Diagnosis and Management of Esophageal Eosinophilia and Eosinophilic Esophagitis

Esophageal eosinophilia, the finding of eosinophils in the squamous epithelium of the esophagus, is abnormal and the underlying cause should be identified. (Strong  “We recommend”, Moderate)

EoE is clinicopathologic disorder diagnosed by clinicians taking into consideration both clinical and pathologic information without either of these
parameters interpreted in isolation, and defined by the following criteria:

• Symptoms related to esophageal dysfunction
• Eosinophil-predominant inflammation on esophageal biopsy, characteristically consisting of a peak value of ≥15 eosinophils per high-power field (eos/hpf)
• Mucosal eosinophilia is isolated to the esophagus and persists after a PPI trial
• Secondary causes of esophageal eosinophilia excluded
• A response to treatment (dietary elimination; topical corticosteroids) supports, but is not required for, diagnosis.

(Strong  “We recommend”, Low)

Esophageal biopsies are required to diagnose EoE. 2 – 4 biopsies should be obtained from both the proximal and distal esophagus to maximize the likelihood of detecting esophageal eosinophilia in all patients in whom EoE is being considered. (Strong  “We recommend”, Low)

At the time of initial diagnosis, biopsies should be obtained from the antrum and/or duodenum to rule out other causes of esophageal eosinophilia in all children and in adults with gastric or small intestinal symptoms or endoscopic abnormalities. (Strong  “We recommend”, Low)

Proton-pump inhibitor esophageal eosinophilia (PPI-REE) should be diagnosed when patients have esophageal symptoms and histologic findings of esophageal eosinophilia but demonstrate symptomatic and histologic response to proton-pump inhibition. At this time, the entity is considered distinct from EoE, but not necessarily a manifestation of GERD. (Conditional (weak)  “We suggest”, Low)

To exclude PPI-REE, patients with suspected EoE should be given a 2-month course of a PPI followed by endoscopy with biopsies. (Strong  “We recommend”, Low)

A clinical, endoscopic and/or histologic response to a PPI does not establish gastroesophageal reflux as the cause of esophageal eosinophilia. To determine whether reflux is contributing to esophageal eosinophilia, additional evaluation for GERD, as per standard clinical practice, is recommended. This may include ambulatory pH testing in selected cases. (Conditional (weak)  “We suggest”, Low)