Eosinophilic esophagitis (EoE) is a chronic, immune system disease that affects the esophagus. The esophagus is a tube that carries food from your mouth to your stomach. In individuals with EoE, a specific type of white blood cell, called an eosinophil, accumulates in large quantities within the esophageal lining. These eosinophils release substances that trigger inflammation. It’s important to note that a healthy esophagus typically does not contain eosinophils. The presence of inflammation and elevated eosinophil levels in the esophagus are hallmarks of EoE, leading to a variety of symptoms.
EoE symptoms can differ depending on age. Infants and young children might exhibit feeding refusal or failure to thrive. School-aged children often experience reduced appetite, recurrent abdominal pain, swallowing difficulties, or vomiting. Teenagers and adults can share these symptoms, but they frequently struggle with swallowing dry, dense, or solid foods. This difficulty arises from esophageal inflammation and, in severe cases, esophageal narrowing, which can obstruct food passage. When food becomes lodged in the esophagus, it’s termed a “food impaction.” This situation can become a medical emergency if the food doesn’t naturally progress to the stomach or is not promptly expelled through vomiting.
Medical professionals, including allergists and gastroenterologists, are observing an increasing number of EoE cases. This rise is attributed to both a genuine increase in EoE incidence and improved awareness and recognition of the condition among physicians. It’s important to understand that EoE is considered a long-term condition that requires ongoing management, although effective treatments are available.
It’s crucial to recognize that eosinophils can be present in esophageal tissue in conditions other than EoE. A common example is acid reflux disease (GERD). Therefore, to ensure an accurate Eoe Diagnosis, other conditions that may cause eosinophil accumulation in the esophagus must be ruled out.
How is Eosinophilic Esophagitis Diagnosed?
Currently, the definitive method for eoe diagnosis is through an upper endoscopy combined with esophageal biopsies. An upper endoscopy is a medical procedure where a thin, flexible tube equipped with a light and camera is inserted into the esophagus. This allows the physician to visually inspect the esophageal lining for signs of inflammation. During the endoscopy, small tissue samples, known as biopsies, are taken from the esophagus. These biopsies, about the size of a pen tip, are then examined under a microscope by a pathologist to detect the presence of eosinophils and other inflammatory indicators.
Allergists, gastroenterologists, and pathologists adhere to specific diagnostic criteria to confirm eoe diagnosis. These criteria involve the presence of symptoms consistent with EoE, coupled with findings from the upper endoscopy and the pathologist’s examination of esophageal tissue biopsies that are indeed indicative of EoE.
The Link Between Eosinophilic Esophagitis and Allergies
A significant proportion of individuals diagnosed with EoE are atopic. Atopy refers to a predisposition to developing allergic diseases. An atopic person may experience symptoms of conditions such as asthma, allergic rhinitis (hay fever), atopic dermatitis (eczema), and food allergies. EoE can also have a familial component, occurring in multiple family members. Given the strong association with atopy, patients with EoE might initially consult an allergist. The allergist may suspect EoE and subsequently refer the patient to a gastroenterologist to confirm the eoe diagnosis. Conversely, if a gastroenterologist makes the initial eoe diagnosis, the patient might be referred to an allergist for further evaluation and management of EoE and any co-existing allergic conditions. Consulting with an allergist provides valuable insights for the patient, their family, and the gastroenterologist, enabling comprehensive management of the allergic aspects of EoE. Furthermore, an allergist can play a crucial role in designing dietary strategies and guiding the eventual reintroduction of foods into the patient’s diet.
Environmental Allergies and EoE
Environmental allergies to common airborne allergens like pollens, pet dander, dust mites, and molds may contribute to EoE in some individuals. Some patients report a perceived worsening of their EoE symptoms during pollen seasons. Allergy testing for these prevalent environmental allergens is frequently included in the evaluation process for eoe diagnosis and management.
Food Allergies and EoE
Immune responses to foods are recognized as the primary drivers of EoE in the majority of patients. Allergists possess specialized expertise in evaluating and managing EoE related to food allergies. However, the relationship between food allergy and EoE is intricate. In classic Immunoglobulin E (IgE)-mediated food allergies, triggers are typically straightforward to identify due to immediate reactions like hives and vomiting occurring within minutes of consuming the offending food. In EoE, identifying food triggers is more challenging because reactions are often delayed, developing over hours or even days. This delayed response makes pinpointing specific trigger foods significantly more complex. Common food triggers for EoE include dairy products, wheat, egg, and soy. Unfortunately, standard allergy tests such as skin prick tests, blood allergy tests, and patch tests are not consistently reliable in identifying food triggers for EoE. This is because the majority of food-related reactions in EoE involve delayed immune mechanisms that are not primarily IgE-mediated. An individual with EoE may react to one or multiple food triggers. Once the causative food(s) are identified and eliminated from the diet, esophageal inflammation and symptoms typically improve within a few weeks. It’s important to note that symptom improvement doesn’t always accurately reflect the level of inflammation in the esophagus. Therefore, follow-up biopsies are essential to objectively assess the effectiveness of dietary interventions and definitively confirm which food(s) are causing EoE.
Eosinophilic Esophagitis Treatment Approaches
Empiric Elimination Diets
Eliminating common food allergens from the diet is a recognized and accepted treatment strategy for EoE. Typically, this involves removing foods such as dairy, wheat, egg, and soy. Empirical elimination diets have demonstrated considerable effectiveness in managing EoE, although they can be challenging to adhere to, particularly without guidance from a registered dietitian experienced in EoE management. Foods are usually reintroduced one at a time, accompanied by follow-up endoscopies, to pinpoint specific foods that trigger EoE. Alternatively, dietary approaches may begin with the elimination of dairy alone, followed by the removal of additional food groups if inflammation persists.
Elemental Diets
Elemental diets represent a more restrictive form of elimination diet where all potential sources of allergens are removed. In this approach, patients receive their nutrition primarily from an amino acid formula, sometimes supplemented with one or two simple foods considered low in allergenic potential. All other foods are excluded. In young children undergoing elemental diet therapy, a feeding tube may be necessary to ensure adequate nutritional intake, as they might struggle to consume sufficient formula orally. Elemental diets are generally reserved for children with multiple food triggers for EoE who haven’t responded to other treatment modalities.
Medical Therapies
Dupixent (dupilumab) is a notable medical therapy approved by the Food and Drug Administration (FDA) for treating eosinophilic esophagitis in patients aged 1 year and older with specific weight criteria. Dupixent is an injectable medication, classified as a monoclonal antibody or biologic, administered weekly. It works by reducing the inflammation associated with EoE and improving the patient’s ability to swallow.
Proton pump inhibitors (PPIs), medications that reduce stomach acid production, have also demonstrated the ability to reduce esophageal inflammation in some EoE patients. Consequently, PPIs are frequently used as an initial treatment for EoE. However, not all patients respond to PPIs, and alternative therapies such as swallowed topical corticosteroids or food elimination diets may be considered. Close medical supervision by a physician experienced in EoE management is crucial.
Corticosteroids, known for their anti-inflammatory properties, are valuable medications for EoE treatment. Swallowing low doses of corticosteroids to directly coat the esophageal lining is a common treatment approach. Various forms of swallowed corticosteroids are available, and the FDA recently approved budesonide oral suspension (Eohilia) for EoE treatment in patients 11 years and older. Once esophageal inflammation is effectively controlled, the swallowed corticosteroid dosage is gradually reduced to the minimum level needed to maintain EoE control and minimize potential steroid side effects.
Collaborative Care with Your Doctors
EoE is a complex condition that necessitates a collaborative approach to care. Patients should actively engage with their gastroenterologist for guidance on EoE management and determining the necessity of endoscopies to monitor disease progression or improvement. Simultaneously, close collaboration with an allergist/immunologist is essential to identify and manage any allergic components contributing to EoE. An allergist/immunologist can provide tailored advice on food avoidance and manage related allergic conditions like asthma, eczema, and allergic rhinitis. Effective communication and agreement between the gastroenterologist and allergist regarding the patient’s care plan are vital. For patients following dietary interventions for EoE, seeking support from a registered dietitian with expertise in elimination diets for EoE is strongly recommended.
Upon receiving an eoe diagnosis, it’s natural to feel overwhelmed. Support groups and organizations can provide valuable resources and peer support for patients and families navigating EoE. Organizations like the American Partnership for Eosinophilic Disorders (APFED) and Campaign Urging Research for Eosinophilic Disease (CURED) offer reliable information and maintain connections with the AAAAI.
Your allergist/immunologist can provide further details on EoE, allergy testing, and treatment options.
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Revised: 5/1/2023
