**18. Endoscopic treatment**

Esophageal dilation has definitive role in the management of EoE. Dilation is not indicated in patients with normal caliber esophagus and signs of inflammation during endoscopy [56]. It is very effective in symptomatic esophageal stricture (esophageal diameter < 10 mm), long segment narrowing and narrow caliber esophagus. This modality of treatment improves dysphagia and quality of life but does not reduce esophageal eosinophilia [57]. Either hydrostatic balloon dilation or wire guided bougie dilation can be done. Esophageal diameter should be 15 to 18 mm to relieve dysphagia. Patients may need multiple sessions to achieve this. There is an increased risk of mucosal tear causing postdilation chest pain for several days [58]. Although initially thought that EoE patients carry higher risk of perforation after esophageal dilation, systematic review did not show any higher risk of perforation (0.1%) in this group of patients [59].

#### **18.1 Endoscopic surveillance**

Currently there is no guideline when surveillance endoscopy should be done in EoE patients who have achieved remission. In clinical practice, endoscopic and histologic assessment should be done 6 to 8 weeks after initiation or change of treatment to evaluate the efficacy of the treatment. When the disease is under remission, less frequent assessment/surveillance is done on a yearly basis or less frequently depending on the clinical scenario and the clinician.

#### **18.2 Prognosis**

As mentioned earlier, EoE is a chronic inflammatory disease of the esophagus. The inflammation leads to remodeling, fibrosis and stricture. Fortunately, no case of esophageal malignancy has been reported in EoE. Patients are generally diagnosed after several years of their symptoms. Although symptomatic improvement occurs after treatment, recurrence is common after discontinuation of treatment. So maintenance therapy is needed to prevent recurrences. At the present time there is no head to head study to suggest the best maintenance treatment. Continuation of PPI, swallowed glucocorticosteroid and/or dietary therapy should be done in all EoE patients particularly in those with history of food impaction, dysphagia, esophageal stricture, and in those with rapid symptomatic and histologic relapse following initial treatment.

#### **19. Summary**

EoE has become a common clinical entity in patients with dysphagia and esophageal food impaction. Although the disease is more common in young male patients with allergic disorders, any person can get affected. High degree of suspicion is essential to diagnose this disease. So multiple proximal and distal esophageal biopsies should be taken in EoE suggestive mucosa (EREFS) and even in normal looking mucosa. Other causes of esophageal eosinophilia particularly GERD, eosinophilic gastroenteritis and hypereosinophilic syndrome should be considered. The morbidity can be managed and long-term complications can be prevented by a multidisciplinary team which includes gastroenterologists, pathologists, allergists and dietitians. Patients with EoE should be given PPI therapy or topical glucocorticosteroids for 8 to 12 wk. If there is no clinicoopathological improvement i.e., in treatment-resistant cases, esophageal dilation should be offered [60]. Esophageal

*Eosinophilic Esophagitis in 2021 DOI: http://dx.doi.org/10.5772/intechopen.97166*

dilation in combination with PPI therapy or topical glucocorticosteroid therapy should be offered to patients with esophageal strictures and narrow caliber lumen. Lowest effective dose of PPI therapy or topical glucocorticosteroid should be continued to all EoE patients as maintenance therapy to reduce progression of the disease and relapse. Patients with EoE should be referred to the dietitians interested in food allergies and EoE patients. The AGA/JTF recommends using immunomodulators, IL-4 inhibitor or IL-13 inhibitor *only* in the context of clinical trial.
