Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
Dig Dis. 2014;32(1-2):134-8. doi: 10.1159/000357296. Epub 2014 Feb 28.
BACKGROUND/AIMS: Whereas most children and adults respond to traditional eosinophilic esophagitis (EoE) treatments, such as exclusion of dietary allergens or the use of topical steroids, a small fraction may not.
Based on clinical experience and a review of the literature, the aim of this work is to provide practical advice for caring for 'refractory' patients with EoE.
The approach to this type of patient continues to evolve and decision-making should consider a number of issues including the patient's age, lack of a complete understanding of the natural history of this disease, risks of monitoring, and side effects of treatments. Next, one needs to define the term 'refractory' in that this can refer either to persistent symptoms or to continued inflammation in the face of presumably effective drug or diet therapy. Before considering alternative treatments, it is important to rule out any other cause of persistent symptoms. For instance, could they be related to an occult esophageal narrowing not identified at the time of endoscopy? Esophagrams may be necessary to identify localized or longitudinal narrowing that could be amenable to dilation. If symptoms and inflammation persist and no narrowing is appreciated, an elemental diet can be considered; however, the long-term use of this in older children and adults may be difficult. Prednisone or systemic steroids may be indicated to induce remission, but side effects and complications associated with chronic use are limiting. Finally, the use of immunosuppression or biological agents has been reported in case reports and studies; use of these may be limited by side effects or the need to utilize compassionate use protocols.
As the scope of esophageal eosinophilia continues to evolve, the clinical and molecular characterization of new clinical phenotypes will be important so that new therapeutic targets can be identified.
背景/目的：虽然大多数儿童和成人对传统的嗜酸性粒细胞性食管炎 (EoE) 治疗方法（如排除饮食过敏原或使用局部类固醇）有反应，但一小部分人可能没有反应。
根据临床经验和文献回顾，本研究旨在为“难治性”EoE 患者的护理提供实用建议。
这种类型患者的治疗方法仍在不断发展，决策应考虑多个问题，包括患者的年龄、对这种疾病自然史缺乏全面了解、监测风险以及治疗的副作用。其次，需要定义“难治性”一词，因为这可能是指持续存在症状，或者在药物或饮食治疗可能有效的情况下持续存在炎症。在考虑替代治疗之前，重要的是要排除持续症状的任何其他原因。例如，它们是否与内镜检查时未发现的隐匿性食管狭窄有关？食管造影可能有助于识别可能适合扩张的局部或纵向狭窄。如果症状和炎症持续存在且没有发现狭窄，可以考虑使用要素饮食；然而，在年龄较大的儿童和成人中长期使用可能会很困难。泼尼松或全身类固醇可能有助于诱导缓解，但长期使用的副作用和并发症有限。最后，已在病例报告和研究中报告了免疫抑制或生物制剂的使用；由于副作用或需要使用同情使用协议，这些药物的使用可能会受到限制。
随着食管嗜酸性粒细胞增多症范围的不断扩大，新临床表型的临床和分子特征的描述将非常重要，以便能够确定新的治疗靶点。
