Eosinophilic Esophagitis (EoE), also known as allergic esophagitis, is an inflammatory disease of the esophagus. In Eosinophilic Esophagitis, the lining of the esophagus is infiltrated with eosinophils, a type of white blood cell that cause inflammation in the presence of allergens. Food allergies are most often the suspected caused, but environmental allergens can also play a part. People who have Eosinophilic Esophagitis often have other allergies as well, such as hay fever and asthma.
The disease was first described in children, but it can also appear later in life, as an adult. The condition is not well understood, but it is becoming more common. The exact incidence is unknown, but it is estimated to occur in 1 in 10,000 children, and 1-3 in 10,000 adults.
The first symptom is usually difficulty swallowing, and this can become so severe that food is impacted, or gets ‘stuck’ in the esophagus. This is extremely painful, and sometimes requires a trip to the Emergency Room to have the food removed via endoscopy.
In severe cases, the esophagus needs to be stretched (dilated) to allow food to pass into the stomach and the patient to eat normally again.
Symptoms of Eosinophilic Esophagitis
The symptoms vary in severity from person to person but common symptoms are:
- Difficulty swallowing
- Food impaction (swallowing food and having it get stuck in your throat)
- Chest pain (due to food being stuck) which can be severe
- Choking on and/or regurgitating food
- Severe reflux, Indigestion and heartburn, not responsive to medications that reduce stomach acid production
- Upper abdominal pain
When the disease becomes severe, it becomes impossible to swallow solid food at all, and patients sometimes require a liquid only diet.
Causes of Eosinophilic Esophagitis
The most common cause is food allergy, although some cases are due to environmental allergens, like pollens.
How is Eosinophilic Esophagitis Diagnosed?
Eosinophilic Esophagitis is suspected when a patient has ongoing difficulty swallowing. Diagnosis can only be confirmed with endoscopy, and examining the esophagus. A tissue biopsy will be taken during the endoscopy which is examined under a microscope to look for eosinophils. If eosinophils are present, the diagnosis is confirmed. Sometimes blood tests will show a higher level of eosinophils also, but not always.
Eosinophilic Esophagitis Treatment
Treatment includes dietary changes, medications and sometimes dilatation of the esophagus.
First line treatment are Proton Pump inhibitors, to reduce the production of acid in the stomach, and reduce the scarring of the esophagus. This is not always successful, however.
Steroid puffers used for asthma treatment are used of Eosinophilic Esophagitis, except the medication is swallowed, not inhaled. This is a very low dose of steroid that can reduce the inflammation of the esophagus, prevent scarring and relieve symptoms.
In very severe and long standing cases, not responsive to the above medications, oral steroids such as prednisone are used.
In severe or long standing disease, the esophagus can become so inflamed and scarred that food cannot pass. In these cases, the esophagus needs to be stretched or dilated during an endoscopic procedure to allow the patient to eat solid food again.
In severe cases, a strict elimination diet should be undertaken under the supervision of a qualified dietitian. The so called ‘Top Eight’ allergens – dairy, soy, egg, wheat, peanuts, meat, seafood and corn are removed from the diet for a period of three months.
Removing all of these foods from the diet is very challenging, as most processed foods, soups, sauces, curry pastes, and stocks contain ingredients derived from these allergens. A strict elimination diet and gradual reintroduction of foods is the only way to definitely identify food triggers.
In young children, and amino acid based diet (elemental diet) via a liquid formula is sometimes used. This tends to be impractical in older children and adults, however, because the formula is expensive, doesn’t taste good and the need to forego all food is difficult to manage socially and emotionally.
When all symptoms have been resolved, an endoscopy is performed to check for eosinophils. If clear, the cause is assumed to be a food allergen. Individual foods are slowly introduced, one at a time, to find which foods induce symptoms and trigger inflammation. Symptoms can take weeks to reappear, so foods are often reintroduced at the rate of one new food per month. Treatment is slow, and can be very frustrating, and difficult to conform to. It takes months and even years to identify which foods are problematic and cause inflammation.
The gold standard is to have a repeat endoscopy after every food reintroduction, but in practice this would mean an endoscope every month, so isn’t done, at least in Australia. When symptoms reappear, the offending food is identified, and must be removed from the diet permanently.
Some patients have multiple food allergies, and must live on a very restrictive diet for their entire lives. While a very under recognised condition, Eosinophilic Esophagitis can significantly impair quality of life because of the extremely restrictive diets that those with multiple food allergies must follow.
Eosinophilic Esophagitis management
Eosinophilic Esophagitis is a lifelong disease, and almost always relapses if the patient starts eating the offending foods again. The disease is managed between a gastroenterologist who will perform the repeat endoscopies and biopsies required to diagnose and monitor the condition. An allergist/immunologist may perform skin prick allergy testing, and will oversee the treatment plan and a dietitian is required to ensure that the patient receives all the necessary nutrients while understating such a restrictive diet.
Long term Outlook
Eosinophil Esophagitis has only relatively recently been recognised in adults, previously considered a children’s disease. As such, more study is required on the long term outcomes.
Untreated, patients will relapse and suffer scarring and narrowing of the esophagus, sometimes to the point of not being able to eat solid food at all. Sometimes even liquids can’t be swallowed.
Based on current research, Eosinophilic Esophagitis does not increase a patient’s risk of developing Esophageal Cancer.