Eosinophilic esophagitis: indications for treatment

At present, it is still debated whether the focus of treatment in eosinophilic esophagitis (EoE) should be directed toward a symptomatic or histological response, or even toward a combination of both. This question cannot be answered as long as we have no solid data evaluating the long-term consequences of untreated symptoms and untreated inflammation. Nevertheless, today there are at least three established reasons to treat patients with clinically and histologically active EoE. First, dysphagia has a substantial negative impact on the patient's daily life. Despite the fact that patients often cope with this symptom and accept even marked restrictions in their nutritional habits, they usually experience a marked enhancement in quality of life under treatment. Second, untreated EoE harbors the risk of long-lasting food impactions. There is evidence that this unpleasant, unforeseeable and even risky incident can be prevented by efficient treatment of the eosinophilic inflammation. Third, it has been demonstrated in several clinical studies as well as in animal models that unbridled eosinophilic inflammation leads to a so-called remodeling of the esophagus with wall thickening, stiffness of the organ and stricture. Prevention of esophageal damage caused by tissue remodeling is therefore another reason to strongly advocate a consequential treatment. Finally, there is increasing evidence that untreated EoE might be a risk factor for acute infection of the esophagus with herpes simplex virus (HSV), leading to a severe ulcerative and extremely painful esophagitis. Prevention of HSV esophagitis might therefore be a fourth indication for treating EoE.