Eosinophilic Esophagitis (cont.)
How is eosinophilic esophagitis treated?
The treatment of eosinophilic esophagitis is with gentle
esophageal dilatation, and medications. The goal of treatment is to relieve symptoms
of dysphagia.
Esophageal dilatation
For decades, gastroenterologists have been treating patients with dysphagia from
eosinophilic esophagitis in the same manner as patients with dysphagia due to
esophageal strictures and Schatzki rings, i.e., esophageal dilatation.
Esophageal dilatation involves physically stretching the strictures or
fracturing the rings, thus allowing freer passage of solid food. Stretching or
fracturing can be performed with endoscopes, long and flexible dilators of
different diameters inserted through the mouth, or with balloons inserted into
the esophagus through the channels of endoscopes. The balloons are positioned at
the level of the strictures or rings and then inflated.
While esophageal dilatation has been an effective and usually safe treatment,
doctors have observed that some patients with eosinophilic esophagitis develop
tears in the esophageal lining that can lead to severe chest pain after
dilation. Rare cases of esophageal perforations (tears through the entire
esophageal wall) also have been reported. Esophageal perforations are a serious
complication that can lead to infections within the chest. Thus, although
doctors may still use dilatation to treat dysphagia from eosinophilic
esophagitis, they now are more likely to use smaller dilators and less force
than they would when treating esophageal strictures and rings. Moreover, doctors
also are more commonly using medications to treat dysphagia from eosinophilic
esophagitis and using dilation only when meditations fail.
Medications
The
medications used in treating eosinophilic esophagitis are proton pump inhibitors
(Protonix, Nexium, Aciphex, Prevacid, Prilosec, and Zegarid), and fluticasone
propionate (Flovent).
Fluticasone propionate (Flovent)
The current treatment of eosinophilic esophagitis is with swallowed (not
inhaled) fluticasone propionate. Fluticasone propionate is a man-made steroid
that is related to the naturally occurring steroid hormone, cortisol or
hydrocortisone, produced by the adrenal glands. These steroids have potent
anti-inflammatory actions. When used as an inhaler, fluticasone propionate
reduces inflammation in the airways of patients with asthma, thus relieving
wheezing and breathing
difficulties. When fluticasone propionate is
swallowed, it has been shown to
reduce the eosinophils in the esophagus and relieve dysphagia among patients with eosinophilic
esophagitis.
In treating eosinophilic esophagitis, fluticasone propionate is administered
with the same inhaler as for asthma but without the usual spacer in the
inhaler. The removal of the spacer causes the fluticasone propionate to deposit
in the mouth rather than enter the lungs. The fluticasone propionate that
deposits within the mouth then is swallowed with a small amount of water,
usually twice daily for several weeks. Patients are instructed not to eat or
drink for two hours after each treatment. Improvement in dysphagia usually is
prompt, within days or weeks. Some patients may develop recurrent symptoms
months after stopping treatment and require retreatment.
When used in low doses, little fluticasone propionate is absorbed into the body
and therefore side effects are
minimal. One possible side effect is thrush (infection of the mouth and throat
by a fungus, candida). When higher doses are
used for a prolonged period, enough fluticasone propionate may be absorbed to
cause side effects elsewhere in the body. Side effects of high doses of
fluticasone propionate are similar to the side effects of oral steroids such as
prednisone and cortisone.
Proton pump inhibitors
Proton pump inhibitors, pantoprazole (Protonix), esomeprazole (Nexium),
rabeprazole (Aciphex), lansoprazole (Prevacid), and omeprazole
(Prilosec, Zegarid) reduce production of acid by the stomach. They are
very safe and effective treatment for the symptoms of acid reflux and esophagitis.
Since acid reflux may aggravate esophagitis in some patients with eosinophilic
esophagitis, doctors frequently use proton pump inhibitors for treating
eosinophilic esophagitis.
Next: What about elimination diets for treating
eosinophilic esophagitis? »
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