopneumonia .

Children

During childhood, eosinophilic esophagitis manifests itself above all with typical reflux disorders that do not respond to usual therapy, such as heartburn and food regurgitation .

Inflammation of the esophagus can also be associated with less specific symptoms, such as:

• Vomiting with frequent presence of mucus;
• Loss of appetite and refusal of food;
• Agitation and crying during meals;
• Rumination;
• Belching;
• Hiccup;
• Abdominal or chest pain;
• Intoleranceto some foods;
• Reduced weight gain or weight loss;
• Retrosternal burning;
• Epigastricor abdominal pain.

Complications and concomitant pathologies

• Untreated chronic inflammation can lead to narrowing (stricture) of the esophagus.
• People suffering from eosinophilic esophagitis may present manifestations of allergies or other atopic pathologies (such as asthma, allergic rhinitis , eczema, etc.).

Diagnosis

Eosinophilic esophagitis is considered by the doctor when episodic dysphagia, esophageal food impaction, or noncardiac chest pain occur. The diagnosis is made with endoscopy of the upper digestive tract, supported by biopsy.

Complete medical history

Generally, the first symptoms appear in young adults (from 20 to 30-35 years), but the age at diagnosis can be very variable (1-89 years). The pathology can also be suspected by the doctor when gastroesophageal reflux does not respond to acid-suppressive therapy with proton pump inhibitors (even at high doses).

Endoscopy of the upper digestive tract

The diagnosis of eosinophilic esophagitis is confirmed after performing an endoscopy of the upper digestive tract with a flexible probe ( esophagogastroduodenoscopy , EGDS).

Endoscopic findings often associated with eosinophilic esophagitis include:

• Longitudinal narrowing of the esophageal caliber or isolated stricture (proximal or distal);
• Longitudinal discontinuities of the mucosa along the entire course of the esophagus;
• Exudates or diffuse whitish stippling of the mucosa;
• Diffuse nodularity and/or granularity;
• Multiple esophageal rings, not completely flattened by insufflation (feline folds or felinization of the esophagus);
• Pseudo- diverticulosis.

When the endoscope passes through, the esophageal mucosa , due to its frequent fragility , can bleed or crack.

The radiological study with barium meal can be indicated as a complementary examination to endoscopy. In addition to confirming the reduction in the caliber of the esophagus, this assessment provides information on the distensibility of the walls.

Biopsy of the esophageal mucosa

During endoscopy, the doctor takes tissue samples to analyze under a microscope ( biopsy ). The biopsy examination demonstrates the presence of significant eosinophilic infiltration (more than 15 eosinophils/per high microscopic magnification field) at the level of the squamous epithelium of the esophagus. Biopsy samples are essential to establish the diagnosis of eosinophilic esophagitis, as the appearance of the esophageal mucosa may be apparently normal on endoscopic vision .

In patients with associated gastrointestinal disorders (e.g. diarrhea and abdominal pain), tissue sampling from the stomach and duodenum must be added to the biopsy sampling of the esophagus ; this allows us to verify the involvemen