Eosinophilic Esophagitis

Additional Info

• Audio File:uab/ua117.mp3
• Doctors:Callaway, James
• Featured Speaker:James Callaway, MD
• CME Series:Quality and Outcomes
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=5710
• Guest Bio:Dr. James Callaway is a gastroenterologist in Birmingham, Alabama and a UAB Faculty Member. He received his medical degree from Medical College of Georgia School of Medicine.
  
  Learn more about James Callaway, MD 
  
  Release Date: May 15, 2019
  Reissue Date: April 29, 2022
  Expiration Date: April 28, 2025
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Faculty:
  James Callaway, MD
  Assistant Professor in Gastroenterology
  
  Dr. Callaway has the following financial relationships with ineligible companies:
  Board Membership/Payment for Lectures, Including Service on Speakers Bureaus - Sanofi
  
  All relevant financial relationships have been mitigated. Dr. Callaway does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
  
  Welcome. In this podcast today, we’re talking about eosinophilic esophagitis and here to tell us about that is my guest, Dr. James Callaway. He’s a gastroenterologist and an Assistant Professor at UAB Medicine. Dr. Callaway, it’s sometimes referred to as EOE. Tell us about eosinophilic esophagitis and how prevalent it is.
  
  James Callaway, MD (Guest): Absolutely. Thank you for having me today. Eosinophilic esophagitis is becoming increasingly prevalent in the United States. Currently it is of around 25 or 26 per 100,000 people and it’s a condition that involves primarily difficulty swallowing that’s related to allergies, food allergies specifically that affects the esophagus.
  
  Host: So, are allergists and gastroenterologists seeing more patients with EOE? What do you attribute this to? Is it on the increase or is there an increased recognition of it?
  
  Dr. Callaway: Sure. Great question. It’s probably a little bit of a combination of both. We know that most of the prevalence is just increased awareness itself that we are finding. We are more cognizant of this condition and so because of that; we are looking for it and we are biopsying for it on our routine endoscopies or diagnostic endoscopies that we are doing. In the allergy world, they are seeing increased prevalence of all sorts of types of atypic and allergic type conditions. And this is another one that just happens to be what we think both food related and potentially aeroallergen related as well.
  
  Host: That’s so interesting and we’re going to get into some of the etiology of it in a minute, but how is it similar to GERD and yet different? Is it difficult to diagnose because of that?
  
  Dr. Callaway: Sure, great question as well. Both conditions actually can give eosinophils which are a particular type of inflammatory cell in the esophagus and so there can be some overlap with what these things may look like when we actually look at the biopsies. That being said, reflux disease oftentimes will present differently. Again, it presents more as chest pain and heartburn whereas eosinophilic esophagitis at least in adults, is primarily difficulty swallowing and what we refer to as dysphagia. That being said, reflux disease and eosinophilic esophagitis are not exclusive of each other. And so since the prevalence of reflux disease is almost between 25-40% of the population; oftentimes, patients with eosinophilic esophagitis will also have gastroesophageal reflux disease at the same time. And so, that’s part of our job as physicians is helping determine which of their symptoms may be related to one versus the other and how to best treat them.
  
  Host: Thank you for clarifying that. That was really very clear the way that you did that. So, tell us about some common conditions and factors that can lead to it. Is there a genetic component? Who is at risk for this?
  
  Dr. Callaway: Sure. Absolutely. So, first and foremost, we do think that there is a immune/antigen mediated component to this. meaning that there has to be a certain exposure. We think the primary risk factor for that are actually particular foods. And if a patient has the right predisposition again, most patients, the patients that we typical see eosinophilic esophagitis in is almost always they have a history of either asthma or allergic conditions as a child and so they are predisposed to having allergic type conditions later in adolescence and then in adulthood as well. So, that’s the primary population that we see it in. But it is an antigen-mediated response meaning that there is a clear exacerbant that causes the inflammation to occur and we think that most of these are foods.
  
  Host: Then tell us how we know. What’s the clinical presentation? You mentioned in whether it’s routine or diagnostic endoscopy that you are looking for those eosinophils and what would send somebody to the doctor anyway? People think they have GERD or reflux as you say it’s pretty popular. What else might we notice?
  
  Dr. Callaway: Absolutely. So, the biggest thing that we see in these patients is actually the presence of difficulty swallowing, especially in adults. It actually presents slightly differently in children. In children, they may have more food intolerances, sometimes nausea, vomiting, sometimes failure to thrive may be a presentation for that. So, pediatricians are looking for it with a variety of gastrointestinal symptoms.
  
  In adults, it appears to be more of difficulty swallowing is the primary presentation for this. there are a few cases where we find it when we are actually looking for gastroesophageal reflux disease as well, we will on the side just find eosinophilic esophagitis but primarily, these patients present with difficulty swallowing and then the most fear complication that they present with is what’s called a food impaction where food actually gets stuck in the esophagus and they can’t get additional food or liquids down and require what we call a dis-impaction, where we have to go tin with a camera scope to relieve that obstruction.
  
  Host: Yeah, that’s a scary circumstance. So, please review treatment strategies for us and the current guidelines from the American College of Gastroenterology on this condition. And what are your primary goals of treatment Doctor?
  
  Dr. Callaway: Absolutely. So, since this is felt to be an allergic response to different antigens itself, we have a couple of different approaches to treatment that we have. Some are dietary, some would be consider pharmacologic and then lastly would be what’s called dilation therapy of the esophagus. When we are talking about dietary therapy specifically, we are talking about trying to figure out which types of food may be causing the allergy or inflammation to occur. And we try to avoid those. And we have a couple of different ways that we will go in to actually test to see if you are – once you eliminate a food, test and see if you actually have had a response, meaning we can see that the inflammatory cells are going down if you are avoiding one of the main foods.
  
  Again, the main foods that have been associated with this disease are dairy, wheat, eggs, shellfish, soy, and I don’t know if I mentioned wheat, already, but there six main foods that we have that we call a six food elimination diet that we will oftentimes empirically put patients on because those are the most commonly associated foods with this condition.
  
  If dietary therapy proves to be too difficult to do, we may talk about what’s called pharmacologic therapy. Which will be the use of topical steroids or glucocorticoids or using proton pump inhibitors like Prilosec or Nexium which have both been shown to decrease the inflammatory response as well.
  
  Lastly, I did mention dilation therapy. So, if patients have that longstanding inflammation from the eosinophilia and from the allergy response that’s actually caused scarring to occur; you can get stricture formation in the esophagus. And stricture formation is where that scarring causes narrowing that is basically what the food ends up hanging up on later on over time. And so we can actually go in and stretch the esophagus and try to break up these strictures to allow for easier passage of solid foods.
  
  From a guidelines standpoint, we do like to rule out other conditions that would mimic eosinophilic esophagitis including looking into the presence or absence of gastroesophageal reflux disease. Also, obviously there are a number of guidelines that are associated with this condition looking at both the diagnosis of this and also treatment. From a purely treatment standpoint, we do know that dietary therapy has shown to be effective, topical steroids have been shown to be effective, proton pump inhibitors are used frequently and then dilation therapy are the main treatment mechanisms that have all been shown to be helpful in the long run.
  
  Host: Would that scarring Dr. Callaway then predispose them to Barrett’s?
  
  Dr. Callaway: So, it doesn’t predispose them to Barrett’s but as I mentioned, there is an overlap between gastroesophageal reflux disease and eosinophilic esophagitis. So, if they do have concomitant reflux symptoms, we should screen them for Barret’s as well. Barret’s is typically seen as from chronic reflux disease which again, can lead to chronic inflammation and scarring but it’s a slightly different physiology just because the inflammatory cells are different. The eosinophils versus the inflammatory cells seen in reflux disease.
  
  Host: Thank you so much for clarifying that as well. So, tell us a little bit about treatment response and what you expect when you try whether it’s the dilation therapy or steroids or the six food elimination diet. What do you expect as far as results and kind of give us your best summary of what you would like other providers to take away from this when you feel it’s important that they should refer to the specialists at UAB.
  
  Dr. Callaway: Absolutely. Great. So, with regards to results, there are two main things that I will kind of talk to my patients about as what our overall goals with therapy for this condition. First and foremost, I would like to prevent that dreaded complication of food impactions that I described earlier. It’s very frustrating for patients coming to the hospital at wild hours in the middle of the night because food is stuck and things of that nature. So, that’s first and foremost the things we are trying to prevent. And most of the time, we can achieve that goal with adherence to one of the therapies that we talked about before.
  
  Topical steroids appear to be very effective and can be taken long term. Proton pump inhibitors like Nexium again, are commonly used for reflux disease and do have some overlap in the treatment of EOE and so because of that; there also appears to be some at least response or long term response that we have seen. And lastly, dietary therapy. Again, have over a 70% rate of actually decreasing the amount of eosinophils to normal levels if we can identify the exact food that is causing it and if strict dietary avoidance can be adhered to.
  
  So, again, the treatments actually work fairly well at the inflammatory component. When there are strictures that develop; that can sometimes be a little bit trickier, but dilation therapy also has some long term data at being able to prevent food impactions and improve symptoms of difficulty swallowing.
  
  Overall, this is an increasingly prevalent condition which is clearly related to food allergens that is resulting in more and more difficulty swallowing and a population that typically presents in their 20s and 30s. So, we are seeing these patients early and I would encourage physicians and referring physicians if they are having patients that are either having difficulties swallowing, have any history of allergies as a child or asthma as a child or atypical reflux symptoms that are not responding to typical reflux therapy and then we should be thinking about eosinophilic esophagitis and we should consider referral to a gastroenterologist in that situation.
  
  Host: Thank you so much Dr. Callaway for coming on, sharing your expertise about this condition and how it is becoming more prevalent in what you’re seeing. Thank you again. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.
• Hosts:Melanie Cole, MS