Immunology and AllergyTier 1Disease (DEADMAN)

Allergic disorders - eosinophilic oesophagitis (EoE)

Description

Chronic, antigen (usually food)-driven, eosinophil-predominant oesophageal disease
Clinicopathological diagnosis - symptoms plus histology, neither alone is sufficient
PPI-responsive oesophageal eosinophilia is no longer a separate diagnosis from EoE - PPI response does not exclude EoE, it is simply one form of treatment response (2018 consensus, still current)

Rising incidence, now the commonest cause of dysphagia/food bolus obstruction in young adults
M>F (~3:1), strong association with other atopic disease (asthma, allergic rhinitis, food allergy, atopic dermatitis)

Th2-mediated food-antigen driven oesophageal inflammation (IL-5, IL-13 axis)
Chronic eosinophilic inflammation -> oesophageal remodelling and fibrosis -> rings, strictures, narrow-calibre oesophagus if untreated
Common trigger foods: milk, wheat, egg, soy - overlapping with common food allergens but EoE is not typically IgE-mediated (skin prick testing poorly predicts trigger foods)

Criteria

Symptoms of oesophageal dysfunction (dysphagia, food impaction, reflux-like symptoms unresponsive to standard therapy - in children, feeding difficulty/failure to thrive)
>=15 eosinophils per high-power field on oesophageal biopsy
>=6 biopsies from >=2 oesophageal levels (proximal and distal) - patchy disease, single-level biopsy misses cases
Exclude other causes of oesophageal eosinophilia (other than concurrent GORD, which does not exclude EoE)

Endoscopy

EREFS scoring system - Edema, Rings, Exudates, Furrows, Stricture - standardised endoscopic reporting
Endoscopy may look normal in a minority - biopsy regardless if EoE is clinically suspected

First-line - three co-equal options

Option	Notes
Swallowed topical corticosteroid (budesonide oral suspension/orodispersible tablet, or fluticasone via inhaler swallowed)	Strongest evidence; take after food, nil by mouth 30-60 min after dosing
PPI (high-dose)	Reasonable first-line, not just for PPI-REE; a proportion achieve histological remission
Empiric elimination diet (commonly 4- or 6-food elimination - milk, wheat, egg, soy +/- nuts, seafood)	Effective but burdensome; systematic reintroduction to identify true triggers

Refractory to first-line therapy

Dupilumab - approved for age >=1 year (children unresponsive to PPI) and >=12 years generally; consider earlier if coexistent moderate-severe asthma/atopic dermatitis
Endoscopic dilatation for fibrostenotic disease (strictures) - symptom relief only, does not treat the underlying inflammation, use alongside anti-inflammatory therapy

Monitoring

Repeat endoscopy + biopsy to confirm histological response (symptoms alone correlate poorly with histological activity) - do not rely on symptom improvement alone to declare remission
Long-term maintenance therapy generally needed - EoE recurs on stopping effective treatment

Other atopic disease - asthma, allergic rhinitis, atopic dermatitis, IgE-mediated food allergy
Oesophageal food bolus obstruction - a common presenting emergency
Oesophageal strictures/narrow-calibre oesophagus in long-standing untreated disease

Chronic, relapsing disease - untreated progressive fibrostenotic remodelling over years
Early effective anti-inflammatory treatment reduces (may prevent) stricture formation
Stopping treatment - relapse is the norm, not the exception - most patients need long-term maintenance

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