By Ed Sutton, MD
Eosinophilic Esophagitis (EoE), first described in 1993, is a relatively new GI disorder. It is allergy-mediated and marked by the infiltration of eosinophils into the esophagus. The allergic response leads to intense pain, a loss of mobility and stretch, and eventually esophageal fibrosis. The infiltration of eosinophils is much greater than what would normally be seen with tissue damage from GERD and often involves the entire length and full thickness of the esophagus.
Eosinophils (eosin-loving) derive their name from the strong affinity for the stain Eosin. Eosin derives its name from the Greek goddess Eos, the goddess of the dawn; she was thought to be responsible for the bright pink colors of the new day. Eosinophils are very easily recognized on smear after H & E staining because of their large, bright, reddish cytoplasmic granules, which are full of destructive inflammatory mediators and cytokines, making these cells the “big guns” from the myeloid line. These cytokines cause the esophageal mucosa to be leaky and even more permeable to allergic antigens, thus enhancing and worsening the process; this eventually leads to loss of motility and fibrosis. Because of their destructive capacity, eosinophils often increase with allergies, parasites, and bulky malignant tumors.
As adult anesthesia providers, we’ll often see EoE patients with multiple allergies who present late in the disease process and who require deep sedation with symptoms of dysphagia and food bolus obstruction; pediatric anesthesia providers often see infants and children who present with feeding difficulties and vomiting. The classic patient is a young adult without typical symptoms of GERD but with severe dysphagia and persistent pain. Esophageal diameter is often reduced to one-quarter the caliber of a normal esophagus and often in the upper to mid esophagus. Expect multiple biopsies, as GI docs will want to know the full extent of the disease. Be mindful of the possibility of deep mucosal tears, perforation, and even major bleeding. Successful dilation may require multiple EGDs and several sessions, as they must be done slowly and with caution. They often will be on metered dose steroids from an MDI that they intentionally swallow instead of inhaling and proton pump inhibitors.
Unfortunately, the post-impressionist Vincent Van Gogh picked Eosin as his red pigment of choice. The Eosin has faded with time, making his “Field with Irises,” which were originally purple, now faded and only blue irises. Somewhat fitting, as the pinks and reds of dawn never withstand the brightness of day.
