What is Eosinophilic Esophagitis
Eosinophilic (ee-uh-sin-uh-fil-ik) esophagitis (EoE) is a chronic allergic inflammatory condition that affects the esophagus. A person with EoE will have inflammation or swelling of the esophagus, a tube that sends food from the mouth to the stomach.
The inflammation of the esophagus is caused by the presence of a large number of white blood cells, called eosinophils, in the lining of the esophagus. In people without EoE there are no eosinophils in the esophagus.
This allergic/immune condition has become more prevalent in recent years due to better diagnosis and awareness.
Symptoms of Eosinophillic Esophogitis
EoE affects people of all ages but its symptoms vary with age. Infants with this condition often refuse their food and have slower growth. Children complain about frequent abdominal pains, have difficulty swallowing. Adults most often have difficulty swallowing (dysphagia), persistent heartburn, upper abdominal pain and pain in the center of the chest. Another symptom of EoE is food impaction. This is a condition where the esophagus narrows considerably that food gets stuck and is a medical emergency.
Other diseases can also result in eosinophils in the esophagus such as including gastro esophageal reflux diseases (GERD), food allergy, and inflammatory bowel disease.
Diagnosis of Eosinophilic Esophagitis
EoE is diagnosed with an upper endoscopy and biopsy of the esophagus. Upper endoscopy is a non-surgical procedure used to examine a person’s digestive track. During upper endoscopy doctor will insert an endoscope, a flexible tube with light and camera at its tip, to view the esophagus, stomach and upper part of the small intestine on a TV monitor. Endoscopy of a person affected with EoE may show furrowing, rings, white patches or be visually normal. During a biopsy to diagnose EoE, tissue samples of the esophagus will be taken and analyzed for Eosinophils. A positive diagnosis for EoE is made when Eosinophils numbering greater than 15 per high powered field despite therapy with an acid blocking medication are found in the biopsy. This diagnosis has to be done in the context of symptoms consistent with EoE.
The EoE diagnosis is made by a gastroenterologist, pathologist, and allergist.
Eosinophilic Esophagitis and Allergies
The majority of people with eosinophilic esophagitis may also have food allergies, environmental allergies, asthma, atopic dermatitis or chronic respiratory disease. EoE has also been shown to occur in other family members with a possible genetic predisposition.
Environmental allergies to substances such as dust mites, animals, pollen and molds can play a role in EoE. For some patients, their EoE is worse during pollen seasons. Allergy testing for these common environmental allergies is often part of the EoE evaluation.
Eosinophilic Esophagitis: Food Allergies
Adverse immune responses to food are the main cause of EoE in a large number of patients.
Allergists are experts in evaluating and treating EoE related to food allergies. However the relationship between food allergy and EoE is complex. Allergy testing with skin tests and blood tests can be done especially in those people who have a history of an allergic reaction to certain foods. Skin prick testing for foods can come from commercial companies or provided by the family.
In people with EoE determining the role of food can be difficult due to the number of different components of the immune system that can be involved. Foods such as dairy products, egg, soy, wheat, and fish are main causes of EoE with a direct allergic reaction or through other immune mechanisms. A trial of food avoidance can be performed and monitor for improvement in symptoms over a period of time. Sometimes an allergist may do a blood test (called a serum specific immune assay) to see if you have allergies. This test can be helpful in certain conditions linked to food allergies.
Eosinophilic Esophagitis: Food Patch Tests
Eliminating foods based on prick skin testing alone does not always control EoE. Food patch testing is another type of allergy test that can be useful in diagnosing EoE. Patch testing is performed to diagnose delayed food reactions and non IgE mediated reactions. The patch test is done by placing a small amount of a fresh food in a small disc called a Finn chamber. The Finn chamber is then taped on the person’s back. The food in the chamber stays in contact with the skin for 48 hours. It is then removed and the allergist reads the results at 72 hours. Areas of skin that came in contact with the food and have become inflamed point to a positive delayed reaction to the food. The results from the food patch test will help your doctor see if there are foods you should avoid.
Eosinophilic Esophagitis: Treatment
- If you are diagnosed with specific food allergies after prick skin testing and patch testing then avoidence of those specific foods in the diet can help control EoE.
- Elimination diets can be considered, where major food allergens are eliminated from the diet. These typically include egg, wheat, soy, dairy, peanuts and tree nuts. These diets have been shown to be very helpful in treating EoE, although they can be very difficult to follow. Foods are typically added back one at a time with follow up endoscopies to make sure that EoE remains in control.
- Elemental diet with hypoallergenic amino acid base formula can be considered. In this diet, all sources of protein are removed from the diet. All other food is removed from the diet. This approach is generally reserved for children with multiple food allergies who have not responded to other forms of treatment.
No medications are currently FDA approved to treat EoE. However, medications have been shown to decrease the number of eosinophils in the esophagus and improve symptoms.
A common medical treatment for EoE involves the use of topical steroids. Glucocorticosteroids , help control inflammation, are the most effective for treating EoE. It involves swallowing inhaled steroids in small doses alone or in conjunction with dietary treatments. Different forms of swallowed corticosteroids are available.
Acid suppression therapy which includes Proton pump inhibitors and histamine blockers, which control the amount of acid produced, have also been used to help diagnose and treat EoE. This therapy can be beneficial to those with EoE because the esophagus is already inflamed and may have an increased risk of being injured further from acidity. Some patients respond well to proton pump inhibitors and have a large decrease in the number of eosinophils and inflammation when a follow up endoscopy and biopsy is done.
New types of treatment which could greatly help patients are being studied.
Working with Your Doctors
EoE is a complex disorder. It’s important for patients to work as a team with their gastroenterologist and allergist/immunologist. Follow advice from the gastroenterologist on managing EoE and figuring out when endoscopies are needed to check to see if the condition is getting better or worse. Patients work closely with their allergist / immunologist to find out if allergies are playing a role. An allergist / immunologist will also be able to tell if you need to avoid any foods and can help you manage related problems like asthma and allergic rhinitis. If you are following a diet to treat your EoE, it’s often recommended to visit a dietitian.
When you first find out you have EoE, it can be overwhelming. Families often benefit from participating in support groups and organizations. Visit APFED and CURED. Your allergist / immunologist can give you more information on EoE, allergy testing and treatment.
Reviewed and edited by Neha Reshamwala MD.