Australian Doctor 14th June Issue | Page 21

Box 3 . Eosinophilic oesophagitis endoscopic reference score ( EREFS score )

• Oedema ( loss of vascular markings ): — Grade 0 : Distinct vascularity . — Grade 1 : Absent or decreased .

• Rings ( trachealisation , see figure 3 ): — Grade 0 : None . — Grade 1 : Mild ( ridges ). — Grade 2 : Moderate ( distinct rings ). — Grade 3 : Severe ( scope will not pass ).

Samir / CC BY : bit . ly : 3QOQEGN

performed at about 8-12 weeks after starting treatment to assess response . Second-line therapy is discussed and implemented if there is no response to initial therapy . This is again determined by evaluating the advantages and disadvantages of each treatment and collaborating with the patient in order to formulate a treatment approach .

The duration of therapy for each management approach is not well defined ; however , multiple studies have demonstrated that maintenance therapy is necessary because of a high relapse rate . A 2020 study evaluating maintenance therapy with BOTs reported disease relapse

• Exudate ( white plaques ): — Grade 0 : None . — Grade 1 : Mild . — Grade 2 : Severe .

• Furrows ( vertical lines ): — Grade 0 : None . — Grade 1 : Mild . — Grade 2 : Severe .

at a median of 87 days in their placebo group

37 , 38

.

PPI therapy

PPI therapy is thought to improve

EoE via both acid blockade and direct anti-inflammatory effects , including decreasing the production of IL-13-induced eotaxin-3 . 40

• Stricture : — Grade 0 : Absent . — Grade 1 : Present .

Eotaxin-3 is a chemoattractant and thereby lures eosinophils into the oesophagus in EoE . 41 A high-dose PPI — for example , 40mg pantopra-

Adapted from Hirano et al 2013 26

Figure 3 . Ringed oesophagus .

zole bd — is recommended . 42 This approach leads to histological remission

in 50.5 % of patients and symp-

Box 4 . Diagnostic criteria for eosinophilic oesophagitis

• Symptoms of oesophageal dysfunction ( dysphagia , food bolus impaction , heartburn , noncardiac chest pain .

• Endoscopic biopsies demonstrating histological features of 15 or more eosinophils / high-powered field .

• Alternative causes of oesophageal dysfunction with eosinophilia excluded ( eg , achalasia , infection , connective tissue disorder , hypereosinophilic syndrome , coeliac disease , inflammatory bowel disease and medication-related oesophagitis ).

Note : All three criteria are needed to make a diagnosis . Source : Dellon ES et al 2018 31

Box 5 . Diseases associated with oesophageal eosinophilia

• Gastro-oesophageal reflux disease ( see figures 6 and 7 ).

• Eosinophilic oesophagitis .

• Eosinophilic gastroenteritis .

• Coeliac disease .

• Crohn ’ s disease .

• Infection ( fungal , viral or parasitic ).

• Drug-induced eosinophilic oesophagitis .

• Achalasia ( see figure 8 ).

• Hypereosinophilic syndrome .

• Vasculitis .

• Connective tissue disease .

• Graft-versus-host disease .

Figure 4 . Histopathology of eosinophilic oesophagitis , showing multiple intraepithelial eosinophils and oedema seen as white clearings . H & E stain .

JVinocur / CC BY / bit . ly / 3SwgySi Mikael Häggström , M . D / CC BY : bit . ly / 3QMYXEg

tomatic improvement in 60.8-71 %. 42 PPI therapy improves fibrous remodelling in patients with EoE . 43 Further benefit was not found with treatment of longer than 12 weeks , with no significant difference between the different PPI drugs when used at equivalent doses . 44 In patients who responded to PPI therapy , a reduced dose was effective in maintaining histological remission in 69.2 %. 44

Patients with a stricturing phenotype ( rings and / or strictures ) have a significantly reduced response ( by approximately 50 %) to PPI therapy compared with those who have an inflammatory phenotype . 44

Dietary therapy

Historically , the dietary approach

to EoE consisted of elimination of the six most common food allergens — including dairy , gluten , egg , soy , nuts , fish and seafood — for 6-8 weeks . This was termed the sixfood elimination diet ( 6-FED ) and achieved histological remission in 70 % of patients . 2 To detect the specific food trigger , sequential reintroduction of the food group is initiated followed by endoscopy , with biopsy performed after each reintroduction . This process is challenging for many patients given the numerous appointments and repeat endoscopies required .

Comparing the 6-FED and 4-FED ( this eliminates dairy , soy , egg and wheat ), it emerged that dairy and gluten were the most common culprits

for triggering EoE in patients .

Subsequently , the 2-FED was

helpful but is not required for the

designed . This approach restricted

diagnosis . 35

dairy and gluten in patients and

MANAGEMENT

PROMPT , targeted therapy is imper-

demonstrated a 43 % symptomatic and histological remission . 44A Non-responders were subsequently

ative in managing EoE successfully to prevent both symptoms and progression to fibrostenotic disease .

Figure 5 . Barium swallow showing features of eosinophilic oesophagitis .

offered a 4-FED for six weeks , and if there was no response , a 6-FED was then commenced , with remission

Progression to fibrosis has been

rates of 60 % and 79 %, respectively .

demonstrated in 57-90 % of patients

20 years ). 36 In addition , patients also

topical corticosteroids ( STC )/ budes-

with all management options dis-

This step-up approach enabled a 20 %

with EoE . 29 This increases with the

demonstrate increased development

onide orodispersible tablet ( BOT )

cussed at time of diagnosis to ensure

decrease in endoscopic procedures

duration of delay in the diagnosis :

of strictures with a delay in diagnosis .

therapy , dietary therapy and endo-

adherence is maximised ( see fig-

as well as less time on a restrictive

46.5 % ( diagnostic delay 0-2 years ) to

Current treatment recommen-

scopic therapy . The treatment

ure 9 ). Depending on the approach ,

diet . 44A The efficacy of long-term die-

87.5 % ( diagnostic delay longer than

dations include : PPIs , swallowed

approach is targeted to the patient ,

an endoscopy with biopsies is

tary therapy is poor , with

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