Makindo Medical Notes

📖 About

• Eosinophilic Oesophagitis (EoE) = chronic, immune-mediated inflammation of the oesophagus.
• First recognised as a distinct disease in the 1990s.
• Food antigens (🥛 milk, 🌾 wheat, 🍳 eggs, 🐟 seafood, 🌱 soy) strongly implicated.
• Pathology = infiltration of eosinophils → mucosal inflammation → fibrosis → stricturing.

📊 Incidence

• Predominantly affects white men aged 30–50.
• Estimated incidence ≈ 7 per 100,000 per year (rising with improved recognition).

🧬 Aetiology & Pathophysiology

• Genetics: Variants in CAPN14 and TSLP (thymic stromal lymphopoietin) genes increase susceptibility.
• Barrier dysfunction: Loss of anti-proteases → increased epithelial permeability → allergen penetration.
• Immune signalling: ↑ eotaxin-3 expression → recruitment of eosinophils → chronic inflammation.
• Result = mucosal fibrosis, trachealisation of oesophagus, stricture formation.

🧾 Diagnostic Criteria

• Symptoms of oesophageal dysfunction (e.g. dysphagia, food bolus impaction).
• > 15 eosinophils / high power field on oesophageal biopsy 🔬.
• Persistent eosinophilia despite 8-week PPI trial 💊.
• Exclusion of secondary causes of eosinophilia (see below).

🩺 Clinical Features

• Dysphagia (solids > liquids) 🍞🥩
• Food bolus impaction 🍗 (often requiring A&E attendance)
• Chest pain or reflux-like symptoms despite PPI use
• Narrow-calibre oesophagus → slow eating, avoidance of hard textures
• Children may present with feeding difficulties, failure to thrive

🔬 Investigations

• Endoscopy (OGD):
  • Rings (“trachealisation” of oesophagus) 🔄
  • Linear furrows 📏
  • White exudates ❄️
  • Friability, mucosal oedema, loss of vascular pattern
  • Fixed strictures in advanced disease
• Biopsy: > 15 eosinophils/hpf confirms diagnosis (after PPI trial).
• Bloods: May show peripheral eosinophilia, but not diagnostic.

📌 Causes of Oesophageal Eosinophilia

• Eosinophilic oesophagitis ✅
• GORD (reflux disease)
• PPI-responsive oesophageal eosinophilia
• Achalasia
• Crohn’s disease
• Parasitic infection 🪱
• Drug hypersensitivity 💊
• Connective tissue disease (e.g. scleroderma, dermatomyositis)
• Coeliac disease 🌾
• Hypereosinophilic syndrome

💡 Exam tip: A PPI trial (8 weeks) is essential before diagnosing EoE to exclude GORD.

💊 Management

• Dietary modification:
  • Empirical elimination diet (milk, wheat, eggs, soy, seafood) 🍞🥛🍳
  • Elemental diet in severe cases
  • Consider formal allergy testing
• Pharmacological:
  • High-dose PPI (also helps differentiate from GORD)
  • Topical swallowed steroids (fluticasone, budesonide via inhaler MDI without spacer) → reduce inflammation
  • Course: typically 8 weeks, then re-scope
• Endoscopic intervention:
  • Dilatation for strictures 🚑
  • Reserved for refractory or critically narrowed oesophagus

📋 References

• RACGP – Guide for Primary Care
• JAMA Review on Eosinophilic Oesophagitis