Management of Eosinophilic Esophagitis

Last updated May 27, 2022

Key Points  

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

Management

In patients with symptomatic esophageal eosinophilia, the AGA/JTF suggests using proton pump inhibition over no treatment. ( Very Low , Conditional (weak) )
612

In patients with EoE, the AGA/JTF recommends pical glucocorticosteroids over no treatment. ( Moderate , Strong )
612

In patients with EoE, the AGA/JTF suggests topical glucocorticosteroids rather than oral glucocorticosteroids. ( Moderate , Conditional (weak) )
612

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.
612

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.
612

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.
612

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.
612

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) )
612

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 )
612

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 )
612

In patients with EoE, the AGA/JTF suggests against the use of anti-IgE therapy for EoE. ( Very Low , Conditional (weak) )
612

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 )
612

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

Recommendation in favor of empiric elimination diets is based on the published experience with the six food elimination diet ( 2SFED). 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.

Due to the potential limited accuracy of the currently available, allergy-based testing for the identification of specific food triggers for 4EoE, 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.


Recommendation Grading

Abbreviations

  • AGA/JTF: American Gastroenterology Association/Joint Task Force
  • EoE: Eosinophilic Esophagitis
  • IL: Interleukin
  • IgE: Immunoglobulin E
  • SFED: Six Food Elimination Diet
  • TNF: Tumor Necrosis Factor

Disclaimer

This pocket guide attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care, and providers at all levels. This pocket guide should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation. Neither IGC, the medical associations, nor the authors endorse any product or service associated with the distributor of this clinical reference tool.

Codes

CPT Codes

Code Descriptor
95044 Patch or application test(s) (specify number of tests)
95004 Percutaneous tests (scratch
95028 Intracutaneous (intradermal) tests with allergenic extracts
95024 Intracutaneous (intradermal) tests with allergenic extracts
43220 Esophagoscopy
95079 Ingestion challenge test (sequential and incremental ingestion of test items
95076 Ingestion challenge test (sequential and incremental ingestion of test items
95027 Intracutaneous (intradermal) tests
43195 Esophagoscopy
43213 Esophagoscopy

ICD-10 Codes

Code Descriptor Documentation Concepts Quality/Performance
K20.0 Eosinophilic esophagitis Type, Contributing factors RXHCC68