December 8, 1013
Research has shown that more than a third of patients with eosinophilia of the esophagus respond to Proton Pump Inhibitors with resolution of the findings clinically and on biopsy. Eosinophilic Esophagitis is an allergic disorder seen in adults and children who develop scar tissue and narrowing in the esophagus food pipe due to a food allergy. The most common symptom is swallowing disturbance but heartburn and regurgitation are very common. It is called Eosinophilic Esophagitis due to the presence of allergic cells called eosinophils on the biopsy specimens of the esophagus. It is usually treated with dietary elimination of potentially offending food allergies. It can also be treated with swallowed corticosteroids that coat the esophagus.
There are several studies that support this treatment. Investigators at the University of North Carolina reported in the October 2013 American Journal of Gastroenterology on 173 patients with endoscopy for swallowing disturbances. Almost 40% of these selected patients had allergic cells called eosinophils on biopsies of the esophagus. Over 35% responded to twice daily dosing of potent acid suppressors called Proton Pump Inhibitors. Over 60% were diagnosed as Eosinophilic Esophagitis. One patient had Eosinophilic Gastroenteritis, a disorder where the eosinophils involve other areas of the gastrointestinal tract including the stomach and intestine.
Researchers from the Mayo Clinic in Jacksonville, Florida reported in November 2013 their findings in 60 consecutive patients who had not been treated with dietary elimination or ingested steroids. They used the Proton Pump Inhibitor (PPI) omeprazole 20mg twice a day for eight weeks for their patients. This dose is twice the dose used for Gastroesophageal Reflux Disease.
Over a third of the patients had resolution of their long standing problems. 55% had clinical improvement. 40% had normalization of their biopsies. We refer to these patients who resolve with Proton Pump Inhibitors as PPI Responsive Eosinophilic Esophagitis, and the people who do not respond as having Eosinophilic Esophagitis. Biopsies of the stomach and small bowel are required to exclude Eosinophilic Gastroenteritis.
This information raises several questions. Is the allergic condition related to acid reflux? The authors did not measure acid reflux to know how many of the patients suffer from reflux. Other researchers have previously not found that the response to PPI was related to whether there is reflux or not. There are indications that Proton Pump Inhibitors may have an anti-inflammatory effect. This very exciting information suggests that we may be doing more than just blocking acid with these medications.
Another question is what is the best initial therapy for Eosinophilic Esophagitis. The University of North Carolina and Mayo Clinic studies failed to compare the patients to placebo or to another treatment. It is not likely that placebo would have had any effect as these patients had symptoms of their disease for usually over five years before diagnosis. This is typically a longstanding illness that is diagnosed late. Two other groups of researchers did compare swallowing the inhaler fluticasone to PPI therapy with generally similar to better results with the PPI. Comparisons with the inhaler budesonide or an elimination diet have not been performed. The American College of Gastroenterology Clinical Guidelines published in 2013 require treatment with Proton Pump Inhibitor to exclude PPI Responsive Esophageal Eosinophilia. At the Reflux Care of New York we recommend twice daily PPI for eight weeks followed by repeat endoscopic biopsies in three sites of the esophagus, as well as stomach and small intestine.
Is Eosinophilic Esophagitis a different disease than PPI Responsive Esophageal Eosinophilia? The difference is based on the response to treatment. The study from UNC looked for differences in these patients and found none. Perhaps it will be determined over time that these are different subtypes of Eosinophilic Esophagitis and not truly different.
Finally the question is raised as to what happens after eight weeks. Do we need to sustain this effect with long term acid suppression. Can we reduce the dose after seeing an improvement? Is this just a bridge until we find the foods that are triggering the allergy? Are we masking the allergies and will we then have a harder time figuring out which foods is the person sensitive to? There have been reports of children with PPI Responsive Esophageal Eosinophilia who relapsed and then had Eosinophilic Esophagitis. So we do not know the durability of response to PPI or even if PPI Responsive Esophageal Eosinophilia is just a type of Eosinophilic Esophagitis.
Patients with a clear diagnosis of eosinophilic esophagitis should be initially treated with twice daily Proton Pump Inhibitors (or perhaps once daily Dexilant due to its dual delivery). A careful food history and allergy and asthma history should be obtained, looking for potential triggers. A consultation with an allergist is needed but conventional allergy testing may be of limited value. The patient should have repeat endoscopy after eight weeks. Based on response, the patient may then need swallowed topical steroids or dietary modification such as a Six Food Elimination diet. Repeat testing with biopsies every two to three months after any changes in dietary or pharmacologic therapy to clarify the response to therapy is needed.