Eosinophilic Esophagitis Is Enigmatic in Adults

LOS ANGELES — Eosinophilic esophagitis appears to be a different disease in adults than it is in children, sharing similar pathophysiologic features and perhaps an allergic etiology, but displaying a different pattern of symptoms, Dr. David A. Katzka said at the annual Digestive Disease Week.

“Certainly this is a new kid on the block, with many of us feeling this is a totally new disease,” said Dr. Katzka, director of the swallowing program at the University of Pennsylvania in Philadelphia.

It is generally agreed that eosinophilia is on the rise. Children with eosinophilic esophagitis complain of a “plethora” of symptoms, including nausea and vomiting, epigastric pain, heartburn, and dysphagia. “In adults, by far and away, the most dominant symptom is dysphagia,” Dr. Katzka stressed. “It may be intermittent. It may be catastrophic,” he said, noting that it has become a highly prevalent cause of food impaction, despite the fact the disease was only described in 1993.

At first believed to be a variant of gastroesophageal reflux disease (GERD), the disease is clearly a distinct entity with a genetic component in some families. On the other hand, many adults with the disease have GERD symptoms and some respond to aggressive acid suppression with proton pump inhibitors, making the connection between the two entities vexing.

In both children and adults, the diagnosis is pathologic and based on an ill-defined elevated rate of eosinophils found in a patchy pattern in the esophageal mucosa.

He emphasized the importance of taking multiple biopsies, since there may be 5 eosinophils per high-powered field in one spot, and “50 in another.”

Longitudinal furrows are very common findings on endoscopy in all age groups.

In addition, rings throughout the esophagus and strictures are commonly seen in adults (and less often, in children) even on radiographic films.

Eosinophilic abscesses, visualized as white specks, are seen in 17%–20% of children with the disease and are “almost pathopneumonic” in adults. The esophagus may have a “firm, woody feel,” he said.

Debate rages as to whether a person with a normal-appearing esophagus can have the disease. Dr. Katzka said he believes it is possible.

The peripheral eosinophil count is normal in about 90% of patients.

Although studies have not been done in adults to direct management, Dr. Katzka recommends RAST testing, patch testing, and skin testing to try to identify an allergen or combination of allergens that may be responsible. However, he warned of an “imprecise correlation between skin, blood, and esophageal findings” and said some adult patients do not respond to avoidance of known allergens.

The biggest problem is convincing patients to avoid foods that may be contributing to the condition.

In children, treatment with steroids, leukotriene inhibitors, and mast cell stabilizers have been shown effective.

In adults, “we're flying by the seat of our pants” in regard to treatment, he said.

He recommends a 2-month course of fluticasone propionate and possibly, maintenance with montelukast, noting that some specialists also suggest a 1− to 2− month course of proton pump inhibitors prior to performing a second endoscopy.

“We will treat these patients very aggressively for 2 months before thinking about dilation,” he said.

In children, eosinophilic esophagitis seems to stabilize and improve over time, while in adults, limited studies suggest it persists or worsens.

“One of our fears is that in adults, this is a progressive or static disease that has to be recognized and treated early.”

LOS ANGELES — Eosinophilic esophagitis appears to be a different disease in adults than it is in children, sharing similar pathophysiologic features and perhaps an allergic etiology, but displaying a different pattern of symptoms, Dr. David A. Katzka said at the annual Digestive Disease Week.

“Certainly this is a new kid on the block, with many of us feeling this is a totally new disease,” said Dr. Katzka, director of the swallowing program at the University of Pennsylvania in Philadelphia.

It is generally agreed that eosinophilia is on the rise. Children with eosinophilic esophagitis complain of a “plethora” of symptoms, including nausea and vomiting, epigastric pain, heartburn, and dysphagia. “In adults, by far and away, the most dominant symptom is dysphagia,” Dr. Katzka stressed. “It may be intermittent. It may be catastrophic,” he said, noting that it has become a highly prevalent cause of food impaction, despite the fact the disease was only described in 1993.

At first believed to be a variant of gastroesophageal reflux disease (GERD), the disease is clearly a distinct entity with a genetic component in some families. On the other hand, many adults with the disease have GERD symptoms and some respond to aggressive acid suppression with proton pump inhibitors, making the connection between the two entities vexing.

In both children and adults, the diagnosis is pathologic and based on an ill-defined elevated rate of eosinophils found in a patchy pattern in the esophageal mucosa.

He emphasized the importance of taking multiple biopsies, since there may be 5 eosinophils per high-powered field in one spot, and “50 in another.”

Longitudinal furrows are very common findings on endoscopy in all age groups.

In addition, rings throughout the esophagus and strictures are commonly seen in adults (and less often, in children) even on radiographic films.

Eosinophilic abscesses, visualized as white specks, are seen in 17%–20% of children with the disease and are “almost pathopneumonic” in adults. The esophagus may have a “firm, woody feel,” he said.

Debate rages as to whether a person with a normal-appearing esophagus can have the disease. Dr. Katzka said he believes it is possible.

The peripheral eosinophil count is normal in about 90% of patients.

Although studies have not been done in adults to direct management, Dr. Katzka recommends RAST testing, patch testing, and skin testing to try to identify an allergen or combination of allergens that may be responsible. However, he warned of an “imprecise correlation between skin, blood, and esophageal findings” and said some adult patients do not respond to avoidance of known allergens.

The biggest problem is convincing patients to avoid foods that may be contributing to the condition.

In children, treatment with steroids, leukotriene inhibitors, and mast cell stabilizers have been shown effective.

In adults, “we're flying by the seat of our pants” in regard to treatment, he said.

He recommends a 2-month course of fluticasone propionate and possibly, maintenance with montelukast, noting that some specialists also suggest a 1− to 2− month course of proton pump inhibitors prior to performing a second endoscopy.

“We will treat these patients very aggressively for 2 months before thinking about dilation,” he said.

In children, eosinophilic esophagitis seems to stabilize and improve over time, while in adults, limited studies suggest it persists or worsens.

“One of our fears is that in adults, this is a progressive or static disease that has to be recognized and treated early.”

LOS ANGELES — Eosinophilic esophagitis appears to be a different disease in adults than it is in children, sharing similar pathophysiologic features and perhaps an allergic etiology, but displaying a different pattern of symptoms, Dr. David A. Katzka said at the annual Digestive Disease Week.

“Certainly this is a new kid on the block, with many of us feeling this is a totally new disease,” said Dr. Katzka, director of the swallowing program at the University of Pennsylvania in Philadelphia.

It is generally agreed that eosinophilia is on the rise. Children with eosinophilic esophagitis complain of a “plethora” of symptoms, including nausea and vomiting, epigastric pain, heartburn, and dysphagia. “In adults, by far and away, the most dominant symptom is dysphagia,” Dr. Katzka stressed. “It may be intermittent. It may be catastrophic,” he said, noting that it has become a highly prevalent cause of food impaction, despite the fact the disease was only described in 1993.

At first believed to be a variant of gastroesophageal reflux disease (GERD), the disease is clearly a distinct entity with a genetic component in some families. On the other hand, many adults with the disease have GERD symptoms and some respond to aggressive acid suppression with proton pump inhibitors, making the connection between the two entities vexing.

In both children and adults, the diagnosis is pathologic and based on an ill-defined elevated rate of eosinophils found in a patchy pattern in the esophageal mucosa.

He emphasized the importance of taking multiple biopsies, since there may be 5 eosinophils per high-powered field in one spot, and “50 in another.”

Longitudinal furrows are very common findings on endoscopy in all age groups.

In addition, rings throughout the esophagus and strictures are commonly seen in adults (and less often, in children) even on radiographic films.

Eosinophilic abscesses, visualized as white specks, are seen in 17%–20% of children with the disease and are “almost pathopneumonic” in adults. The esophagus may have a “firm, woody feel,” he said.

Debate rages as to whether a person with a normal-appearing esophagus can have the disease. Dr. Katzka said he believes it is possible.

The peripheral eosinophil count is normal in about 90% of patients.

Although studies have not been done in adults to direct management, Dr. Katzka recommends RAST testing, patch testing, and skin testing to try to identify an allergen or combination of allergens that may be responsible. However, he warned of an “imprecise correlation between skin, blood, and esophageal findings” and said some adult patients do not respond to avoidance of known allergens.

The biggest problem is convincing patients to avoid foods that may be contributing to the condition.

In children, treatment with steroids, leukotriene inhibitors, and mast cell stabilizers have been shown effective.

In adults, “we're flying by the seat of our pants” in regard to treatment, he said.

He recommends a 2-month course of fluticasone propionate and possibly, maintenance with montelukast, noting that some specialists also suggest a 1− to 2− month course of proton pump inhibitors prior to performing a second endoscopy.

“We will treat these patients very aggressively for 2 months before thinking about dilation,” he said.

In children, eosinophilic esophagitis seems to stabilize and improve over time, while in adults, limited studies suggest it persists or worsens.

“One of our fears is that in adults, this is a progressive or static disease that has to be recognized and treated early.”