| This talk will present an overview of diagnosis and management of eosinophilic esophagitis (EoE) in 2020. EoE remains a clinicopathologic disease, defined by symptoms of esophageal dysfunction and the presence of an esophageal eosinophilic infiltrate (≥15 eos/hpf). Historically, a PPI trial was required to attempt to differential EoE from GERD and PPI-responsive esophageal eosinophilia (PPI-REE), but with emerging data suggesting that PPI-REE was most likely a subtype of EoE, recent guidelines have been updated to eliminate the PPI trial from the diagnostic algorithm. However, with this change it becomes even more critical to consider the different diagnosis of esophageal eosinophilia and to evaluate for other conditions that may contribute to this finding. Much has also been learned about how diagnostic delay can impact the presentation of EoE; the longer that symptoms persist prior to diagnosis and treatment, the more likely there is to be structuring or narrowing of the esophagus. This, in turn, has suggested that in many, but not all, patients the natural history of EoE may progress from inflammation to fibrostenosis. After diagnosis, there are three treatments that can be considered for first line anti-inflammatory treatment – PPIs, topical/swallowed steroids, and dietary elimination. There are as of yet no head-to-head comparative studies, so choice of treatment is dependent on patient and provider preferences, as well as the clinical situation. Research is active in developing novel topical steroid preparations that are esophageal-specific, and studying more efficient elimination diet approaches. Esophageal dilation is an important adjuvant treatment in patients with strictures, and it is now felt to be safe to perform, if a cautious approach is used. A number of novel treatments, including biologics, are being developed and tested to treat EoE, targeting important inflammatory mediators in the pathogenic pathway. These include medications directed at IL-5 and the IL-5 receptor, IL-13, the IL-4 receptor, and the siglec-8 receptor, among others. While initial results are promising, none of these treatments are yet approved for EoE and remain experimental. As EoE is a chronic condition, it is further appreciated that maintenance treatment should be considered in all patients. Along with this, new ways to understand and measure treatment response in EoE are being developed. This informs the approach to treatment-refractory patients, who present a number of clinical challenges. |
