How to Approach a Patient With Eosinophilic Esophagitis Ikuo Hirano  Gastroenterology  Volume 155, Issue 3, Pages 601-606 (September 2018) DOI: 10.1053/j.gastro.2018.08.001 Copyright © 2018 AGA Institute Terms and Conditions

Figure 1 Improvement in endoscopically identified esophageal features of eosinophilic esophagitis with topical corticosteroid therapy. The upper 3 images depict edema (absence of vascular markings), rings (moderate, distinct rings), exudate (severe, >10% esophageal surface area), furrows and stricture of the esophagus before therapy in a patient with eosinophilic esophagitis and weekly dysphagia. After 2 months of treatment with swallowed, topical fluticasone 1 mg orally twice a day, the esophagus appears almost normal. Corresponding with the endoscopic improvement, the patient’s symptoms resolved, and biopsies improved from 100 to 3 eosinophils per high power field. The example illustrates the use of combined symptom, endoscopic and histologic endpoints as targets defining successful treatment response in eosinophilic esophagitis. Gastroenterology 2018 155, 601-606DOI: (10.1053/j.gastro.2018.08.001) Copyright © 2018 AGA Institute Terms and Conditions

Figure 2 Estimation of esophageal stricture diameter. Endoscopic estimation of esophageal luminal diameter is challenging when viewed anterograde unless the stricture prevents passage of an endoscope of known diameter (A, D). Retroflexion with visualization of the esophagogastric junction diameter relative to the diameter of the endoscope is a useful technique that can inform decisions on the performance of esophageal dilation of distal esophageal strictures. Estimated diameters are 12 mm for B, 14 mm for C, 15 mm for E, and 18 mm for F. Gastroenterology 2018 155, 601-606DOI: (10.1053/j.gastro.2018.08.001) Copyright © 2018 AGA Institute Terms and Conditions

Figure 3 Suggested management algorithm for eosinophilic esophagitis (EoE) in adults. The diagnosis of EoE is based upon presenting clinical symptoms of esophageal dysfunction combined with esophageal pathology demonstrating eosinophil predominant inflammation (ie, ≥15 eosinophils per high power field or approximately 60 eosinophils/mm2). Careful consideration of secondary causes of esophageal eosinophilic inflammation is advised, acknowledging that specific disease states can coexist without being causally related. Medical treatment options include the off-label use of proton pump inhibitors and swallowed topical corticosteroids. Owing to the limited accuracy of currently available allergy tests, empiric elimination diets are preferred over IgE-based testing directed diets. Esophageal dilation is highly effective at relieving dysphagia due to esophageal strictures that persist after medical or diet therapies. Dilation can be considered before the initiation of medical/diet therapy in patients with high-grade esophageal strictures or those unwilling to commit to maintenance medical/diet therapy (dashed line). The high rates of symptom and histologic recurrence support the consideration of maintenance therapy for symptomatic patients with EoE. PTEN, protein tyrosine phosphatase. Gastroenterology 2018 155, 601-606DOI: (10.1053/j.gastro.2018.08.001) Copyright © 2018 AGA Institute Terms and Conditions