GiT Updates and More

Eosinophilic Esophagitis Summary 1. Definition and Diagnostic Criteria Eosinophilic Esophagitis (EoE) = Chronic immune/antigen-mediated esophageal disease characterized by: • Symptoms of esophageal dysfunction (mainly dysphagia or food impaction). • ≥15 eosinophils/high-power field (eos/hpf) in esophageal biopsies. • Exclusion of other causes (GERD, infections, autoimmune or drug-induced esophagitis). Diagnosis follows the AGREE (2018) and ACG 2025 guidelines . ⸻ 2. Clinical Presentation • Adults: dysphagia, food impaction, adaptive behaviors (slow eating, avoiding certain foods). • Children: feeding difficulty, vomiting, failure to thrive. • Often associated with atopy (asthma, rhinitis, food allergy). Use the mnemonic IMPACT to reveal subtle symptoms: Imbibing liquids with food, Modifying texture, Prolonging meals, Avoiding sticky foods, Chewing well, Turning away pills . ⸻ 3. Endoscopic & Histologic Findings • Typical endoscopic features: edema, rings (trachealization), exudates, furrows, narrowing, pseudodiverticula. • EoE Endoscopic Reference Score (EREFS) used to grade findings. • Multiple biopsies from proximal and distal esophagus recommended. ⸻ 4. Initial Management Management is stepwise, combining: • Anti-inflammatory therapy (dietary or pharmacologic) • Dilation if fibrostenotic narrowing is present. a. Dietary Therapy • Empiric elimination diets preferred (not allergy-test directed): • 1-food elimination: remove dairy/milk • 2-food elimination: remove dairy + wheat • Assess response with repeat endoscopy + biopsy. b. Pharmacologic Therapy • Proton Pump Inhibitors (PPIs): e.g., omeprazole 40 mg daily Mechanism: reduce eosinophil recruitment + improve mucosal barrier. • Topical corticosteroids: e.g., budesonide oral suspension 2 mg twice daily (FDA-approved ≥11 years). If first-line therapy fails → confirm adherence and correct technique before labeling as refractory . ⸻ 5. Step-Up Therapy If nonresponsive to PPI and steroid → Dupilumab (IL-4Rα blocker) is FDA-approved for patients ≥1 year and ≥15 kg. • Targets IL-4 and IL-13 signaling. • Weekly subcutaneous injection (300 mg in adults). • Shown to improve symptoms, histology, and esophageal caliber (NEJM 2022, 2024). Consider dupilumab early if patient has other atopic diseases or intolerance to PPIs/steroids . ⸻ 6. Dilation • For fibrostenotic disease or critical narrowing. • Gradual dilation to 16–18 mm recommended. • Should always be combined with anti-inflammatory therapy to prevent recurrence. ⸻ 7. Long-Term Management • EoE is chronic; relapse occurs when therapy stops. • Long-term maintenance therapy (e.g., ongoing dupilumab or topical steroid) is required. • Follow-up: individualized (clinic and endoscopy). Usually repeat endoscopy after 1 year to monitor histologic remission and luminal diameter.

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