Recently, a healthy 43-year-old male presented to me complaining of a several-month history of "food getting stuck." He delivered a progressive history of solid-food dysphagia frequently uncomfortable enough for him to excuse himself from table company to deal with matters. He was a nonsmoker, and no other red flag symptoms were identified.
The esophagram was consistent with eosinophilic esophagitis (EoE) and also suggested a Schatzki’s ring. An EGD was obtained for possible ring dilatation, during which a biopsy confirmed the diagnosis of esophageal eosinophilia. I dutifully updated myself on the disorder, talked to the patient, and called in a prescription for fluticasone. As it would happen, I knew the gastroenterologist performing the EGD and phoned him to discuss the biopsy.
I told him my plan, and he said, "Try a PPI first."
Indeed, a recent study by Dr. Fouad J. Moawad and his colleagues evaluated the comparative efficacy of the histological and clinical response of patients with esophageal eosinophilia treated with swallowed fluticasone or esomeprazole (Am. J. Gastroenterol. 2013;108:366-72).
In this study, 42 patients with a new diagnosis of esophageal eosinophilia were randomized to fluticasone 440 mcg twice daily (21 patients) or esomeprazole 40 mg once daily (21 patients) for 8 weeks. Patients underwent repeat endoscopies and biopsy. The primary outcome was histological response of esophageal eosinophilia. Patients were also stratified by the presence of GERD (eight patients, with four in each treatment arm).
Overall, no significant differences in resolution of esophageal eosinophilia were observed between the fluticasone group and the esomeprazole group. That pattern was mirrored in the 36 patients who didn’t have GERD: There was no significant difference in esophageal eosinophilia resolution between the two treatment groups.
However, differences did emerge in the presence of GERD. While none of the four patients with GERD who took fluticasone demonstrated resolution of esophageal eosinophilia, all four GERD patients on esomeprazole saw their esophageal eosinophilia resolve.
My patient improved. He could be one of the patients who are now recognized by the more recent and updated EoE consensus statement as having "PPI-responsive esophageal eosinophilia." Another win for phoning the expert.
Dr. Ebbert is professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He reports having no conflicts of interest. The opinions expressed are those of the author.