Eosinophilic oesophagitis: practical management and novel therapeutics

Eosinophilic oesophagitis (EoE) is a chronic type 2 allergic inflammatory disease of the oesophagus, with a rising prevalence in adults and children. Intermittent dysphagia and/or food impaction occurs in the presence of eosinophilic infiltration of the oesophagus. Patients tend to have a history of atopy. The underlying cause of EoE is an antigen-driven effect occurring only in the oesophagus, with food the most likely source of antigens. All adults with dysphagia or food bolus obstruction require endoscopy and at least six biopsies from the lower, mid- and upper oesophagus if they have signs associated with EoE or have a normal-looking oesophagus. Oesophageal histology showing a peak eosinophil count of ≥15 eosinophils/0.3 mm2 is diagnostic. The development of new therapeutics has progressed immensely and includes structured elimination diets, proton pump inhibitors, swallowed topical corticosteroids, biological therapy and endoscopic dilatation. Budesonide orodispersible tablets are the most effective induction and maintenance treatment for EoE, with histological remission in >90% of patients and symptom relief in 85% at 12 weeks. The risk of perforation during endoscopic dilatation of EoE strictures is no higher than those in other benign conditions. All patients require continued monitoring of symptoms.