Reply to A. J. Lucendo, D. De Rezende

 

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Eosinophilic esophagitis is an increasingly well-recognized disease entity. This form of esophagitis has been recognized in children for many years and there is now increasing evidence that the prevalence of the condition has been greatly underestimated in adults. Only recently, Ronkainen et al. [1] have shown in a random sample of 1000 adults that the prevalence of eosinophilic esophagitis is approximately 1 %. When the disease becomes symptomatic, patients most commonly present with dysphagia, food impaction, and heartburn [2], symptoms also experienced in esophageal stenosis with other causes and in reflux disease. We have therefore proposed that before treatment in these patients is considered, biopsies should be taken and the diagnosis of eosinophilic esophagitis confirmed or excluded histologically [3]. Sampling of five esophageal biopsies has been shown to reach a 100 % diagnostic sensitivity using a cutoff of ≤ 15 eosinophils per high-power field [4].

Although the underlying pathology in eosinophilic esophagitis is not completely understood, it resembles and to some degree is associated with allergic disorders [2] [5]. Consequently, it has been referred to as the ”asthma of the eophagus” [6]. Thinking along this pathogenetic pathway, steroid treatment is what comes to mind. The first randomized controlled trial of fluticasone propionate treatment in pediatric patients with eosinophilic esophagitis was published recently and this study provided evidence of the efficacy and safety of steroid treatment in these patients [7].

We and others have shown that dilation treatment in esophageal esophagitis carries a considerable risk of perforation. In the case we described, the situation was complicated by the presence of a long-segment stenosis of the esophagus which could not be passed with a standard endoscope. The esophagus was therefore dilated in order to allow for an adequate endoscopic examination and to obtain multiple biopsies to establish the diagnosis.

It is not yet known how many patients present with an esophageal stenosis so severe that it needs to be dilated before a definitive diagnosis can be established. Moreover, it is unclear for how long patients require conservative treatment using steroids in order to open a severe stenosis which is preventing the patient from eating. With only a few perforations described in the literature, we believe that there are insufficient data to state that the risk of esophageal perforation caused by dilation therapy is unacceptably high in patients who otherwise might have to be fed parenterally over a period of several months.

Eosinophilic esophagitis is a relatively newly recognized and very exciting condition in the field of gastrointestinal disease. More controlled studies addressing the pathobiology, diagnostic criteria, and treatment algorithms are needed to truly understand the disease and to provide definite recommendations for its treatment.

Competing interests: None

References

• 1 Ronkainen J, Talley N J, Aro P. et al . Prevalence of oesophageal eosinophils and eosinophilic oesophagitis in adults: the population-based Kalixanda study.  Gut. 2006;  November 29 [Epub ahead of print]
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C. Eisenbach,MD 

Department of Gastroenterology

University Hospital of Heidelberg

Im Neuenheimer Feld 410

69120 Heidelberg

Germany

Fax: +49-6221-566858

Email: Christoph_Eisenbach@med.uni-heidelberg.de