Eosinophilic esophagitis: an evidence-based approach to therapy

In recent years, several randomized controlled trials and meta-analyses have evaluated the efficacy of the various therapeutic options available for treating patients with eosinophilic esophagitis, including dietary modifications, proton pump inhibitors, topical corticosteroids, and endoscopic esophageal dilation. Proton pump inhibitors are currently considered the first-line treatment for eosinophilic esophagitis, achieving histological remission and improvement of symptoms in 50.5% and 60.8% of patients, respectively. The efficacy of topical corticosteroids in eosinophilic esophagitis has been assessed in several trials. Meta-analyses summarizing results indicate that budesonide and fluticasone propionate are significantly superior to placebo, both in decreasing eosinophil densities in the esophageal mucosa and in relieving symptoms. However, owing to differences in drug delivery, viscous budesonide seems to be the best pharmacological therapy for eosinophilic esophagitis. Results for dietary modifications have been mixed depending on the type of diet prescribed. Thus, while exclusive amino acid-based elemental diets are the most effective in inducing histological remission of eosinophilic esophagitis (90.8%), their severe drawbacks limit their implementation in clinical practice. Allergy testing-based food elimination provides a suboptimal remission rate of 45.5%, although this is lower in adults than in children (32.2% vs 47.9%, respectively). In addition, the various available studies are highly heterogeneous. Empirical 6-food elimination diets were shown to be the best diet-based therapy, with a homogeneous remission rate of 72%. Simpler, more convenient empirical schemes have also been evaluated. The aim of this review is to provide an evidence-based overview on the efficacy of the options available for treatment of eosinophilic esophagitis along with a practical management algorithm (AU)

Varios ensayos clínicos controlados y meta-análisis han evaluado la eficacia de distintas opciones terapéuticas disponibles para la esofagitis eosinofílica (EoE), incluyendo modificaciones dietéticas, inhibidores de la bomba de protones (IBP), esteroides tópicos y dilatación endoscópica. Los IBP constituirían actualmente el tratamiento de primera línea, pues logran remisión histológica y mejoría sintomática en el 50,5% y el 60,8% de los pacientes con EoE, respectivamente. La eficacia de los esteroides tópicos ha sido evaluada en varios ensayos, cuyos resultados se resumen en posteriores meta-análisis: budesonida y fluticasona resultaron superiores al placebo, disminuyendo la densidad de eosinófilos en la mucosa esofágica y mejorando los síntomas. Sin embargo, debido a su diferente administración, budesonida viscosa podría constituir la mejor terapia. Igualmente, las modificaciones dietéticas ofrecen resultados variables según la opción empleada. Así, las dietas elementales basadas exclusivamente en aminoácidos resultan las más eficaces para inducir la remisión histológica (90,8%), pero notables inconvenientes limitan su aplicación en la práctica clínica. La eliminación de alimentos dirigida por pruebas de alergia ofrece una tasa de remisión subóptima del 45,5%, menor en adultos que en niños (32,2% frente a 47,9%, respectivamente), con alta heterogeneidad entre los estudios disponibles. Las dietas empíricas de eliminación de seis alimentos constituirían la mejor opción dietética, con una tasa de remisión homogénea del 72%. También han sido evaluados esquemas empíricos más simples y cómodos. Esta revisión proporciona una visión general basada en evidencias sobre la eficacia de las diferentes opciones de tratamiento para la EoE, y un algoritmo para su manejo práctico (AU)

Usefulness of Oral Food Challenge and a Visual Analog Scale in the Etiologic Diagnosis of Eosinophilic Esophagitis

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Immunopathological mechanisms of eosinophilic oesophagitis

Background: Eosinophilic oesophagitis (EO) is achronic inflammatory disease of the oesophagus, with an emergent character, defined by the presence of a dense infiltrate by eosinophilic leukocytes restricted to the mucosa of this organ after excluding gastro-oesophageal acid reflux. It is manifested by chronic and/or recurrent dysphagia and episodes of oesophageal alimentary impaction, with great variation in terms of intensity, frequency, and duration of the attacks. Methods: An Internet-based search was performed for the most recent articles with relevant information concerning immunopathological mechanisms involved in EO. Results: Bibliographical data allow us to define that EO is related to an allergic or hypersensitivity-induce dreaction after exposure to foods or inhalants, with increased prevalence of sensitisation to these allergens. Data published up to now suggest a cellular hypersensitivity reaction rather than a humoral one in the physiopathology of EO. In this disease, sensitised T-lymphocytes mediate a Th2 type response, releasing cytokines such as IL-5, with a possibleTh1 component that requires further investigation.The function of the abundant CD8+ T-lymphocytes present in the oesophageal epithelium has yet to be explained. Mast cells also participate in epithelial inflammatory infiltrate in EO, and it is still unknown ifits activation, mainly through IgE, contributes to the immunopathology of the disease even though EOrarely manifests immediate hypersensitivity reactions.IL-5 and different forms of eotaxins perform an important active role in the recruitment of eosinophils to the oesophagus. Conclusions: EO is an immunologically complex and little studied entity that is associated with otherallergic diseases and in which different effector cells participate, determining an immunological response of cellular rather than a humoral hypersensitivity reaction.The data available point out that EO is a disorder of the Th2 retarded immune response, in which the triggering factor might not be IgE. Although the final inflammatory phenomena observed in EO are common for the different patients, the cascade of inflammatory mediators that lead to them might not be identical in all cases, and the morphological and functional disorders observed in EO would represent the final convergence of different activation forms of the mechanisms of inflammation

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