Differentials
Gastro-oesophageal reflux disease (GORD)
SIGNS / SYMPTOMS
Clinical presentation can overlap with eosinophilic oesophagitis (EoO) and both conditions can be present in the same patient.
No single sign or symptom distinguishes the conditions; however, erosive oesophagitis and a hiatal hernia are less common in EoO than in GORD. EoO can cause secondary reflux due to strictures or oesophageal dysmotility.
GORD may impact EoO by worsening oesophageal mucosal barrier function and potentially providing a route for antigen presentation.
INVESTIGATIONS
Oesophagogastroduodenoscopy: may show oesophagitis, erosions, ulcerations, strictures.
pH or pH/impedance testing: pH <4 more than 4% of the time with acid or non-acid reflux events.
Eosinophilic gastroenteritis
SIGNS / SYMPTOMS
Patients often have gastrointestinal symptoms not directly attributed to the oesophagus such as abdominal pain, nausea, weight loss, gastrointestinal bleeding, diarrhoea, malabsorption, or protein-losing enteropathy.
Oesophageal involvement may be present.
INVESTIGATIONS
Gastric, duodenal, ileal, and/or colonic biopsies: increased levels of eosinophils (threshold varies by location). Eosinophilic infiltration of other areas of the gastrointestinal tract is not present in EoO.
Achalasia
SIGNS / SYMPTOMS
Chronic liquid and solid food dysphagia.
Can be associated with weight loss, heartburn, regurgitation (especially with lying flat), and aspiration pneumonias.
Eosinophilia is thought to be due to a reactive process from stasis of oesophageal contents.
INVESTIGATIONS
Oesophagogastroduodenoscopy: dilated oesophagus with retained secretions and a hypertonic lower oesophageal sphincter.
Barium swallow: classic bird beak-like appearance.
Oesophageal manometry: incomplete relaxation of the lower oesophageal sphincter and oesophageal aperistalsis.
Crohn's disease
SIGNS / SYMPTOMS
Oesophageal involvement is rare. Gastric, small bowel, and/or colonic involvement is likely to be present.
Patients with Crohn's disease often have prolonged diarrhoea, perianal lesions, blood in stools, and fever.
INVESTIGATIONS
Oesophagogastroduodenoscopy and biopsy: oesophageal ulcerations, intramural oesophageal tracts, oesophagobronchial fistulae, non-caseating granuloma.
Colonoscopy or wireless capsule endoscopy: aphthous ulcers, hyperaemia, oedema, cobblestoning, skip lesions.
Connective tissue disorders
SIGNS / SYMPTOMS
Inflammatory arthritis, psoriasis or psoriatic arthritis, or skin changes suggestive of lupus or scleroderma may be seen, depending on the underlying condition.
INVESTIGATIONS
Auto-antibody tests: positive (corresponding to the specific connective tissue disorder).
Hypereosinophilic syndrome
SIGNS / SYMPTOMS
Symptoms reflective of end-organ tissue infiltration by eosinophils.
Constitutional symptoms are common.
INVESTIGATIONS
Peripheral eosinophil count: ≥1.5 x 10⁹ cells/L (1500/mm³).
Bone marrow aspirate: positive. PDGFR-alpha/FIP1L1 gene mutation: positive.
Evidence of eosinophil infiltration of other organs and exclusion of other causes of systemic eosinophilia.
Drug hypersensitivity
SIGNS / SYMPTOMS
Acute onset after drug exposure, or as an idiosyncratic reaction to an established medication.
Common causative medications include antimalarials, antibiotics, ACE inhibitors, anticonvulsants, non-steroidal anti-inflammatory drugs, gold, proton-pump inhibitors, H2 receptor antagonists, tryptophan, aminosalicylates, and chlorpropamide.
INVESTIGATIONS
Removal of the medication: resolution of eosinophilia.
Pill oesophagitis
SIGNS / SYMPTOMS
Acute onset after a history of having a pill stick in the oesophagus after swallowing.
Frequently reported with doxycycline and other antibiotics, non-steroidal anti-inflammatory drugs, and bisphosphonates.
Chest discomfort and odynophagia are typical. Resolves within several weeks with supportive therapy.
INVESTIGATIONS
Oesophagogastroduodenoscopy: focal findings or reveals impacted pill.
Graft-versus-host disease
SIGNS / SYMPTOMS
History of bone marrow or stem cell transplant.
Can involve the entire gastrointestinal tract, including the liver, as well as the skin.
INVESTIGATIONS
Oesophagogastroduodenoscopy: may show gastric, duodenal, or colonic erythema, congestion, or ulceration.
Parasitic infections
SIGNS / SYMPTOMS
May be a history of travel, pet exposure, or unsafe drinking water (depending on the parasite).
Often associated with diarrhoea, abdominal pain, anaemia, or fever.
INVESTIGATIONS
Peripheral eosinophil count: typically elevated.
Stool or serology testing: confirms diagnosis of suspected pathogen.
Adrenal insufficiency
SIGNS / SYMPTOMS
Rare cause of systemic eosinophilia.
Symptoms are non-specific and can include dizziness, nausea, weight loss, and even abdominal pain.
INVESTIGATIONS
Peripheral eosinophil count: may be elevated.
Adrenocorticotropic hormone stimulation test: serum cortisol <497 nanomols/L (<18 micrograms/dL) confirms diagnosis.
Infectious oesophagitis
SIGNS / SYMPTOMS
Presentation tends to be more acute.
Associated with fever, odynophagia, and oral lesions.
INVESTIGATIONS
Oesophagogastroduodenoscopy: with tissue sampling: confirms presence of Candida, herpes simplex virus, or cytomegalovirus.
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