Eosinophilic reported, and case reports have shown

 

Eosinophilic Esophagitis

MS Pharmacology-812

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Eosinophilic
Esophagitis an overview:

Abbreviations:

Ø  GERD= Gastrophageal reflux disease

Ø  GI=Gastrointestinal

Ø  EE/EoE=Eosinophilic Esophagitis

Ø  MDI=meter dose inhaler

Ø  IL=Interleukin

Ø  E=Eosinophil

Anatomy
of esophagus:

The esophagus or gullet is a muscular canal, about 23 to 25 cm. long, extending from the pharynx
to the stomach. It begins in the neck at the lower border of the cricoids
cartilage, opposite the sixth cervical vertebra, descends along the front of
the vertebral column, through the superior and posterior mediastina, passes
through the diaphragm, and, entering the abdomen, ends at the cardiac orifice
of the stomach.

Introduction:

Eosinophilic esophagitis is a
chronic immune system disease. It has been identified only in the past two
decades, but now days considered a major cause of digestive system
(gastrointestinal) illness. In the presence of eosinophilia (an abnormally increase
in a number of white blood cells) the esophagus has been noted in patients who
were believed to have had (GERD). It is an inflammatory condition of the esophagus.
White blood cells build up in the lining of the tube that connects
your mouth to your esophagus. This occurs, due to a reaction to foods,
allergens or acid reflux; causes inflammation or injure the esophageal tissue.
Damaged esophageal tissue can lead to difficulty swallow.

 

Clinical
Sign & Symptoms:

In Adults:

Ø 
Dysphagia

Ø 
Repeated
food Impaction

Ø 
Centrally
located chest pain (not respond to antacid)

Ø 
Not
responded to GERD medication

Ø 
Heart
burn

Ø 
Stomach-ache

Ø 
Undigested
food backflow

Ø 
Diarrhea(Rarely)

Ø 
Nausea

In Children:

Ø 
Feeding
problem in infants

Ø 
Eating
problem in children

Ø 
Emesis

Ø 
Abdominal
pain

Ø 
Poor
growth

Ø 
Malnutrition

Ø 
Weight
loss

Ø 
Heart
burn

Ø 
Food
impaction

 

Age
Grouped:

The patient age group
ranged from 2 months to 89 years.1 It was reported that males are
more commonly affected in both children (66%) and adults (76%).

 

Possible
Etiology of Eosinophilic Esophagitis:

Allergic responses have
been powerfully recommended as a reason of EE. This has been evidenced with
results showing that 50% to 80% of patients with EE have simultaneous
conditions such as atopic dermatitis, allergic rhinitis, asthma, and eczema. The
patients with EE also show allergic antigen sensitization from skin testing or
antigen-specific immunoglobulin E (IgE) presentation from plasma testing.
Interleukin (IL)-4, IL-5, IL-13, and mast cells are found in the esophagus of
patients with EE. Seasonal differences in symptoms have been reported, and case
reports have shown seasonal changes in eosinophilic levels in the proximal
esophagus. The elevated rate of eczema and other atopic allergies requires that
the patient be evaluated by an allergist who is familiar with EE. Inhaled
allergens may also play a role in EE, and the patient should thus be evaluated
for this as a contributing factor. 

Diagnosis:

Diagnostic test for Eosinophilic
Esophagitis includes:

Upper endoscopy. Use a long narrow tube
(endoscope) containing a light and tiny camera and put in it through mouth
down the esophagus. Inspect the lining of esophagus for irritation and amplification,
horizontal rings, vertical furrows, narrowing (strictures), and white patches.

 

Biopsy. In an endoscopy, perform a
biopsy of esophagus by taking a small piece of tissue & take multiple
samples from esophagus and then check the tissue under a microscope for
eosinophils.Blood tests. If suspect EE, some additional
tests to confirm the diagnosis and to begin to seem for the sources of
allergens. Blood tests to check for elevated than normal eosinophil counts
or total immunoglobulin E levels, suggesting allergy.

Treatment
of Eosinophilic Esophagitis:

Treatment strategies for EE are include:

Dietary
control:

If patients have food
allergies, take allergen-free diets. If patients do not respond to food taking
away of specific antigens, amino acid-based formula management is the recent
gold standard for evaluating. This treatment has been very important in
children, with a success rate of 92% to 98%.Resolution of symptoms occurred
within 7 to 10 days, and with histological improvement seen within 4 to 5
weeks. Amino acid-based formulas generally have an unlikable taste, and often
the feedings are given via nasogastral tubes. A slow introduction of certain
foods can be started when symptoms resolve and histology recover. The six most
common allergic foods are:

Dairy,
Eggs, Wheat, Soy, Peanuts and Fish or shellfish

Treatment:

Esophageal dilation may be required
in patients with food impactions cause by fixed strictures as a effect of
esophageal narrowing. Esophageal dilation may be done to treat the stricture in
cases of dysphagia or esophageal impaction. It is suggested that, if feasible,
an endoscopy with biopsy be done earlier to an esophageal dilation, helpful for
medical or dietary treatment. Complications from dilation can effect in
esophageal tears or lacerations. Presently, there are no records to assess
which patients will be at high risk for complications. However, patients who
have already developed esophageal rings, strictures, or narrowing are
considered to be at high risk for difficulty. 

Role of
antibiotics

A  new study information that antibiotic use in
the first year of infancy was related with six times the odds of developing EE.
The usage of antibiotics has been linked to allergy development in mice. Amusingly
the occurrence of Helicobacter
pylori in gastric biopsies is also inversely associated with EE.
There is, however, no indication to recommend that patients undergoing
antibiotic induced H
pylori eradication are at higher risk for EE.

In summary, EE is a
polygenic disorder in which a dysregulated environment in the oesophageal
mucosa shows to lead to inflammatory cell infiltration and disease development
in response to food allergens and aeroallergen). Both genetic and/or
environmental cause appear to manipulate the production of mediators such as
TSLP and eotaxin-3 by epithelial and other stromal cells. Eosinophils, Th2
lymphocytes, and mast cells are conscript to the mucosa. B lymphocytes may go
through local IgE class switching. Increasing evidence show that environmental
factors, in particular medications such as antibiotics, particularly early in
life, could put in to disease development and may even account for the amplified
occurrence of disease observed.

 

 

 

 Lifestyle modification home remedies:

If heartburn, these way of
life modification may help decrease the occurrence or severity of indication:

Maintain a well weight. Excess pounds put pressure on
your abdomen, pushing up your stomach and causing acid to back up into
your esophagus. If weight is at a healthy level, work to maintain it. If
obese, work to slowly drop weight — no more than 0.5 to 1 kg /week. Evade foods and drinks that cause
heartburn.
General triggers, such as fatty or fried foods, tomato sauce, alcohol,
chocolate, mint, garlic, onion, and caffeine, may create heartburn worse. Evade
foods you know will cause your heartburn.Raise the top of your bed. Regularly experience heartburn
at night or while trying to sleep, put gravity to work . If it’s not
possible to elevate your bed, insert a lodge between your mattress and box
spring to elevate your body from the waist up.

 

Alternative medicine

No other medicine remedy
has been proved to treat eosinophilic esophagitis. Still, some complementary
and substitute treatment may provide some release from heartburn or reflux signs.
Other treatments choiceS may include:

Herbal therapy. Herbal therapy sometimes used
for heartburn or reflux symptoms include licorice, slippery elm,
chamomile, marshmallow and others. Herbal treatment can have serious side
effects, and they may hinder with medications. Relaxation treatment. Method to calm stress and
anxiety may decrease signs of heartburn or reflux. such as progressive
muscle relaxation.Acupuncture. Acupuncture involves introduce
thin needles into definite points on your body. Limited data suggests it
may help people with regurgitation and heartburn, but mostly studies have
not show a benefit.

Conclusion

EE is a chronic disorder. Earlier,
it may have been misdiagnosed as GERD. Though GERD can co-exist with EE and
both have mostly same symptoms, EE not respond at high dose (2 mg/kg/day) PPI
therapy. Allergic responses have been strongly recommended as a reason of EE,
and many patients respond to an allergen-free diet. Other non-FDA recommended
treatments consist of short-term use of systemic and topical corticosteroids.
Montelukast has been used to treat a lesser number of EE patients along inhaled
allergens. Reslizumab, anti-IL-5, mepolizumab, and viscous budesonide are presently
in clinical test for the treatment of EE. Finally, esophageal dilation may be necessary
in patients who develop a food impaction as a result of esophageal narrowing.

Main messages:

·        
The
occurrence of eosinophilic oesophagitis (EE) is rising.

·        
EE
is characterized clinically
by signs of dysphagia, food impaction and proton pump inhibitor defiant
dyspepsia, and histologically
by major eosinophilic infiltration of the oesophageal mucosa.

·        
A
minimum of 2–4 oesophageal biopsies should be taken from the proximal and
distal oesophagus to identify EE.

·        
EE
is related with atopy and a T helper type 2 (Th2) reaction. A detailed allergy
history required to be taken before testing for food and aeroallergens in EE
patients.

·        
Genome-wide
analysis studies (GWAS) have found EE to be associated with a region on
chromosome 5q22 in a paediatric cohort. The gene for thymic stromal
lymphopoietin (TSLP) is localised to this region.

REFERENCES

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