REMEDY : BNSSG referral pathways

Eosinophilic Oesophagitis

Checked: 03-12-2018 by Rob.Adams Next Review: 03-01-2019

Overview

Eosinophilic oesophagitis is a relatively common condition affecting up to 1 in 100 in Western populations. It initially presents in a similar way to classic GORD but may not respond to PPI treatment. EO is a chronic allergen driven immune mediated disease and can affect both adults and children. The majority of patients have comorbid allergic disease (up to 80%).

Presentation varies with age of onset:

  • Adults: heartburn, chest pain, dysphagia, food impactions
  • Children: difficulty feeding, vomiting, abdominal pain, failure to thrive.

Diagnosis is by endoscopic biopsy showing characteristic histopathology, followed by an 8 week trial of PPI and re-endoscopy to identify persisting eosinophils. 

Management advice

There are currently no clear national or local guidelines on the management of Eosinophilic Oesophagitis (EO).

There is a useful (but wordy) article published by the American College of Gastroenterology.

A treatment algorithm is also under development locally.

This is likely to suggest treatment with steroid inhaler (fluticasone evohaler 250 - 2 sprays twice daily) which is sprayed into the patients mouth and then swallowed (and not inhaled). Patients should not eat or drink for 30 minutes afterwards.

If response within one week then continue for 8 weeks.

If no response then consider referral to dietician.

If response but then relapse when treatment is stopped, then discuss maintenance treatment with steroid inhaler or dietary approach.

(Please note that at present there is no clear pathway for dietician referral for EO locally so referrals to them may be rejected - we hope that this will be resolved shortly - Referral Service Team)

 

Advice from Michael Sproat, GPSI at PRIME suggests the following:

'GPs typically prescribe inhalers by brand name, and I have come across patients being given "breath-actuated inhalers" which clearly are inappropriate for oral administration even if the dose is correct! My clinic letters therefore advise that patients are given Flixotide (Fluticasone) 250mcg Evohaler two sprays twice daily.

Otherwise, I am aware of the possible role of food allergens and dietary exclusion, but the most consistently effective treatment is the oral ingestion of low dose steroid (as above) and so I would personally only recommend dietician referral if there are complications of steroid use eg oesophageal thrush, or an individual has very strong feelings about not using steroids (although the total doses used here are low). That said, if referring to a dietician this condition will be beyond the remit of BCH community dieticians and so need hospital dietician input and that equally may mean secondary care Gastroenterology input too.
 
The issue of GORD and PPI use is interesting. EO is a definite, separate clinical entity and is NOT as a rule helped by PPI use. But, that said, reflux is much more common and can ALSO cause eosinophils to be seen on Oesophageal biopsy. When seeing patients, therefore, I do think we need to take great care to ensure that we are not confusing the two conditions. I can attest to seeing patients in our clinic who have had oesophageal biopsies which meet biopsy criteria for EO, but clinically show 100% response to PPI use- and so these people just need to continue their omeprazole! 
 
Reflecting this, all patients seen at Prime who are found to have possible EO on biopsy at time of OGD are seen in clinic by me for review. If doubt remains re GORD v EO it is best to repeat the OGD and biopsies again whilst continuing high dose PPI. Any persistent eosinophils then seen allow a more confident diagnosis of true EO. 
We are very happy to see these patients in the clinic at Prime for discussion and advice.'

Referral

Eosinophilic oesophagitis is diagnosed by endoscopy so if clinically suspected then please refer to the endoscopy page.

Once histological diagnosis has been made then the endoscopist should give advice on treatment. In most cases this can be managed in primary care so secondary care referral is rarely needed.

If further advice on treatment is required then please consider:

  • Referral to PRIME community gastroenterology clinic via eRS
  • Gastroenterology Advice and Guidance.
  • Secondary care referral via eRS should be reserved for patients who do not respond to treatment in primary care