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Eosinophilic esophagitis: an underdiagnosed cause of dysphagia and food impaction to be recognized by otolaryngologists

Eosinophile Ösophagitis: Eine zu selten diagnostizierte Ursache von Dysphagie und Nahrungsimpaktion, die der HNO-Arzt erkennen sollte

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Abstract

Eosinophilic esophagitis (EoE) is a recently recognised pathologic entity whose prevalence has risen significantly since first being described in 1993. Defined as a chronic, local immune-mediated disease with predominant eosinophil infiltration, it is nowadays the leading cause of dysphagia and food bolus impaction in children and young adults. Genetic and environmental risk factors, and especially food antigens, trigger the disease and are in the focus of investigation as avoidance can cure three quarters of patients. The most common antigen involved is milk, followed by egg and gluten. These patients frequently come undiagnosed to the otolaryngologist with complaints of dysphagia and recurrent non-sharp food impactions, although pharyngolaryngeal reflux symptoms and other airway complaints could also be a first sign. Delayed diagnosis and treatment can produce fibrostenosis of the esophagus that greatly impairs patients’ quality of life.

In-office transnasal esophagoscopy with esophageal biopsy offers a unique opportunity to promptly diagnose and follow-up these patients, without causing the morbidity of repeated sedations and reducing exploration overload in gastroenterology departments. The search for food-antigen triggers, response evaluation to swallowed steroids, or proton pump inhibitors (PPIs) make multiple endoscopies and biopsies necessary every 6 to 8 weeks.

There are three first-line interchangeable treatments with the same recommendation: PPIs, dietary allergen elimination and topical swallowed steroids. The choice should be discussed with the patient on an individual basis.

The objective of this article is to raise awareness of this condition, update otolaryngologists with the new EoE consensus, and highlight the need for biopsy in patients with dysphagia to rule out EoE.

Zusammenfassung

Die eosinophile Ösophagitis (EÖ) ist ein kürzlich anerkanntes Krankheitsbild, dessen Prävalenz seit der Erstbeschreibung im Jahr 1993 deutlich gestiegen ist. Definiert als eine chronische, lokale immunvermittelte Erkrankung mit überwiegend eosinophilem Infiltrat ist die EÖ heute die Hauptursache von Dysphagie und Nahrungsbolusimpaktion bei Kindern und jungen Erwachsenen. Genetische und umweltbezogene Risikofaktoren, insbesondere Nahrungsmittelantigene, lösen die Erkrankung aus und stehen im Fokus der Forschung, da ihre Vermeidung bei drei von vier Patienten zur Heilung führt. Als Antigen am häufigsten involviert ist Milch, gefolgt von Ei und Gluten. Betroffene Patienten suchen nicht selten ohne Diagnose den Hals-Nasen-Ohren-Arzt auf und klagen über Dysphagie sowie wiederholte Impaktionen nichtspitzer Nahrungsmittel, auch wenn pharyngolaryngeale Refluxsymptome und andere Atemwegsbeschwerden ebenfalls ein erstes Erkrankungszeichen sein können. Eine verzögerte Diagnose und Behandlung können eine Fibrostenose des Ösophagus zur Folge haben, die die Lebensqualität der Patienten stark beeinträchtigt.

Die transnasale Ösophagoskopie mit Ösophagusbiopsie bietet in der HNO-Praxis die einmalige Möglichkeit, unverzüglich eine Diagnose zu stellen und die Patienten weiter zu beobachten. Dabei wird eine durch wiederholte Sedierungen bedingte gesundheitliche Beeinträchtigung vermieden und die diagnostische Überlastung gastroenterologischer Abteilungen reduziert. Die Suche nach Nahrungsmittelantigenen, die als Auslöser wirken, sowie die Beurteilung des Ansprechens auf oral eingenommene Steroide oder Protonenpumpenhemmer (PPI) erfordern regelmäßige Endoskopien und Biopsien alle 6 bis 8 Wochen.

Drei gleichwertige Erstlinientherapien mit derselben Empfehlung stehen zur Auswahl: die PPI-Gabe, die Beseitigung des Nahrungsmittelallergens und die topische Behandlung mit oral eingenommenen Steroiden. Der Patient sollte in die individuelle Therapieentscheidung einbezogen werden.

Mit dem vorliegenden Beitrag soll das Bewusstsein für die EÖ geschärft werden. Zudem werden die aktuellen Konsensusempfehlungen vorgestellt. Unterstrichen werden soll die Notwendigkeit der Biopsie zum Ausschluss einer EÖ bei Patienten mit Dysphagie.

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References

  1. Landres RT, Kuster GG, Strum WB (1978) Eosinophilic esophagitis in a patient with vigorous achalasia. Gastroenterology 74(6):1298–1301

    PubMed  CAS  Google Scholar 

  2. Attwood SE, Smyrk TC, Demeester TR, Jones JB (1993) Esophageal eosinophilia with dysphagia. A distinct clinicopathologic syndrome. Dig Dis Sci 38(1):109–116

    Article  PubMed  CAS  Google Scholar 

  3. Furuta GT, Liacouras CA, Collins MH, Gupta SK, Justinich C, Putnam PE et al (2007) Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 133(4):1342–1363

    Article  PubMed  CAS  Google Scholar 

  4. Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA et al (2011) Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 128(1):3–20e6 (quiz 21-2)

    Article  PubMed  Google Scholar 

  5. Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras CA, Katzka DA et al (2013) ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am J Gastroenterol 108(5):679–692 (quiz 693)

    Article  PubMed  Google Scholar 

  6. Lucendo AJ, Molina-Infante J, Arias Á, von Arnim U, Bredenoord AJ, Bussmann C et al (2017) Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J 5(3):335–358. https://doi.org/10.1177/2050640616689525

    Article  PubMed  PubMed Central  Google Scholar 

  7. Kelly EA, Linn D, Keppel KL, Noel RJ, Chun RH (2015) Otolaryngologic surgeries are frequent in children with eosinophilic esophagitis. Ann Otol Rhinol Laryngol 124(5):355–360

    Article  PubMed  Google Scholar 

  8. Smith LP, Chewaproug L, Spergel JM, Zur KB (2009) Otolaryngologists may not be doing enough to diagnose pediatric eosinophilic esophagitis. Int J Pediatr Otorhinolaryngol 73(11):1554–1557

    Article  PubMed  Google Scholar 

  9. Padia R, Curtin K, Peterson K, Orlandi RR, Alt J (2016) Eosinophilic esophagitis strongly linked to chronic rhinosinusitis. Laryngoscope 126(6):1279–1283

    Article  PubMed  Google Scholar 

  10. Kubik M, Thottam P, Shaffer A, Choi S (2017) The role of the otolaryngologist in the evaluation and diagnosis of eosinophilic esophagitis. Laryngoscope 127(6):1459–1464

    Article  PubMed  Google Scholar 

  11. Benninger MS, Strohl M, Holy CE, Hanick AL, Bryson PC (2017) Prevalence of atopic disease in patients with eosinophilic esophagitis. Int Forum Allergy Rhinol 7(8):757–762

    Article  PubMed  Google Scholar 

  12. Schoepfer AM, Safroneeva E, Bussmann C, Kuchen T, Portmann S, Simon H‑U et al (2013) Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology 145(6):1230–1236.e1-2

    Article  PubMed  Google Scholar 

  13. Molina-Infante J, Bredenoord AJ, Cheng E, Dellon ES, Furuta GT, Gupta SK et al (2016) Proton pump inhibitor-responsive oesophageal eosinophilia: an entity challenging current diagnostic criteria for eosinophilic oesophagitis. Gut 65(3):524–531

    Article  PubMed  CAS  Google Scholar 

  14. Ronkainen J, Talley NJ, Aro P, Storskrubb T, Johansson S‑E, Lind T et al (2007) Prevalence of oesophageal eosinophils and eosinophilic oesophagitis in adults: the population-based Kalixanda study. Gut 56(5):615–620

    Article  PubMed  Google Scholar 

  15. Lucendo AJ, Arias Á, Molina-Infante J, Rodríguez-Sánchez J, Rodrigo L, Nantes Ó et al (2013) Diagnostic and therapeutic management of eosinophilic oesophagitis in children and adults: results from a Spanish registry of clinical practice. Dig Liver Dis 45(7):562–568

    Article  PubMed  Google Scholar 

  16. Sperry SL, Woosley JT, Shaheen NJ, Dellon ES (2012) Influence of race and gender on the presentation of eosinophilic esophagitis. Am J Gastroenterol 107(2):215–221

    Article  PubMed  Google Scholar 

  17. Assa’ad A (2008) Eosinophilic esophagitis: association with allergic disorders. Gastrointest Endosc Clin N Am 18(1):119–132

    Article  PubMed  Google Scholar 

  18. McKenzie C, Tan J, Macia L, Mackay CR (2017) The nutrition-gut microbiome-physiology axis and allergic diseases. Immunol Rev 278(1):277–295

    Article  PubMed  CAS  Google Scholar 

  19. von Arnim U, Wex T, Link A, Messerschmidt M, Venerito M, Miehlke S et al (2016) Helicobacter pylori infection is associated with a reduced risk of developing eosinophilic oesophagitis. Aliment Pharmacol Ther 43(7):825–830

    Article  Google Scholar 

  20. Rajan J, Newbury RO, Anilkumar A, Dohil R, Broide DH, Aceves SS (2016) Long-term assessment of esophageal remodeling in patients with pediatric eosinophilic esophagitis treated with topical corticosteroids. J Allergy Clin Immunol 137(1):147–156.e8

    Article  PubMed  CAS  Google Scholar 

  21. Lucendo AJ, De Rezende L (2007) Endoscopic dilation in eosinophilic esophagitis: a treatment strategy associated with a high risk of perforation. Endoscopy 39(4):376 (author reply 377)

    Article  PubMed  CAS  Google Scholar 

  22. Otteson TD, Mantle BA, Casselbrant ML, Goyal A (2012) The otolaryngologic manifestations in children with eosinophilic esophagitis. Int J Pediatr Otorhinolaryngol 76(1):116–119

    Article  PubMed  Google Scholar 

  23. Yawn RJ, Acra S, Goudy SL, Flores R, Wootten CT (2015) Eosinophilic laryngitis in children with aerodigestive dysfunction. Otolaryngol Head Neck Surg 153(1):124–129. https://doi.org/10.1177/0194599815577568

    Article  PubMed  Google Scholar 

  24. Hirano I, Moy N, Heckman MG, Thomas CS, Gonsalves N, Achem SR (2013) Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut 62(4):489–495

    Article  PubMed  CAS  Google Scholar 

  25. Kim HP, Vance RB, Shaheen NJ, Dellon ES (2012) The prevalence and diagnostic utility of endoscopic features of eosinophilic esophagitis: a meta-analysis. Clin Gastroenterol Hepatol 10(9):988–996.e5

    Article  PubMed  PubMed Central  Google Scholar 

  26. van Rhijn BD, Verheij J, Smout AJPM, Bredenoord AJ (2016) The Endoscopic Reference Score shows modest accuracy to predict histologic remission in adult patients with eosinophilic esophagitis. Neurogastroenterol Motil 28(11):1714–1722

    Article  PubMed  Google Scholar 

  27. Friedlander JA, DeBoer EM, Soden JS, Furuta GT, Menard-Katcher CD, Atkins D et al (2016) Unsedated transnasal esophagoscopy for monitoring therapy in pediatric eosinophilic esophagitis. Gastrointest Endosc 83(2):299–306.e1

    Article  PubMed  Google Scholar 

  28. Salek J, Clayton F, Vinson L, Saffari H, Pease LF, Boynton K et al (2015) Endoscopic appearance and location dictate diagnostic yield of biopsies in eosinophilic oesophagitis. Aliment Pharmacol Ther 41(12):1288–1295

    Article  PubMed  CAS  Google Scholar 

  29. Furuta GT, Kagalwalla AF, Lee JJ, Alumkal P, Maybruck BT, Fillon S et al (2013) The oesophageal string test: a novel, minimally invasive method measures mucosal inflammation in eosinophilic oesophagitis. Gut 62(10):1395–1405

    Article  PubMed  CAS  Google Scholar 

  30. Katzka DA, Geno DM, Ravi A, Smyrk TC, Lao-Sirieix P, Miramedi A et al (2015) Accuracy, safety, and tolerability of tissue collection by Cytosponge vs endoscopy for evaluation of eosinophilic esophagitis. Clin Gastroenterol Hepatol 13(1):77–83.e2

    Article  PubMed  Google Scholar 

  31. Nicodème F, Hirano I, Chen J, Robinson K, Lin Z, Xiao Y et al (2013) Esophageal distensibility as a measure of disease severity in patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol 11(9):1101–1107.e1

    Article  PubMed  PubMed Central  Google Scholar 

  32. Dellon ES, Irani A‑M, Hill MR, Hirano I (2013) Development and field testing of a novel patient-reported outcome measure of dysphagia in patients with eosinophilic esophagitis. Aliment Pharmacol Ther 38(6):634–642

    Article  PubMed  CAS  Google Scholar 

  33. Safroneeva E, Straumann A, Coslovsky M, Zwahlen M, Kuehni CE, Panczak R et al (2016) Symptoms have modest accuracy in detecting endoscopic and Histologic remission in adults with eosinophilic esophagitis. Gastroenterology 150(3):581–590.e4

    Article  PubMed  Google Scholar 

  34. Cheng E, Souza RF, Spechler SJ (2014) Eosinophilic esophagitis: interactions with gastroesophageal reflux disease. Gastroenterol Clin North Am 43(2):243–256

    Article  PubMed  PubMed Central  Google Scholar 

  35. Tobey NA, Hosseini SS, Argote CM, Dobrucali AM, Awayda MS, Orlando RC (2004) Dilated intercellular spaces and shunt permeability in nonerosive acid-damaged esophageal epithelium. Am J Gastroenterol 99(1):13–22

    Article  PubMed  CAS  Google Scholar 

  36. Gómez-Torrijos E, García-Rodríguez R, Castro-Jiménez A, Rodríguez-Sanchez J, Méndez Díaz Y, Molina-Infante J (2016) The efficacy of step-down therapy in adult patients with proton pump inhibitor-responsive oesophageal eosinophilia. Aliment Pharmacol Ther 43(4):534–540

    Article  PubMed  CAS  Google Scholar 

  37. Murali AR, Gupta A, Attar BM, Ravi V, Koduru P (2016) Topical steroids in eosinophilic esophagitis: systematic review and meta-analysis of placebo-controlled randomized clinical trials. J Gastroenterol Hepatol 31(6):1111–1119

    Article  PubMed  CAS  Google Scholar 

  38. Dellon ES, Sheikh A, Speck O, Woodward K, Whitlow AB, Hores JM et al (2012) Viscous topical is more effective than nebulized steroid therapy for patients with eosinophilic esophagitis. Gastroenterology 143(2):321–324.e1

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  39. Kagalwalla AF, Shah A, Li BUK, Sentongo TA, Ritz S, Manuel-Rubio M et al (2011) Identification of specific foods responsible for inflammation in children with eosinophilic esophagitis successfully treated with empiric elimination diet. J Pediatr Gastroenterol Nutr 53(2):145–149

    Article  PubMed  CAS  Google Scholar 

  40. Gonsalves N, Yang G‑Y, Doerfler B, Ritz S, Ditto AM, Hirano I (2012) Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology 142(7):1451–1459.e1 (quiz e14-5)

    Article  PubMed  Google Scholar 

  41. Górriz-Gil C, Villarreal IM, Álvarez-Montero Ó, Rodríguez-Valiente A, Magaz M, García-Berrocal JR (2016) Eosinophilic esophagitis: a relevant entity for the otolaryngologist. Acta Otorrinolaringol Esp 67(3):167–178

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Otolaryngology Head and Neck Surgery, Hospital Universitario Puerta de Hierro Majadahonda, 1 Manuel de Falla Street, Majadahonda, 28222, Madrid, Spain

    C. Górriz Gil, Ó. Álvarez Montero, A. Rodríguez Valiente, C. Fernández Manzano & J. R. García-Berrocal

  2. Department of Gastroenterology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain

    V. Matallana Royo & B. Conde García

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  1. C. Górriz Gil
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Correspondence to C. Górriz Gil.

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C. Górriz Gil, V. Matallana Royo, Ó. Álvarez Montero, A. Rodríguez Valiente, C. Fernández Manzano, B. Conde García and J. R. García-Berrocal declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Video: Patient with eosinophilic esophagitis seen by transnasal esophagoscopy

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Górriz Gil, C., Matallana Royo, V., Álvarez Montero, Ó. et al. Eosinophilic esophagitis: an underdiagnosed cause of dysphagia and food impaction to be recognized by otolaryngologists. HNO 66, 534–542 (2018). https://doi.org/10.1007/s00106-018-0516-3

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