Eosinophilic Esophagitis (EoE) is a chronic immunologic condition that causes inflammation of the esophagus, the tube that moves food between the mouth and stomach. EoE can be caused by a type I, IgE-food specific way or in a type IV, delayed allergy which is caused by damage from immune cells. EoE is named after the eosinophils that are found at areas of damage in the esophagus in higher-than-normal numbers. Eosinophils are one type of white blood cell. They protect us from parasites and certain microbes. When inflammation from eosinophils cause damage to the body, the result is a hypersensitivity disorder.
Symptoms
Symptoms of EoE in small children may be as nonspecific as food refusal and failure-to-thrive or failure to grow at a normal rate. Older children may notice difficulty and pains swallowing, abdominal pain, and vomiting. Teenagers and adults also have chest pain and heartburn, trouble and pain swallowing, sometimes to the point that they are choking and it is difficult for them to breath, especially with dry, solid foods. It can also cause scarring and then narrowing of the esophagus, further impairing the tendency for food to catch in the throat. Food can become impacted, or stuck without ability to move, and this is an EMERGENCY.
Diagnosis
The only way to diagnose EoE is through upper endoscopy and biopsy of the esophagus. The criterion for diagnosis is 20 eosinophils per high powered field of the microscope.
Treatment
EoE cannot be outgrown. It must be managed. The cornerstone of therapy is monitoring the esophagus for damage. Decrease in damage defines therapy success. The first part of treatment consists of defining the allergies that are precipitating EoE, by environmental and food testing. Because the reaction to food is typically delayed, it is much more challenging to pinpoint. The most common food triggers for EoE are:
- Cow’s milk
- Soy
- Wheat
- Egg
- Peanut & Tree nuts
- Seafood (Fish & Shellfish)
For this reason, the treating physician my opt to have a patient attempt a 6-food elimination diet, which causes a remission in nearly 90% of patients. After remission occurs, it is possible to add back foods one at a time to help delineate which foods were causative and to attempt easing dietary restrictions. If this is too cumbersome, eliminating just cow’s milk or milk and soy, or milk soy and wheat, may be enough to cause remission. Unfortunately, because it is a delayed allergy, it can take weeks to months rather than days for the condition to resolve once the trigger food is eliminated from the diet. For this reason, some physicians prefer to perform a food patch testing, in which exposure of foods to skin occurs for 48 hours, the reaction read and then a second reading is performed one week after the foods were applied.
In young children or for patients with refractory symptoms, an elemental diet is introduced. Nutrition is entirely dependent on a formula that has no proteins, but only amino acids, sugars, and essential fatty acids. All other solid food is removed from the diet. Because it is not an appetizing diet, it may need to be administered through a feeding tube.
Some EoE is amenable to treatment with a drug class known as proton-pump inhibitors, and this is then known as proton-pump inhibitor responsive EoE. This is decided if biopsy post-PPI normalizes without additional intervention.
We breathe in environmental pollens as well. Many patients with EoE note that their symptoms flare seasonally. This suggests that environmental allergies should also be tested and treated.
Once elimination of trigger foods and treatment of environmental allergies occurs, the remainder of symptoms may be treated with topical steroids. These are the same, up until recently, that have been used by asthmatics. However, instead of inhaling them, they are sucked in and swallowed. Corticosteroids kill off eosinophils, eliminating the inflammation and decreasing the damage they cause.
If strictures occur, it may be necessary for the patient to have an esophageal dilation performed to be capable of swallowing food without choking.
Thankfully, we now also have Dupilumab or Dupixent, which helps control symptoms of EoE.
References and Resources:
https://www.aaaai.org/Conditions-Treatments/related-conditions/eosinophilic-esophagitis. Revised 2/24/20 and accessed 12/06/2021.
APFED; American Partnership for Eosinophilic Disorders. https://apfed.org/
CURED; Campaign urging research for eosinophilic disease https://curedfoundation.org/
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DISCLAIMER: This blog is not meant to substitute for medical care by an Allergist-Immunologist nor is it intended to provide medical advice or imply a Physician-Patient relationship with its readers or their family. It is intended to provide guidance, direction, and moral support from someone experienced in testing and treating allergies. This is also not meant to be a “do-it-yourself” manual or a “how to” overcome your allergies. Some of the issues mentioned, whether allergic or look-a-like, can be dangerous or if left unchecked, deadly. Please develop a relationship with a Physician you trust to help you with diagnosis, advice, questions, and treatment regarding your and your family’s medical conditions.
