Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
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 of the strictures or fracturing the rings, thus allowing freer passage of solid food. Stretching or
fracturing of the strictures or rings can be performed with endoscopes, long and flexible dilators of
different diameters inserted through the mouth, or with balloons inserted into
the esophagus through a channel in the endoscope. The balloons are positioned at
the level of the stricture or ring and then inflated to break the stricture or
ring.
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 in 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 medications fail.
Medications
The
medications primarily used in treating eosinophilic esophagitis are fluticasone
propionate (Flovent) and proton pump inhibitors
(Protonix, Nexium, Aciphex, Prevacid, Prilosec, and Zegarid).
Fluticasone propionate (Flovent)
Although oral steroids are effective in treating eosinophilic esophagitis, the side effects of orally-administered steroids limit their use. One new oral steroid that is being tested is budesonide, an orally-administered steroid that is absorbed into the body but is rapidly destroyed, resulting in fewer serious side effects. The current treatment of eosinophilic esophagitis is with swallowed (not
inhaled) fluticasone propionate. Fluticasone propionate is a synthetic (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 in 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 in the mouth is then 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. Most patients develop recurrent symptoms
after stopping treatment require treatment and/or continuous retreatment.
When used in low doses, little of the 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), which is relatively easy to treat. When higher doses are
used for a prolonged period, enough fluticasone propionate may be absorbed to
cause side effects throughout 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
(for example, Prilosec, Zegarid, Kapodex) 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. Proton pump inhibitors do not treat the underlying
eosinophilic esophagitis; however, and treatment with fluticasone or another
steroid usually is required as well.
GERD (gastroesophageal reflux disease) is a condition in which the acidified liquid
contents of the stomach backs up into the esophagus. The symptoms of uncomplicated GERD are heartburn,
regurgitation, and nausea. Effective treatment is available for most patients with GERD.
Nausea is an uneasiness of the stomach that often precedes vomiting. Nausea and vomiting are not diseases, but they are symptoms of many conditions. The causes of vomiting differ according to age, and treatment depends upon the cause of nausea and vomiting.
Dysphagia or difficulty in swallowing, swallowing problems. Dysphagia is due to problems in nerve or muscle control. It is common, for example, after a stroke. Dysphagia compromises nutrition and hydration and may lead to aspiration pneumonia and dehydration.
Esophagitis is caused by an infection or irritation of the esophagus. Infections that cause esophagitis include candida yeast infection of the esophagus as well as herpes.
Barrett's esophagus occurs as a complication of chronic gastroesophageal reflux disease (GERD), primarily in white males. GERD refers to the reflux of acidic fluid from the stomach into the esophagus (the swallowing tube), and is classically associated with heartburn.
Achalasia is a disease of the esophagus that mainly affects young adults. Abnormal function of nerves and muscles of the esophagus causes difficulty swallowing and sometimes chest pain.
Gangrene may result when blood flow to a tissue is lost or not adequate to keep the tissue alive. There are two types of gangrene: wet and dry. All cases of wet gangrene are infected by bacteria. Most cases of dry gangrene are not infected. If wet gangrene goes untreated, the patient may die of sepsis and die within hours or days. Dry gangrene usually doesn't cause the patient to die. Symptoms of dry gangrene include numbness, discoloration, and mummification of the affected tissue. Wet gangrene symptoms include swelling, pain, pus, bad smell, and black appearance of the affected tissue. Treatment depends upon the type of gangrene and how much tissue is compromised by the gangrene.
Schatzki (Schatzki's) ring, is a narrow ring of tissue located just above the junction of the esophagus and stomach. The cause of Schatzki ring is not clearly known, however, some doctors believe they are caused by long term acid reflux. The symptoms of a Schatzki ring is primarily poorly chewed food that stays in chunks becoming stuck in the esophagus. Diagnosis of Schatzki's ring is barium x-ray or endoscopy. Treatment is generally a procedure to stretch or fracture the rings.
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