Eosinophilic esophagitis is a newly recognized but common disease defined by the presence of esophageal symptoms in a patient with esophageal mucosal eosinophilia not attributable to gastroesophageal reflux or other causes. It is caused by a combination of an immunoglobulin E response with a TH2 lymphocyte type of allergic reaction to specific food antigens exposed to the esophageal mucosa with normal eating.
This in turn leads to chronic inflammation with dense eosinophilic infiltration. It is more common in men than women and typically affects children, teenagers, and young adults. Both a personal and family history of extraesophageal allergies is common. Children typically have symptoms referable to the inflammatory component of the disease, including failure to thrive, nausea, vomiting, dyspepsia, and heartburn. With time, inflammation leads to fibro sis. As a result, stricture formation is common in this disease, particularly in adults, and dysphagia to solid food becomes the most likely presenting symptom. Strictures may be of variable length, from focal distal strictures to uniform esophageal narrowing (small-caliber esophagus). In addition to strictures, endoscopically, the esophagus has several characteristic features, including white exudates that represent eosinophilic abscesses, linear furrows that are longitudinal mucosal tears, mucosal fragility characterized by easy tearing of the mucosa with minimal trauma, and esophageal rings with a corrugated appearance due to fibrosis. Treatment, particularly in adults, is aimed at both control of the inflammation and dilation of fibrotic strictures. Control of the mucosal eosinophilia may be achieved through medications such as proton pump inhibitors and topical corticosteroids. The ideal treatment is identification and avoidance of the food antigens that trigger the disease in individual patients. Unfortunately, this is often not practical given the inaccuracy of skin and blood allergy testing to predict causative food antigens and a lack of reliable noninvasive testing to monitor the response to multiple trials of food additions and withdrawals and the multiple foods often identified that need to be avoided.