Eosinophilic Esophagitis: The Challenging
Journey to Diagnosis
August 27, 2020
Relevant Topics
Sponsored by Takeda Pharmaceuticals
“I don’t know what’s going on, but it’s been really hard for me to swallow and it feels like I’m
‘choking’ on my food when I eat.” A 35-year-old male visits your office telling you what brings him
in today. When you ask how long this has been happening, he says 15 years, since college. As your
conversation continues, you learn he also has heartburn and recurring abdominal pain in
addition to his dysphagia.
When you ask what prompted him to see you after all this time, he explained the impact on his
day-to-day life: the anxiety of having a choking episode at a work dinner or a date. “I’m 35 years
old,” he says. “I should’ve been able to figure out how to eat without any issues by now.”
For many patients, the road to an Eosinophilic Esophagitis (EoE) diagnosis can be a long,
difficult journey.[1] As a relatively new disease growing in prevalence[2], EoE is a chronic,
immune-mediated inflammatory disease localized in the esophagus.[3] While the exact cause of
EoE is unknown, researchers believe several variables play a role, including genetics,
environmental factors, immune system dysfunction[4] and atopy.4
Impact on Patients
EoE impacts an estimated one in 2,000 people3,[5],[6],[7],8 of all ages and races in the U.S. While
both men and women may be affected, men are approximately twice as likely to develop
EoE.1,[8],[9]
The chronic, persistent inflammation of the esophagus can lead to a range[10] of symptoms that
manifest differently from patient to patient. Younger children including toddlers may exhibit
feeding avoidance or intolerance, regurgitation, and vomiting. Older children may have similar
symptoms and may also have chest or abdominal pain, and adolescents more often also have
dysphagia as well as food impactions in some cases. While adults can experience all of these
symptoms, dysphagia is the most frequently reported symptom. In its most severe cases, EoE
narrows the esophagus leading to strictures that result in food impaction.[11]
Patients with EoE may also present with psychiatric comorbidities.[12] One retrospective study
found that one-third of adults and one in seven children with EoE have received a diagnosis of a
psychiatric condition, like anxiety or depression.*
People with EoE can develop adaptive behaviors to cope with everyday life, especially to
manage their symptoms when eating.[13] These behaviors can include:
• Chewing food excessively
• Eating slowly
• Cutting food into small pieces
• Drinking with most bites of food
• Substituting solids with blended or pureed foods
• Avoiding social settings involving food
Earlier detection is important as it can help reduce a patient’s potential risk of disease
complications.[14],[15]However, identifying EoE can be complex and delayed diagnosis is common
among patients, up to eight years on average for adults according to one systematic
review.1Several factors can contribute to these delays. First, EoE is a relatively new disease2
and can be under-recognized among specialists.10 Symptoms may also be under-reported by
patients — around 50 percent of dysphagia cases may not be discussed with a physician,[16]**
yet it’s the most common symptom of EoE.[17]Additionally, EoE symptoms can mimic other
more common diseases such as gastroesophageal reflux disease (GERD)[18] andpatients can also
present with one or more allergic disorders, such as asthma, rhinitis, atopic dermatitis and food
allergies, making it challenging to assess and diagnose.10
Urgency to Diagnose
An EoE diagnosis first begins with a look at the patient experience. Patients should present
with esophageal symptoms; however, physicians must be astute to adaptive behaviors and the
potential for these behaviors to mask physical symptoms.10
Endoscopic and histopathologic results are other critical factors to consider.17 An endoscopy
can help assess severity of EoE based on specific features, including edema, rings, exudates,
furrows, and strictures.[19] Of those with EoE, up to approximately 25 percent have normal
endoscopic findings.[20] *** Current guidelines stipulate that esophageal biopsy results
demonstratean eosinophil count of ≥15/hpf (high-power field) for a diagnosis of EoE with
biopsy samples taken from multiple levels of the esophagus.21
The diagnosis of EoE is made by this confirmation of esophageal eosinophilia on biopsies in
patients who have signs and symptoms of esophageal dysfunction that is not explained by
another underlying condition.[21]
In combination with the presence of esophageal eosinophilia, the assessment of symptoms and
endoscopic findings, are important in the evaluation for and diagnosis of EoE.11
Meeting the Unmet Patient Need
EoE is not a condition that should be overlooked. The signs of EoE must be seen, spoken about
and managed.
Earlier this year, guidelines for the management of pediatric and adult patients with EoE were
published by the American Gastroenterological Association and the Joint Task Force for
Allergy-Immunology Practice Parameters (The American Academy of Allergy, Asthma, and
Immunology and American College of Allergy, Asthma and Immunology). These guidelines
strongly recommend that physicians use topical glucocorticosteroids over no treatment in
patients with EoE, and conditionally recommend use of proton pump inhibition therapy, an
elemental diet, dietary elimination treatments, and esophageal dilation.[22] Endoscopic
esophageal dilation is a mechanical treatment of stricture to improve symptoms and is not
regarded as impacting underlying inflammation.3 To date, there are no FDA-approved therapies
indicated for the treatment of EoE.
If left untreated, EoE can cause injury and inflammation to the esophagus.13 Any damage to the
esophagus may make eating difficult or uncomfortable over the long-term, potentially resulting
in impaired quality of life, and persistent difficulty swallowing, and pain with swallowing or
other manifestations of chest or abdominal discomfort.13
As healthcare professionals, it is important to ask open-ended questions that can help to
identify adaptive behaviors that, when thought of as normal by patients, may prevent the
recognition of dysphagia and other symptoms that may signal EoE. Importantly, it is key to
assess and continue monitoring all three domains – symptoms, endoscopy and histopathology
– when diagnosing and caring for people with EoE.11 With this approach, the pathway to a
diagnosis of EoE can potentially be shortened and we can sooner help patients address and
manage the manifestations of chronic inflammation in the esophagus and symptomatic burden
of the disease.
For more information about the unseen and unspoken signs of EoE, please
visit www.SeeEoE.com.
*In a study using University of North Carolina EoE Clinicopathologic Database from 2002 to 2018.
Of 883 patients diagnosed with EoE (per consensus guidelines), 241 (28%) had a psychiatric
comorbidity. Study limitations include this is one, single center, retrospective study where a
comparison to the national representative figures was done through non-statistical analysis.
**In an online April 2018 Takeda sponsored self-administered health survey of 31,129 people,
4998 people reported dysphagia. Of these people, 399 confirmed an EoE diagnosis.
***In a retrospective study of 117 patients with EoE, the esophageal mucosa was regarded as
normal in 24.8% of the patients.
References
[1]Shaheen NJ, Mukkada V,Eichinger CS, et.al. Dis Esophagus. 2018;31(8):1-14.
[2]Dellon ES, Hirano I. Gastroenterology. 2018;154(2):319-332.e3.
[3]Furuta GT, Katzka DA. N Engl J Med. 2015;373(17):1640-1648.
[4] Clayton F, Peterson K. Gastrointest Endosc Clin N Am. 2018;28(1):1-14.
[5]O'Shea KM, Aceves SS, Dellon ES, et al. Gastroenterology. 2018;154(2):333-345
[6] Dellon ES. Gastroenterol Clin North Am. 2013;42(1):133-153.
[7] Dellon ES, Jensen ET, Martin CF, et al. Clin Gastroenterol Hepatol. 2014;12(4):589-596.
[8]Dellon ES. Gastroenterol Clin North Am. 2014;43(2):201-218.
[9] Mansoor E. Dig Dis Sci. 2016;61(10):2928-2934.
[10] Muir AB, Brown-Whitehorn T, Gowin B, et al. Clin Exp Gastroenterol. 2019;12:391-399.
[11]Carr S, Chan ES, Watson W. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):58.
[12]Reed CC, Corder SR, Kim E, et al. Am J Gastroenterology. 2018;154(2):333-345.
[13]Hirano I, Futura GT. Gastroenterology. 2020;158(4):840-851.
[14]Dellon ES, Kim HP, Sperry SL, et al, Gastrointest Endosc. 2014;79 (4):577-585.e4.
[15]Schoepfer AM, Safroneeva E, Bussman C, et al. Gastroenterology. 2013;145(6):1230-1236.e1-2.
[16]Adkins C, Takakura W, Spiegel BMR, et al. Clin Gastroenterol Hepatol. 2019;pii:S1542-3565(19)31182-6.doi:10.1016/j.cgh.2019.10.029.[Epub ahead of print].
[17]Safroneeva E, Straumann A, Coslovsky M, et al. Gastroenterology. 2016;150(3):581-590.e4.
[18] Wong S, Ruszkiewicz A, Holloway RH, et al. World J Gastrointest Pathophysiol. 2018;9(3):63-72.
[19] Hirano I. Dig Dis. 2014;32(1-2):78-83.
[20] Muller S, Puhl S, Vieth M, et al. Endoscopy. 2007;39(4):339-344.
[21]Dellon ES, Liacouras C. Gastroenterology. 2018;155:1022-1033.
[22]Hirano I, Bernstein KA, Jonathan A. et al. Gastroenterology, 2020;158(6),1776 – 1786.
