SAVED
File name .JPG
File alt. text
Image should be px wide x px tall.
Select Image
home - Oesophagus - Miscellaneous - Eosinophilic Oesophagitis Written by Dr Sebastian Zeki
Nausea and Vomiting:
Understands the pathophysiology of vomiting.
Appreciates the gastrointestinal conditions that cause nausea and
vomiting as well as the range of extra-intestinal causes

Recognises the influence of neurological conditions and metabolic
derangements such as diabetes

Understands the physiology of gastric emptying and how this is
affected by disease, toxins and drugs

Abdominal Pain:
Knows the causes of acute and chronic abdominal pain that arise
from upper gastrointestinal, biliary and pancreatic diseases

Understands the clinical presentations of the various conditions
causing pain and the means by which they can be diagnosed and
treated

Weight Loss:
Knows the significance of weight loss as a consequence of upper
gastrointestinal disease, knows those conditions that present with
loss of weight and how they are managed

Skills
Makes a detailed clinical assessment of patients presenting with
symptoms indicating possible upper gastrointestinal disease,
construct a management plan and be aware of the various avenues
of treatment

Behaviours
Evaluates patients in a structured and timely manner, carries out
appropriate investigations and formulates management plan.

Eosinophilic Oesophagitis

Written by Dr Sebastian Zeki >15 eosinophils per high powered (400X) field in at least one specimen despite acid suppression with a PPI for one to two months (to distinguish from GERD), and the exclusion of other causes and normal gastric and duodenal mucosal biopsies (distinguish it from eosinophilic gastroenteritis) Associations: Coeliac disease.Eosinophilic gastroenteritis,Peripheral eosinophilia (92%). Clinical Manifestation:Dysphagia(20%) ;GERD (80%).Atopy which is present in > 50% including rhinoconjunctivitis (57%). wheezing (37%), and possible food allergy (46 %).Morphologic abnormalities in the esophagus (68%). EpidemiologyThe incidence is 9 per 100,000 and increasing.A family history is present in 7%.Occurs in males more commonly than females.The average age of onset is 20-30. Eosinophilic Oesophagitis + + Diagnostic Criteria: Treatment:Elimination diets.Topical corticosteroids.Systemic corticosteroids.Topical versus systemic corticosteroids.Purine analogues.Anti-TNF therapy.Acid suppression.Oesophageal dilation.Antihistamines and cromolyn. MepolizumabMepolizumab is a humanized monoclonal antibody against IL-5The preliminary report of a placebo-controlled trial in 11 adults found a significant reduction in blood and tissue eosinophilia but the degree of reduction in tissue eosinophilia did not achieve the primary endpoint of the study. Swallow rather than inhale fluticasone MDITrials done with inhaled fluticasone (440mcg bd) or budesonide if fail fluticasone90% get further symptoms on average 9 months after cessation of topical steroidsGood response rate within 2 weeks but high rate of relapseSlightly more effective with oral prednisalone, but side effects justify fluticasone as preferableA case report described a clinical and histologic response to azathioprine and 6-mercaptopurine in three adults with corticosteroid-dependent eosinophilic esophagitis.Not effective Elimination of six foods associated with allergy (ie, cow-milk protein, soy, wheat, egg, peanut, and seafood). Can give 94 % symptomatic response and 78 % histological responseReintroduction of each food can help to isolate cause- only 22% were skin prick positive for the inciting food May be helpful with symptoms. Activated fibroblast cell Periostin PPI’s Anti-IL5 DietSteroids + H+ IL-5 Chemotaxis + IL-13 Th2 cell Eosinophil Activated epithelial cell B-lymphocyte Mast cell Eotaxin-3 IgE AeroallergensFood allergens Specific for EO Supportive histologic features:-Lamina propria fibrosis and inflammation.-Eosinophil microabscesses. -Surface layering of eosinophils.-Basal layer hyperplasia.-Papillary lengthening.-Degranulating eosinophils. Eosinophilic gastroenteritisDEFINITIONEosinophilic gastroenteritis (EG) represents one member of a family of diseases that includes eosinophilic esophagitis, gastritis, enteritis, and colitis, collectively referred to as eosinophilic gastrointestinal disorders (EGIDs). LabsPeripheral eosinophil counts elevated in 80% (average absolute eosinophil count of 2000 cells/uL)Serum IgE levels can be elevated, especially in childrenBarium not specific or sensitive- typically reveal thickening or nodularity in the antrum and a thickened or "saw-tooth" mucosa in the small bowel.DiagnosisMucosal biopsies: >20 to 25 eosinophils per high power field. Take >5 biposies as disease is patchyEndoscopic findings: nodular or polypoid gastric mucosa, erythema, or erosions. If disease penetrates muscle, can get rigid gut, if subserosal can get eosinophilic ascites. Algorithms for Treatment:All patients need skin allergy testing.Try six food exclusion.Fluticasone MDI into the mouth, then swallowed with water.If no response try topical budesonide.Adding a PPI may help.No need for surveillance endoscopy. PrognosisPrognosis unknown.Untreated, may remain symptomatic or have episodic symptoms, but symptoms dont usually progress.If detected in childhood, it tends to persist into adulthood.No children progressed to other GI disease.In adults it may progress to a fibrostenotic stage, in which the predominant symptom is intermittent dysphagia.The proportion of patients with progressive disease is unknown. High rate of perforation.Usually used in people refractory to medical treatment.May be wise to try course of steroids prior to dilatation and lesser perf rate.Not effective.Montelukast.Helpful with EE but not with eosinophilic gastroenteritis.Doesnt reduce eosinophil counts and need a much higher dose (10x) to induce remission which can cause side effects. Features more likely in EE than GORD:Male.Younger than 45.Dysphagia.Ring.Large numbers of intraepithelial eosinophils. Morphology:Strictures (esp proximal) are the most common manifestation.Mucosal rings (including multiple rings), linear furrowing, ulceration-are usually due to lamina propria fibrosis.Multiple whitish papules (representing eosinophilic abscesses), and oesophageal polyps.

Related Stories

•

•

•

•

•