Orginal article
Eosinophilic esophagitis in adults: An emerging problem with unique esophageal features

https://doi.org/10.1016/S0016-5107(03)02713-5Get rights and content

Abstract

Background

Eosinophilic esophagitis is an inflammatory condition in which there is dense eosinophilic infiltration of the surface lining of the esophagus. Reports of eosinophilic esophagitis pertain almost exclusively to pediatric populations. However, eosinophilic esophagitis is emerging as a clinical affliction of adults. This report describes the clinical and endoscopic findings of eosinophilic esophagitis in the largest cohort of adult patients reported to date.

Methods

Twenty-nine patients (21 men, 8 women; mean age 35 years) with documented eosinophilic esophagitis (≥15 eosinophils per high-power field in biopsy specimens) and a significant history of chronic dysphagia for solid food (24 patients) were evaluated clinically and endoscopically during a 3-year period (1999–2002). Fourteen patients (48%) had a history of asthma, environmental allergy, or atopy. In a subset of 15 patients, the diagnostic accuracy of endoscopy was compared with that of barium contrast esophagography.

Results

Twenty-seven patients (93%) had abnormal endoscopic findings; 25 (86%) had unique esophageal structural changes, associated with a preserved mucosal surface, that were highly atypical for acid reflux injury. Structural alterations seen in adult patients with eosinophilic esophagitis may occur in combination or as a primary characteristic, e.g., uniform small-caliber esophagus, single or multiple corrugations (rings), proximal esophageal stenosis, or 1 to 2 mm whitish vesicles scattered over the mucosal surface. Barium contrast radiography combined with swallow of a barium-coated marshmallow identified 10 (67%) of the primary features observed endoscopically in 15 patients. However, radiography failed to detect other features noted at endoscopy (e.g., only 3/6 patients with proximal stenosis, 5/9 patients with concentric rings and none of 4 patients with small caliber esophagus). Eight of the 29 patients (20%) had a history of chronic heartburn. Twelve patients had been treated with a proton pump inhibitor and only 3 reported some improvement in the severity of dysphagia.

Conclusions

Relatively young age, a history of chronic dysphagia for solid food, and endoscopic detection of unique structural alterations atypical for GERD in an adult patient should prompt a suspicion of EE and subsequent biopsy confirmation. Acid reflux appears to have a secondary role in eosinophilic esophagitis. In an uncontrolled comparison, endoscopy was superior to barium contrast radiography for the diagnosis of eosinophilic esophagitis. The incidence of eosinophilic esophagitis in adults appears to be increasing.

Section snippets

Patients and methods

As a result of earlier experience with EE in a group of patients with a small-caliber esophagus,4 a registry of patients with EE was established. During the years 1999 through 2002, 29 additional patients (21 men, 8 women; mean age 35 years, range 19–65 years) with EE were identified. Twenty-seven were evaluated by using a standard questionnaire and personal interview before or after endoscopic biopsy confirmation of EE (two patients). The medical records of all patients were reviewed. Patients

Results

The majority of patients (24 of 29; 83%) were referred for evaluation because of dysphagia that occurred exclusively with ingestion of solid foods. Eight of these patients (33%) had one or more documented episodes of food impaction that required endoscopic removal. Five patients experienced repetitive episodes of dysphagia as teenagers. Only 8 of the 29 patients (28%) had a history of chronic heartburn, although the majority were referred with a diagnosis of “refractory” GERD. Twelve patients

Discussion

The occurrence of EE in adults has been recognized only recently.1., 2., 3. In a span of 3 years, increasing numbers of relatively young adults with unexplained dysphagia with ingestion of solid food have been encountered by us. In many cases, repetitive diagnostic studies were unproductive despite persistence of dysphagia. Occult or recalcitrant acid reflux disease frequently was the explanation given for the problem.

In the present series, 25 of 29 patients with EE had unique esophageal

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Presented in abstract form at Digestive Diseases Week, May 19–23, 2002, San Francisco, California (Gastroenterology 2002;122:M1718).

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