PPI-REE or proton pump inhibitor-responsive esophageal eosinophilia remains a problematic issue for our eosinophilic esophagitis (EoE) patients. PPI-REE and the 3 D’s (Drugs, diet, and dilatation) have been reviewed recently (Clin Gastroenterol Hepatol 2012; 10: 1066-78).
The issues with PPI-REE that are problematic:
- If a patient with suspected EoE is pretreated with a PPI and they do not have eosinophils present at the time of endoscopy then a diagnosis of PPI-REE cannot be established.
- If patients are not pretreated, then determining that they have PPI-REE compared with typical EoE, requires repeat endoscopy. Furthermore, response to PPI may be transient and/or natural variation in EoE could make definitive diagnosis of PPI-REE quite difficult.
- If a patient presents with classic-appearing EoE, choosing to treat with a PPI is difficult as the response rate is much lower than with either dietary therapy or drug therapy. In addition, many symptomatic patients may have been treated to some extent with a PPI. Do they warrant repeat treatment and repeat endoscopy prior to using more typical treatment for EoE?
Beyond this topic, this review covers the recent consensus guidelines and the typical treatments: diets, drugs, and dilatation.
With regard to dilatation, the author notes that it may be safer than previously believed. Furthermore, in a recent trial, 81% were symptom free at 3 months and 46% were symptom free at 1 year. Despite better safety results, 74% of patients in one study complained of retrosternal pain after in endoscopy (moderate in 21% and severe in 17%).
With regard to drug or dietary therapy, the author recommends checking on the effectiveness after 6-8 weeks with a repeat endoscopy. Until better tools for assessing response to therapy become available, endoscopy remains the only accurate way to determine if treatment is working.
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