macro

onset trigger

Dysphagia Solid/liquid, location Heartburn, chest pain GERD Food triggers, avoidance? Particular: CM, soy, meats, wheat Regurg? Endoscopy / swallow PPI before, response? Topical steroids, response?

AP: Sx consistent with this bc: Endoscopy: PPI trial: IgE mediated food allergy?

The underlying etiology is not fully understood but felt to be food-related in many cases. Unfortunately, we do not have a testing modality to identify culprit foods. The goal of treatment is both histological and clinical improvement.

> We have made a referral to GI / They should continue follow-up with their current GI; we defer to our colleagues regarding timing of repeat endoscopy
> Start empiric 8-week trial of PPI: 40mg pantoprazole BID
> Start topical corticosteroids:
  - Swallowed fluticasone propionate (Flonase) 500-1000 µg/day OR oral viscous budesonide (Jorveza) 1000-2000 µg/day
  - Advised not to eat, drink, or rinse their mouth for 30 min after
> Dietary modifications:
  - Avoidance of food triggers for ~6 weeks; ~30-50% of patients improve with a milk elimination diet, which is the commonest trigger for EoE
  - If dairy avoidance alone is unsuccessful, we will discuss additional empiric 6 week avoidance periods of other foods (ie. fish, shellfish, tree nuts, wheat, soy, legumes), followed by reintroduction, with observation of clinical symptoms
  - Another alternative approaches include the 6-food (wheat, milk, egg, nuts, soy, fish and shellfish) elimination diet or 4 food (wheat, milk, egg, nuts, soy) diet, but should be done working with a dietician; they are harder logistically to implement
> We otherwise defer ongoing surgical management to the GI team
> Should symptoms persist we would consider Dupixent for more advanced disease