Reply to C. Eisenbach et al.

Eosinophilic esophagitis is a rare clinicopathological disorder characterized by an infiltration of eosinophilic leukocytes in the esophageal mucous membrane. Recent clinical studies suggest an allergic cause but the precise allergen remains unknown and is probably unique to each patient [1] [2]. The epidemiology of eosinophilic esophagitis has not been studied to any great extent, but it appears to be a new disease that is increasing in incidence. Some studies even suggest a prevalence that reaches near-epidemic proportions [3].

Although the disorder is more common during childhood, it is becoming increasingly recognized in adults and, for reasons that remain unclear, the majority of affected adults have been men in their 20 s or 30 s [4]. Symptoms associated with eosinophilic esophagitis vary according to the age of presentation. Adults usually present with dysphagia, and a history of food impaction is common. Dysphagia is resistant to treatment with prokinetics and gastric acid-secretion inhibitors [5].

A number of endoscopic signs have been reported in the literature to date: strictures have been observed most consistently; and other findings have included linear furrowing, ulceration, multiple whitish papules, fragile esophageal mucosa, and mucosal rings. These rings block the passage of the endoscope, causing a “paradoxical stenosis” [6]. The fragile esophageal mucosa can easily tear in response to minor trauma during otherwise straightforward diagnostic endoscopy procedures [7].

We read with interest the letter from Eisenbach et al. that was published recently in Endoscopy [8]. However, despite the fact there have been few cases of esophageal perforation described in the literature, we and others believe that tearing and perforation of esophagus can occur with simple passage of the endoscope, in the absence of any perceived resistance ([Fig. 1]) [9]. It is our opinion that fragile esophageal mucosa and loss of mucosal elasticity should alert endoscopists to the presence of this disease. When there is a stenosis of the esophagus that cannot be passed with a standard endoscope, it is necessary to maintain a high degree of clinical suspicion and to obtain multiple mucosal biopsies in order to establish the diagnosis before attempting to pass the endoscope through the “paradoxical stenosis,” so avoiding the risk of perforation.

Fig. 1 In this patient with eosinophilic esophagitis esophageal tearing occurred simply as a result of passage of the endoscope.

Furthermore, the presence of excessive numbers of eosinophils in the proximal esophagus is helpful for distinguishing eosinophilic esophagitis from gastroesophageal reflux disease, in which eosinophils are more often present in the distal esophagus.

Finally, we recommend dilation of the esophagus in eosinophilic esophagitis only in patients who do not respond to medical therapy or in patients who are found not have the disease on the basis of histological examination of multiple mucosal biopsies and in whom is necessary to examine the distal esophagus.

Competing interests: None

References

• 1 Furuta G T, Straumann A. The pathogenesis and management of eosinophilic oesophagitis [review].  Aliment Pharmacol Ther. 2006;  24 173-182
• 2 Straumann A, Simon H. The physiological and pathophysiological roles of eosinophils in the gastrointestinal tract.  Allergy. 2004;  59 15-25
• 3 Glenn T, Furuta G T, Straumann A. Eosinohilic esophagitis: an emerging clinicopathologic disease of children and adults.  Gastroenterol Hepatol. 2006;  2 371-374
• 4 Croese J, Fairley S K, Masson J W. et al . Clinical and endoscopic features of eosinophilic esophagitis in adults.  Gastrointest Endosc. 2003;  58 516-522
• 5 Sgouros S N, Bergele C, Mantides A. Eosinophilic esophagitis in adults: a systematic review.  Eur J Gastroenterol Hepatol. 2006;  18 211-217
• 6 Lucendo A J, Carrión Alonso G, Navarro Sánchez M. et al . Eosinophilic esophagits in adults, an emerging cause of dysphagia: description of 9 cases.  Rev Esp Enferm Dig. 2005;  97 229-239
• 7 Kaplan M, Mutlu E A, Jakate S. et al . Endoscopy in eosinophilic esophagitis: “feline” esophagus and perforation risk.  Clin Gastroenterol Hepatol. 2003;  1 433-437
• 8 Eisenbach C, Merle U, Schirmacher P. et al . Reply to A. J Lucendo, L. De Rezende [letter].  Endoscopy. 2007;  4 377
• 9 Straumann A, Rossi L, Simon H U. et al . Fragility of esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis?.  Gastrointest Endosc. 2003;  57 407-412