The Effect of Sucralfate Slurry in Patients With Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a Th2 type allergy mediated disease that is characterized
by dense esophageal eosinophilia in patients with chronic esophageal symptoms. One of the
mechanisms of eosinophilic esophagitis is exposure of food antigens to antigen recognition
cells in the esophageal mucosa that initiates a chronic allergy-based inflammatory response
[1, 2]. It is believed that this exposure is facilitated through dilation of the
intercellular spaces (DIS) between esophageal epithelial cells (termed spongiosis). This is
substantiated by several studies which have demonstrated that: first, DIS is commonly found
in biopsies from patients with active EoE and reverses with steroid therapy [3]; second, DIS
correlates to physiologic demonstration of increased esophageal epithelial permeability as
shown through transepithelial small molecule flux in mucosal biopsies appraised in Ussing
chambers [4], and third, DIS is associated with decreased expression of specific epithelial
tight junction proteins such as filaggrin [3]. Thus, a suggested sequence of events in EoE
that leads to allergen initiated inflammation includes down regulation of tight junction
proteins, dilation of intercellular spaces in the surface epithelium followed by increased
permeability and facilitated exposure to food antigens.

Of the present therapies available, topical steroids and in a subset of EoE patients, proton
pump inhibitors may improve epithelial permeability. Unfortunately, in the case of proton
pump inhibitors, there is early data suggesting that their therapeutic benefit is not
sustained. With the use of steroids, there are fears of what the long term side effects of
continued use of swallowed steroids might be. The other alternative treatment, diet exclusion
therapy is difficult to tailor to the patient and impractical for most adult patients. As a
result, alternative treatments are need for EoE.

Sucralfate is a medication that was developed for the treatment of acid-peptic diseases. It's
mechanism of action in healing lesions such as gastroduodenal mucosal ulceration still
remains unclear but has been described as a "cytoprotective" agent. Several mechanisms have
been suggested to be responsible for this protection. These include: binding to and
protection of exposed eroded areas, increased prostaglandin production, improved vascular
flow, and increased mucus production. This compound has also been shown to augment potential
difference in gastric mucosa suggesting a decreased in ion flow. The investigators have shown
in measuring mucosal impedance in EoE, this may be related to closure of intercellular spaces
which could make this an attractive therapy for eosinophilic esophagitis. Furthermore, the
side effect profile of sucralfate is excellent with little systemic absorption. Sucralfate is
a category (B) medication, safe for females of child bearing years.

Inclusion criteria:

• Patients between the ages of 18 and 80 with eosinophilic esophagitis diagnosed by a
combination of compatible symptoms, endoscopic findings, histology, and lack of response to
proton pump inhibitors.

Exclusion criteria:

- Medical conditions such as severe heart or lung disease that preclude safe performance
of endoscopy

- Pregnant and lactating females will be excluded

- Diabetic patients will be excluded as episodes of hyperglycemia have been reported

- Patient with chronic renal failure/on dialysis will be excluded

- Patients with conditions known to be associated with esophageal eosinophilia,
including Crohn's disease, Churg-Strauss, achalasia, and hypereosinophilic syndrome

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