Eosinophilic Oesophagitis

Overview

Eosinophilic Oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults. It is more common in men (ratio 3:1) and individuals with a history of atopy (eczema/hayfever/asthma)

It typically presents in adults with retrosternal dysphagia and pain, although it may also present with reflux-like symptoms.  It commonly also presents acutely to A&E departments with food bolus obstruction.

In children and adolescents, vomiting is the most common presenting, followed by dysphagia, abdominal pain and feeding disorders (Ref: Eosinophilic esophagitis in children and adolescents: epidemiology, clinical presentation and seasonal variation. Sorser et al J Gastroenterol 2013)

Diagnosis is made on OGD with typical appearance of the oesophagus, confirmed on biopsy with intraepithelial eosinophils of ≥15 eosinophils per hpf.

Management advice

British Society of Gastroenterology guidelines on the management of Eosinophilic Oesophagitis (EO) were published in May 2022.

Michael Sproat, GPSI at PRIME endoscopy, suggests the following approach to management:

'Treatment options depends on patient preference, the severity of symptoms and risk of complications such as food bolus obstruction or oesophageal strictures.

For patients with mild to moderate symptoms, treatment may include exclusion diets. This involves the initial avoidance of milk and wheat which can be effective in up to 40% of cases. If not helpful, the additional avoidance of eggs, soy, nuts and seafood may provide further symptomatic improvement. Food diaries may be helpful, although allergy tests are not routinely advised. The new BSG guidelines (May 2022) advise that elimination diets are introduced sequentially with repeat endoscopy and biopsies to check for symptomatic and histological remission. Given the need for specialist Dietician support and frequent endoscopies, patients who specifically wish to follow this treatment option should be referred to secondary care gastroenterology (not Prime Endoscopy)

'In terms of medication, Eosinophilic Oesophagitis is not due to acid reflux but many individuals do respond well to high dose PPI. A high dose is required- typically Omeprazole 20mg twice daily- with use continued for at least 8-12 weeks before assessing response. Many individuals have already tried low dose Omeprazole prior to their diagnostic endoscopy, but retrying it at a higher dose can still be helpful, especially if they have co-existent Gastro-oesophageal reflux disease.

Oral steroids remain a mainstay of treatment for individuals with more severe symptoms, or following a failed trial of diet and/or PPI. This had previously been administered using the oral ingestion of an Asthma steroid inhaler such as Fluticasone* 250mcg Evohaler. This, however, has now been largely superceded by the use of an orodispersible formulation of Budesonide (Jorveza)**. It is a safe and effective medication that is initially prescribed for 12 weeks pending repeat endoscopy and biopsy on treatment. Longer term use of orodispersible Budesonide as maintenance treatment may also be considered in patients with refractory symptoms.

Prime Endoscopy are always very happy to help with initial diagnosis^, advice and management. Individuals with poorly controlled symptoms and/or those requiring long term orodispersible Budesonide however may need to be subsequently also seen in secondary care Gastroenterology"

^ In an adult presenting with dysphagia, please consider referral via the Upper GI - USC (2WW) pathway.

* Please note: Fluticasone for eosinophilic oesophagitis remains non-formulary

**BNSSG Formulary Group approved a shared care protocol and pathway for budesonide orodispersible tablets (Jorveza) for maintenance treatment of eosinophilic oesophagitis at the meeting on 14^th June 2022. Jorveza remains TLS red for induction of remission but for maintenance treatment this is now TLS amber (after initial 3 months induction).

The SCP and pathway are available in the formulary part of Remedy under the listing for budesonide orodispersible tablets: https://remedy.bnssgccg.nhs.uk/formulary-adult/chapters/1-gastro-intestinal-system/14-disorders-of-gastric-acid-and-ulceration/ A link to the SCP is also available here: https://remedy.bnssgccg.nhs.uk/formulary-adult/scps/scps/ 

Red Flags

Patients presenting with red flags such as dysphagia should be referred via a 2WW pathway:

Upper GI - USC (2WW)

Referral

Eosinophilic oesophagitis is diagnosed by endoscopy so if clinically suspected then please refer to the endoscopy page.

Once histological diagnosis has been made then the endoscopist should give advice on treatment. 

If further advice on treatment is required then please consider:

• Referral to PRIME community gastroenterology clinic via eRS
• Gastroenterology Advice and Guidance.
• Secondary care referral via eRS - should be reserved for patients who do not respond to treatment in primary care and/or need assessment for induction on treatment with oral budesonide.

Resources

(1) Overview | Budesonide orodispersible tablet for inducing remission of eosinophilic oesophagitis | Guidance | NICE - June 2021

(2) BSG and BSPGHAN joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults - The British Society of Gastroenterology - May 2022

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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