Article
Eosinophilic Esophagitis: The Challenging Journey to Diagnosis
Sponsored by Takeda Pharmaceuticals
Uncovering the unseen and unspoken signs of eosinophilic esophagitis
“I don’t know what’s going on, but it’s been really hard for me to swallow and it feels like I’m ‘choking’ on my food when I eat.” A 35-year-old male visits your office telling you what brings him in today. When you ask how long this has been happening, he says 15 years, since college. As your conversation continues, you learn he also has heartburn in addition to his dysphagia.
When you ask what prompted him to see you after all this time, he explained the impact on his day-to-day life: the anxiety of having a choking episode at a work dinner or a date. “I’m 35 years old,” he says. “I should’ve been able to figure out how to eat without any issues by now.”
For many patients, the road to an Eosinophilic Esophagitis (EoE) diagnosis can be a long, difficult journey.1 As a disease that is growing in prevalence2, EoE is a chronic, immune-mediated inflammatory disease localized in the esophagus.3 While the exact cause of EoE is unknown, researchers believe several variables play a role, including genetics, environmental factors, immune system dysfunction4 and atopy.4
Impact on Patients
EoE impacts an estimated one in 2,000 people3,5,6,7,8 of all ages and races in the U.S. While both men and women may be affected, men are approximately twice as likely to develop EoE.1,8,9
The chronic, persistent inflammation of the esophagus can lead to a range10 of symptoms that manifest differently from patient to patient. Younger children including toddlers may exhibit feeding avoidance or intolerance, regurgitation, and vomiting. Older children may have similar symptoms and may also have chest or abdominal pain, and adolescents more often also have dysphagia as well as food impactions in some cases. While adults can experience all of these symptoms, dysphagia is the most frequently reported symptom. Adults with unrecognized, long-standing inflammation and potential esophageal scarring can also experience episodes of food impaction.11
Patients with EoE may also present with psychiatric comorbidities.12 One retrospective study found that one-third of adults and one in seven children with EoE have received a diagnosis of a psychiatric condition, like anxiety or depression.*
People with EoE can develop adaptive behaviors to cope with everyday life, especially to manage their symptoms when eating.13 These behaviors can include:
- Chewing food excessively
- Eating slowly
- Cutting food into small pieces
- Drinking with most bites of food
- Substituting solids with blended or pureed foods
- Avoiding social settings involving food
Earlier detection is important as it can help reduce a patient’s potential risk of disease complications.14,15 However, identifying EoE can be complex and delayed diagnosis is common among patients, up to eight years on average for adults according to one systematic review.1 Several factors can contribute to these delays. EoE can be under-recognized among specialists.10 Symptoms may also be under-reported by patients — around 50 percent of dysphagia cases may not be discussed with a physician,16** yet it’s the most common symptom of EoE.17Additionally, EoE symptoms can mimic other more common diseases such as gastroesophageal reflux disease (GERD)18 and patients can also present with one or more atopic disorders, such as asthma, rhinitis, atopic dermatitis and food allergies, making it challenging to assess and diagnose.10
Urgency to Diagnose
An EoE diagnosis first begins with a look at the patient experience. Patients should present with esophageal symptoms; however, physicians must be astute to adaptive behaviors and the potential for these behaviors to mask physical symptoms.10
Endoscopic and histopathologic results are other critical factors to consider.17 An endoscopy can help assess severity of EoE based on specific features, including edema, rings, exudates, furrows, and strictures.19 Of those with EoE, up to approximately 25 percent have normal endoscopic findings.20*** Current guidelines stipulate that esophageal biopsy results demonstrate an eosinophil count of ≥15/hpf (high-power field) for a diagnosis of EoE with biopsy samples taken from multiple levels of the esophagus.21
The diagnosis of EoE is made by this confirmation of esophageal eosinophilia on biopsies in patients who have signs and symptoms of esophageal dysfunction that are not explained by another underlying condition.21
In combination with the presence of esophageal eosinophilia, the assessment of symptoms and endoscopic findings are important in the evaluation for and diagnosis of EoE.11
Meeting the Unmet Patient Need
EoE is not a condition that should be overlooked. The signs of EoE must be seen, spoken about and managed.
Earlier this year, guidelines for the management of pediatric and adult patients with EoE were published by the American Gastroenterological Association and the Joint Task Force for Allergy-Immunology Practice Parameters (The American Academy of Allergy, Asthma, and Immunology and American College of Allergy, Asthma and Immunology). These guidelines strongly recommend that physicians use topical glucocorticosteroids over no treatment in patients with EoE, and conditionally recommend use of proton pump inhibition therapy, an elemental diet, dietary elimination treatments, and esophageal dilation.22 Endoscopic esophageal dilation is a mechanical treatment of stricture to improve symptoms and is not regarded as impacting underlying inflammation.3 To date, there are no FDA-approved therapies indicated for the treatment of EoE.
If left untreated, EoE can cause injury and inflammation to the esophagus.13 Chronic inflammation in EoE can change the way patients eat, which could negatively impact their social lives. It can also be a burden for parents of children with EoE.23,24,25,26,27
As healthcare professionals, it is important to ask open-ended questions that can help to identify adaptive behaviors that, when thought of as normal by patients, may prevent the recognition of dysphagia and other symptoms that may signal EoE. Importantly, it is key to assess and continue monitoring all three domains – symptoms, endoscopy and histopathology – when diagnosing and caring for people with EoE.11 With this approach, the pathway to a diagnosis of EoE can potentially be shortened and we can sooner help patients address and manage the manifestations of chronic inflammation in the esophagus and symptomatic burden of the disease.
For more information about the unseen and unspoken signs of EoE, please visit www.SeeEoE.com.
*In a study using the University of North Carolina EoE Clinicopathologic Database from 2002 to 2018. Of 883 patients diagnosed with EoE (per consensus guidelines), 241 (28%) had a psychiatric comorbidity. Study limitations include this is one, single center, retrospective study where a comparison to the national representative figures was done through non-statistical analysis.
**In an online April 2018 Takeda sponsored self-administered health survey of 31,129 people, 4,998 people reported dysphagia; however, only half sought healthcare for it. Of these people, 399 confirmed an EoE diagnosis.
***In a retrospective study of 117 patients with EoE, the esophageal mucosa was regarded as normal in 24.8% of the patients.
US-NON-0565v1.0 12/20
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