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Editorial

Eosinophilic Esophagitis

Esofagitis eosinofílica

Víctor Arbeláez victorarbelaez9@gmail.com

Universidad Nacional de Colombia, Colombia

Revista colombiana de Gastroenterología, vol. 39, no. 4, pp. 373-375, 2024
Asociación Colombiana de Gastroenterología

Received: 03 December 2024

Accepted: 04 December 2024

DOI: https://doi.org/10.22516/25007440.1313

This issue of the Revista Colombiana de Gastroenterología features two articles related to eosinophilic esophagitis (EoE). The first, by Drs. Castaño, Álvarez, and colleagues¹, examines a cohort of 330 patients retrospectively collected from esophageal biopsy pathology results at four centers in Medellín. The study compares demographic characteristics, endoscopic findings, eosinophil counts in esophageal mucosa, concomitant atopic diseases, treatments received, diagnostic delays, and disease phenotypes between adolescents aged 12-17 and adults over 18. Undoubtedly, this is a noteworthy contribution, deserving of recognition and congratulations, as it helps the medical community in Colombia to more frequently and promptly identify and diagnose patients with this relatively new disease, whose global incidence has been increasing over the past few decades.

In addition, two leaders in the field of gastroenterology, Drs. Juliao and Lúquez², provide an enlightening state-of-the-art review on EoE. Their extensive, engaging, and up-to-date review covers the most relevant information on the epidemiology, pathophysiology, diagnosis, and treatment of the condition. Without doubt, this represents a significant contribution to the knowledge and education surrounding this disease in Colombia.

Dr. Castaño and colleagues’ study highlights that 80% of patients with EoE are adults, with the remaining 20% being adolescents, most of whom are male. The study identified an average diagnostic delay of two years in adults, significantly longer than the 12-month delay observed in adolescents. This finding underscores the need to increase awareness of the disease among general practitioners, family physicians, and internists, among others. Differences were also observed in the frequency of stenotic/mixed and inflammatory phenotypes, which were more common in adults-likely due to the disease’s longer duration and differences in treatment approaches between adolescents and adults³. However, the study was unable to determine whether clinical presentation differed significantly between the two age groups, possibly because the adolescents studied had an average age of 14. As noted in the publication by Drs. Juliao and Lúquez, the presentation in children is primarily characterized by abdominal pain, vomiting, feeding difficulties, and growth delays², which are likely the predominant manifestations in younger children.

In summary, EoE is a chronic inflammatory disease driven by a type 2 immune response involving food allergens. It is histologically characterized by an increase in eosinophils (>15 per high-power field) in the esophageal mucosa, leading to esophageal dysfunction with defined clinical manifestations. Approximately 30% of cases may develop strictures or a narrow-caliber esophagus^4,5. The condition has several treatment options with variable efficacy and differing profiles of adverse effects, convenience, costs, and availability, making its management a significant challenge.

Treatment decisions should be made collaboratively with the patient and their family, particularly in pediatric cases. As highlighted in the review by Juliao and Lúquez, all proposed treatments have evidence of efficacy, which is further supported by a systematic review and meta-analysis of maintenance therapies presented at the American Digestive Disease Week 2024⁶. Empiric food elimination therapy is an effective treatment for patients of all ages. However, there is debate over whether to begin with a six-food elimination diet or to eliminate only cow’s milk, which is an appealing option as it simplifies dietary restrictions. Arguments exist for both approaches^7,8, and overall adherence rates for long-term dietary maintenance are reported to be low, at approximately 20%. A recent study by Wang and colleagues found that 57% of patients who completed the six-food elimination diet entered the maintenance phase, with 100% maintaining remission at three years⁴.

Proton pump inhibitors (PPIs) have demonstrated efficacy, are widely available, reasonably priced, and have a high tolerance and safety profile. Topical corticosteroids are effective medications; however, their prolonged use can lead to adverse effects, such as candidiasis (7%)⁹. There have been no significant changes in bone biomarkers with budesonide use^10,11, and the incidence of adrenal insufficiency is low⁹. Esophageal dilations performed using the appropriate technique are effective and carry a very low risk of complications¹².

Biological therapy with dupilumab may be considered a first-line treatment for patients with moderate-to-severe disease who also have asthma, atopic dermatitis, or nasal polyposis and who strongly prefer to avoid dietary restrictions or topical steroids. It may also be suitable for those with a low likelihood of responding to PPIs or topical steroids.

The development of a severity scale, available as an application, could significantly improve therapeutic decision-making in the near future. The goal of treatment is to achieve and maintain clinical, endoscopic, and histologic remission, whether through monotherapy or a combination of available therapies.