Australian Doctor 14th June Issue | Page 26

14 JUNE 2024 ausdoc . com . au

Figure 10 . Dysphagia Symptom Questionnaire .

Question Response options Score

2 . Since waking up this morning , has food gone down slowly or been stuck in your throat ?

3 . For the most difficult time you had swallowing food today ( in the past 24 hours ), did you have to do anything to make the food go down or to get relief ?

4 . The following question concerns the amount of pain you have experienced when swallowing food . Describe the worst pain you have experienced while swallowing food over the past 24 hours ? c

1 . Which THREE may be presenting features of eosinophilic oesophagitis ( EoE ) in adults ? a Weight gain . b Food impaction . c Dysphagia . d Odynophagia .

2 . Which ONE is not a feature of EoE in children ? a Food bolus impaction . b Projectile vomiting . c Abdominal pain . d Faltering growth .

3 . Which THREE factors are implicated in the development of EoE ? a A decline in the frequency of

Helicobacter pylori . b The rise in atopic conditions . c Decrease in inflammatory bowel disease . d An increase in gastro-oesophageal reflux disease with the associated increase in PPI use .

4 . Which THREE statements regarding EoE are correct ? a Acute complications include mucosal tears or oesophageal perforation .

No 0 Yes 2

No , it got better or cleared up on its own

Yes , I had to drink liquid to get relief

Yes , I had to cough and / or gag to get relief

Yes , I had to vomit to get relief 3

Yes , I had to seek medical attention to get relief

None , I had no pain 0 Mild 1 Moderate 2 Severe 3

Very severe 4 a

The scoring algorithm was constructed from responses to questions 2 and 3 to ensure that the final Dysphagia Symptom Questionnaire ( DSQ ) score was driven by the frequency and severity of dysphagia b

Responses to question 1 were unscored c

Responses to question 4 were not included as part of the psychometric analysis ; question 4 is a standalone item on the DSQ The DSQ ( version 4.0 ) and score for each response option a

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b The most common risk factor for EoE in adults is atopy . c Patients often describe adaptive mechanisms to cope with the symptoms . d The symptoms of dysphagia correlate well to mucosal inflammation so are a useful guide to gauge healing .

5 . Which ONE is not a consistent feature of EoE on endoscopy ? a Rings . b Strictures . c Abscesses . d Oedema .

6 . Which ONE histological feature is diagnostic of EoE ? a Acanthotic epithelium . b Fifteen or more eosinophils / high-power field ( hpf ). c The presence of micro abscesses . d Deposition of eosinophil granule proteins extracellularly .

7 . Which THREE are diagnostic criteria for EoE ? a Symptoms of oesophageal dysfunction . b Endoscopic biopsies demonstrating histological features of 15 or more eosinophils / hpf . c A trial of a PPI . d Alternative causes of oesophageal dysfunction with eosinophilia excluded .

8 . Which THREE statements regarding the management of EoE are correct ? a Dietary therapy is preferred in all patients as it has the best long-term efficacy . b Prompt , targeted therapy will prevent symptoms and progression to fibrostenotic disease .

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EOSINOPHILIC OESOPHAGITIS

a waxing and waning course , characterised by symptomatic episodes followed by periods of relative remission from symptoms . 60

Although the long-term prognosis for patients with EoE is unknown , there have been no reports of EoE causing cancer or transforming into a more diffuse eosinophilic gastrointestinal disorder . 58 Diagnostic delay is , however , associated with an increased risk of fibrostenotic disease , including rings and strictures . 59

CASE STUDIES

Case study one

JONATHON , 25 , presents to his GP with a two-year history of worsening dysphagia , lower chest pain and a sensation that food was getting ‘ stuck ’ after eating . He has a history of asthma and was frequently unwell with recurrent exacerbations but did not require hospital admission . He also has hay fever . His current medications include a salmeterol 25mcg / fluticasone 50mcg inhaler , salbutamol inhaler prn and loratadine prn . He is a nonsmoker and does not drink alcohol . There is no family history of gastrointestinal conditions or allergies .

Jonathon is referred by his GP for blood tests to check his nutritional status and exclude coeliac disease , infection and rarer causes of dysphagia such as hypereosinophilic syndrome . He is also referred to a gastroenterologist for a consultation and gastroscopy with biopsies . The gastroscopy demonstrates subtle rings ( trachealisation ) and furrows in the mid-oesophagus . Biopsies taken during the procedure demonstrate an eosinophil count of 17 eosinophils / hpf in the upper oesophagus , 25 eosinophils / hpf in the middle

c Maintenance therapy is necessary because of a high relapse rate . d Patients with a stricturing phenotype have a significantly reduced response to PPI therapy .

9 . Which ONE is the most common culprit for triggering EoE in patients ? a Fish and seafood . b Dairy . c Nuts . d Gluten .

10 . Which THREE statements regarding the management of EoE are correct ? a Combining an effective drugor dietary-based EoE therapy with dilation reduces the need for repeated procedures . b Dilation has a high rate of perforation . c The most frequent side effect of BOT therapy is candidiasis . d Given that the efficacy of STC depends on mucosal contact , it is critical patients are given clear administration instructions . and 35 eosinophils / hpf in the lower oesophagus .

Jonathon is diagnosed with EoE and is started on budesonide orally disintegrating tablets 1mg twice daily for 10 weeks . Follow up gastroscopy demonstrates an excellent response with histology demonstrating zero eosinophils / hpf in the upper oesophagus , three eosinophils / hpf in the middle and four eosinophils / hpf in the lower oesophagus . He is maintained on twice daily BOT with a significant improvement in his dysphagia symptoms and a preserved histological response on follow up endoscopy one year later .

Case study two

Peter , a 19-year-old university student , presents to his GP describing a choking sensation when swallowing a hamburger the day prior . He managed to swallow the food after drinking a cup of water . Peter is referred for a pathology test and a gastroenterology review for an endoscopic assessment to exclude EoE . The blood test demonstrates mild eosinophilia , and the endoscopy shows evidence of longitudinal furrows with trachealisation of the oesophagus . Histology reveals more than 100 eosinophils / hpf in the upper and middle oesophagus and 70 / hpf in the lower oesophagus .

After discussion of the treatment options , the gastroenterologist refers Peter to a dietitian for initiation of a 2-FED . Dairy and gluten are removed from his diet , and he undergoes a repeat gastroscopy after eight weeks . This demonstrates a marked improvement in the oesophageal findings , with only mild furrows present and moderate trachealisation . Histological assessment demonstrates five eosinophils / hpf in the upper , six eosinophils / hpf in the middle and six eosinophils / hpf in the lower oesophagus .

Gluten is then reintroduced and he undergoes a repeat gastroscopy after eight weeks . This demonstrates mild furrows and subtle trachealisation of the oesophagus . Histology reveals four eosinophils / hpf in the upper oesophagus and two eosinophils / hpf in the middle and lower segments . Peter is maintained on a dairy-free diet with no ongoing symptoms of dysphagia .

CONCLUSION

THE prevalence of EoE is increasing worldwide . GPs have a critical role in identifying and referring patients whose symptoms may be consistent with EoE to ensure the initiation of prompt , targeted therapy .

Adults may present with symptoms of dysphagia , heartburn , non-cardiac chest pain or food impaction . Patients may also describe adapting / coping strategies when eating , which may be indicative of underlying pathology , such as EoE . Treatment involves either PPIs , dietary elimination or STC . Biological therapy is a possible future treatment option .

RESOURCES

• Australasian Society of Clinical Immunology and Allergy : Eosinophilic oesophagitis bit . ly / 3VjS1kL

References Available on request from howtotreat @ adg . com . au