Key Points
- Eosinophilic esophagitis (EoE) was first characterized in the early 1990s and understood to be a food antigen-driven Th2 inflammatory condition.
- A large body of evidence suggests that EoE subjects have aeroallergen sensitization and concurrent atopic diseases including asthma, allergic rhinitis and eczema.
- There is a close interaction between these organ-specific diseases and a potential for common triggering antigens in EoE and other atopic conditions.
Management
In patients with symptomatic esophageal eosinophilia, the
AGA/JTF suggests using
proton pump inhibition over no treatment.
( Very Low, Conditional (weak) ) In patients with
EoE, the
AGA/JTF recommends topical
glucocorticosteroids over no treatment.
( Moderate, Strong ) In patients with EoE, the AGA/JTF suggests using elemental diet over no treatment. ( Moderate, Conditional (weak) )
Comment: Patients who put a higher value on avoiding the challenges of adherence to an elemental diet and the prolonged process of dietary reintroduction may reasonably decline this treatment option.
In patients with EoE, the AGA/JTF suggests using an empiric, 6-food elimination diet over no treatment. ( Low, Conditional (weak) )
Comment: Patients who put a higher value on avoiding the challenges of adherence to diet involving elimination of multiple common food staples and the prolonged process of dietary reintroduction may reasonably decline this treatment option.
In patients with EoE, the AGA/JTF suggests using an allergy testing-based elimination diet over no treatment. ( Very Low, Conditional (weak) )
Comment: Due to the potential limited accuracy of currently available, allergy-based testing for the identification of specific food triggers for EoE, patients may prefer alternative medical or dietary therapies to an exclusively testing-based elimination diet.
In patient with EoE in remission after short-term use of topical glucocorticosteroids, the AGA/JTF suggests continuation of topical glucocorticosteroids over discontinuation of treatment. ( Very Low, Conditional (weak) ) Comments: Patients who put a high value on the avoidance of long-term topical steroid use and its possible associated adverse effects, and/or place a lower value on the prevention of potential long-term undesirable outcomes (ie, recurrent dysphagia, food impaction, and esophageal stricture), could reasonably prefer cessation of treatment after initial remission is achieved, provided clinical follow-up is maintained.
In adult patients with dysphagia from a stricture associated with EoE, the AGA/JTF suggests endoscopic dilation over no dilation. Comment: Esophageal dilation does not address the esophageal inflammation associated with EoE. ( Very Low, Conditional (weak) )
In patients with EoE, the AGA/JTF recommends using anti-IL-5 therapy for EoE only in the context of a clinical trial. ( Evidence Gap, No recommendation )
In patients with EoE, the AGA/JTF recommends using anti-IL-13 or anti-IL-4 receptor a therapy for EoE only in the context of a clinical trial. ( Evidence Gap, No recommendation )
In patients with EoE, the AGA/JTF suggests against the use of anti-IgE therapy for EoE. ( Very Low, Conditional (weak) )
In patients with
EoE the
AGA/JTF suggest using
montelukast,
cromolyn sodium, immunomodulators, and anti-
TNF for
EoE only in the context of a clinical trial.
( Evidence Gap, No recommendation )
Treatment
Treatment of Eosinophilic Esophagitis (EoE) Clinical Decision Support Tool
1 Secondary causes of esophageal eosinophilia:
- Gastroesophageal reflux disease
- Eosinophilic gastrointestinal disease
- Achalasia
- Hypereosinophilic syndrome
- Esophageal Crohn’s disease
- Infections (fungal, viral)
- Connective tissue disorders
- Autoimmune disorders
- Vasculitis
- Drug hypersensitivity reactions
- Pill esophagitis
- Stasis esophagitis
- Graft versus host disease
- Marfan syndrome type II
- Hyper-IgE syndrome
- PTEN hamartoma tumor syndrome
- Netherton’s syndrome
- Severe atopy metabolic wasting syndrome
2 Recommendation in favor of empiric elimination diets is based on the published experience with the six food elimination diet (SFED). Patients who put a higher value on avoiding the challenges of adherence to diet involving elimination of multiple common food staples and the prolonged process of dietary reintroduction may reasonably decline this treatment option. Emerging data on less restrictive diets (4 food, milk elimination, 2-4-6 step up diet) may increase both provider and patient preference for diet therapy.
3 Patients who put a higher value on avoiding the challenges of adherence to an elemental diet and the prolonged process of dietary reintroduction may reasonably decline this treatment option.
4 Due to the potential limited accuracy of the currently available, allergy-based testing for the identification of specific food triggers for EoE, patients may prefer alternative medical or dietary therapies to an exclusively testing-based elimination diet.
5 Esophageal dilation does not address the esophageal inflammation associated with eosinophilic esophagitis.
GRADE Strength of Recommendations and Implications
Abbreviations
- AGA/JTF
- American Gastroenterology Association/Joint Task Force
- EoE
- eosinophilic esophagitis
- IgE
- immunoglobulin E
- IL
- interleukin
- SFED
- six food elimination diet
- TNF
- tumor necrosis factor
Source Citation
Ikuo Hirano, Edmond S. Chan, Matthew A. Rank, Rajiv Sharaf, Neil H. Stollman, David R. Stukus, Kenneth Wang, Matthew Greenhawt, Yngve Falck-Ytter. American Gastroenterological Association and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis. Ann Allergy Asthma Immunol. 2020;124:416-423.
Disclaimer
This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.
