Original Article
Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings, and response to treatment with fluticasone propionate

https://doi.org/10.1016/j.gie.2005.07.049Get rights and content

Background

Eosinophilic esophagitis is an increasingly recognized disorder characterized by intense eosinophilic infiltration of the esophageal mucosa. The aim of this study was to define the clinical syndrome, the endoscopic features, and the distribution of the eosinophil infiltrate in adults with eosinophilic esophagitis. We undertook a prospective evaluation of the symptomatic and histologic response to treatment with fluticasone propionate.

Methods

Twenty-six patients (18 men; mean age 36 years) had symptom assessment and barium studies, esophageal motility recordings, and 24-hour esophageal pH studies. Upper-GI endoscopy was performed with quantitative eosinophil counts of biopsy specimens from the proximal and distal esophagus, the gastric antrum, and the duodenum. Nineteen subjects received 4 weeks of swallowed fluticasone propionate. After treatment, symptom assessment and endoscopic biopsies were repeated.

Results

All 26 patients had a history of dysphagia, and 11 presented acutely with food-bolus obstruction. Esophageal peristalsis was normal in most and gastroesophageal reflux coexisted in 10 patients. Characteristic endoscopic findings of furrows (20) and rings (18) were observed. All 19 treated patients had symptom improvement and a significant decrease in esophageal eosinophil counts.

Conclusions

Eosinophilic esophagitis is a distinct entity that may coexist with gastroesophageal reflux. Swallowed fluticasone propionate is an effective treatment.

Section snippets

Patients

Twenty-six adult patients (aged ≥ 17 years) with a histologic diagnosis of EE were enrolled in this prospective study. Patients were excluded if systemic or inhaled corticosteroids had been used in the preceding 3 months. Histologic diagnosis required a mean intraepithelial eosinophil density >15 eosinophils/high power field (HPF) in the absence of gastric or duodenal eosinophil infiltrates. Esophageal biopsy specimens were taken in patients with a history of dysphagia or food-bolus

Patients

Between November 2002 and December 2003, 26 patients (18 men, 8 women) were recruited. Nineteen patients (13 men, 6 women) completed baseline investigation, treatment, and follow-up. Seven patients dropped out of the study before commencing treatment. The mean age of the pretreatment cohort was 36 years (range 17-65 years).

Clinical features

Baseline clinical characteristics of the pretreatment group are shown in Table 1. All 26 patients had a history of dysphagia for solid food. Seventeen had prior episodes of

Follow-up

All 19 treated patients (including 10 with significant reflux) had a dramatic improvement in symptoms with 4 weeks of treatment. Eleven became asymptomatic. The mean symptom score decreased from 5.42 to 0.68 (p < 0.0001) (Fig. 2). All patients had histologic improvement. Eighteen subjects had a significant decrease in the eosinophils/HPF count in both the proximal and the distal esophageal biopsy specimens, with complete resolution in 4. One patient had a rise in his proximal count (38.4-61

Discussion

EE is a distinct clinicopathologic entity that extends beyond childhood. There appears to be a lack of awareness of EE, its defining features (which can be subtle), and treatment options among adult gastroenterologists. Most series have been published within the last 5 years and raise the question: Is EE increasing in incidence or increasing in recognition? Recent pediatric population based and adult observational studies30, 31 support the concept of increasing incidence. Our local experience

Acknowledgments

The authors thank the gastroenterologists who contributed patients to the study and Linda Fletcher, PhD, who provided technical assistance and statistical analysis.

References (45)

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