Esophageal Dysmotility in Patients Who Have Eosinophilic Esophagitis

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The understanding of esophageal motility alterations in patients who have eosinophilic esophagitis (EE) is in its infancy despite the common presenting complaint of dysphagia. A diversity of motility disorders has been reported in patients who have EE including achalasia, diffuse esophageal spasm, nutcracker esophagus, and nonspecific motility alterations including high-amplitude esophageal body contractions, tertiary contractions, abnormalities in lower esophageal sphincter pressure, and other peristaltic problems. Some evidence suggests that treatment of EE will improve motility. Technological advances such as high-resolution manometry and combined manometry with impedance may provide new insight into more subtle motility abnormalities.

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Dysphagia

Intermittent dysphagia and food impactions are the most common presenting symptoms associated with EE in older children and adults. In a report of 103 children, 26% of patients (mean age, 13 years) presented with dysphagia and 6.8% (mean age, 16 years) presented with food impaction [1]. Other pediatric series have found that food impaction was the initial presenting symptom in up to 20% of the patients [2]. In adults, the main presenting symptom is dysphagia, which has been reported in 29% to

Etiopathogenesis of esophageal dysmotility

The etiopathogenesis of esophageal dysmotility is not well understood. It may be related to the eosinophilic infiltration of the esophageal mucosa and its interactions with the microenvironment. Studies in which full-thickness biopsies were performed in patients who had EE found eosinophilic infiltration in all esophageal layers [7], [8], [9], [10], [11].

The exact mechanism by which eosinophilic infiltration may produce esophageal dismotility is not certain, but several speculations exist.

Stationary esophageal manometry

Esophageal motility has not been well characterized in patients who have EE. The results of stationary manometry are varied and include findings ranging from normal peristalsis to ineffective peristalsis (particularly after meals), including simultaneous and high-amplitude esophageal body contractions, achalasia, diffuse esophageal spasms, tertiary contractions, aperistalsis, nonspecific motor disorders, nutcracker esophagus, and high-amplitude contractions, particularly in the lower esophagus

Studies with high-resolution manometry

High-resolution manometry offers some advantages over standard manometry; the catheters have more recording sites and less space between them, allowing the clinician to define the intraluminal pressures completely and to reduce movement-related artifacts [29], [30]. The technology allows seamless, dynamic representation of peristalsis at every axial position within and across the esophagus, although the role of this additional data in clinical management is unclear [29], [30]. Recent studies

Studies with combined esophageal impedance and manometry

Technological advances have allowed the pairing of impedance sensors with pressure sensors in a single catheter. The addition of impedance provides insight into the transit of liquid, viscous, and solid food in the esophagus and its relationship with esophageal peristalsis. The sensors provide information about the transit time of substances down the esophagus and can identify areas of the esophagus that retain ingested contents, suggesting impaired motility. Studies in adults showed that

Studies with prolonged esophageal manometry

The majority of patients who have EE and dysphagia have normal esophageal stationary manometry. Although this result may reflect a limitation of the technology, other possibilities explaining the normal results include the study's short duration, its performance during fasting rather than meal periods, and the lack of symptoms that typically occur during the short study duration. Prolonged esophageal manometry, conducted over 24 hours, allows the clinician to measure motility during meal

Effect of treatment on esophageal motility abnormalities

It is not clear if nonspecific motor abnormalities are responsible for the dysphagia, and it has been suggested the abnormalities found during stationary manometry may be nonspecific. Three case reports and one prospective study tried to establish if the motor abnormalities would disappear after successful treatment (Table 3). In one case report of a patient who had achalasia and EE, normal peristalsis returned after myotomy. Two other patients experienced resolution of nonspecific motor

Other possible explanations for the dysphagia

It often is difficult to determine if subtle motor abnormalities are responsible for symptoms; adult studies have shown that nonspecific motor disorders do not consistently result in functional abnormalities [35]. As mentioned previously, patients who have EE have a high incidence of esophageal narrowing and strictures that may represent diffuse thickening of the muscularis propria or a functional constriction related to the marked infiltration of the myenteric plexus [11]. It also has been

Summary

The ethiopathogenesis of the dysphagia in patients who have EE is probably multifactorial. Primary motility disorders such as achalasia or diffuse esophageal spasms, as well as nonspecific motility disorders including abnormal peristalsis and high-amplitude contractions, have been described. These abnormalities probably result from the interactions between eosinophils and mast cells with the esophageal microenvironment. Even though some of the observed motility abnormalities improve after

References (58)

  • A. Straumann et al.

    Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5

    Gastroenterol

    (2003)
  • A.S. Arora et al.

    Topical corticosteroid treatment of dysphagia due to eosinophilic esophagitis in adults

    Mayo Clin Proc

    (2003)
  • J. Croese et al.

    Clinical and endoscopic features of eosinophilic esophagitis in adults

    Gastrointest Endosc

    (2003)
  • S. Vasilopoulos et al.

    The small-caliber esophagus: an unappreciated cause of dysphagia for solids in patients with eosinophilic esophagitis

    Gastrointest Endosc

    (2002)
  • M. Kaplan et al.

    Endoscopy in eosinophilic esophagitis: “feline” esophagus and perforation risk

    Clin Gastroenterol Hepatol

    (2003)
  • A. Straumann et al.

    Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years

    Gastroenterology

    (2003)
  • P. Cantu et al.

    Ringed oesophagus and idiopathic eosinophilic oesophagitis in adults: an association in two cases

    Dig Liver Dis

    (2005)
  • M. Remedios et al.

    Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings, and response to treatment with fluticasone propionate

    Gastrointest Endosc

    (2006)
  • N. Gonsalves et al.

    Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis

    Gastrointest Endosc

    (2006)
  • S.R. Orenstein et al.

    The spectrum of pediatric eosinophilic esophagitis beyond infancy: a clinical series of 30 children

    Am J Gastroenterol

    (2000)
  • S. Khan et al.

    Eosinophilic esophagitis. Strictures, impactions, dysphagia

    Dig Dis Sci

    (2003)
  • S.N. Sgouros et al.

    Eosinophilic esophagitis in adults: a systematic review

    Eur J Gastroenterol Hepatol

    (2006)
  • S.V. Walsh et al.

    Allergic esophagitis in children: a clinicopathological entity

    Am J Surg Pathol

    (1999)
  • A.G. Nicholson et al.

    Full thickness eosinophilia in oesophageal leiomyomatosis and idiopathic eosinophilic oesophagitis. A common allergic inflammatory profile?

    J Pathol

    (1997)
  • S. Evrard et al.

    Idiopathic eosinophilic oesophagitis: atypical presentation of a rare disease

    Acta Gastroenterol Belg

    (2004)
  • U. Zagai et al.

    The effect of eosinophils on collagen gel contraction and implications for tissue remodeling

    Clin Exp Immunol

    (2004)
  • A.M. Dvorak et al.

    Ultrastructural identification of exocytosis of granules from human gut eosinophils in vivo

    Int Arch Allergy Immunol

    (1993)
  • A. Tottrup et al.

    Eosinophil infiltration in primary esophageal achalasia. A possible pathogenic role

    Dig Dis Sci

    (1989)
  • S.P. Hogan et al.

    A pathological function for eotaxin and eosinophils in eosinophilic gastrointestinal inflammation

    Nat Immunol

    (2001)
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    This work was supported in part by the Pappas Foundation and by NIH grant 1K23DK073713-01A1.

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