What is eosinophilic esophagitis?
Eosinophilic esophagitis (EoE) is an inflammatory condition in which the wall of the esophagus becomes filled with large numbers of white blood cells called eosinophils. Because this condition inflames the esophagus, someone with EoE may have trouble swallowing and experience pain, regurgitation and vomiting. Over time, the disease can cause the esophagus to narrow, which may result in food becoming stuck or impacted within the esophagus, requiring emergency removal. Other side effects can include nausea and abdominal pain.
In young children, many of the symptoms of EoE resemble those of gastroesophageal reflux disease (GERD) — including feeding disorders and poor weight gain — so the child may be mistakenly diagnosed with GERD. However, proper diagnosis of EoE in children is important because it is a serious disease that can cause lifelong problems if left undiagnosed.
How is EoE diagnosed?
Currently, the only way to accurately diagnose EoE is through upper endoscopy and biopsy. Several visual findings have been associated with EoE, such as the esophagus appearing “furrowed,” “ring-like” or showing multiple “white plaques.” However, these symptoms do not guarantee presence of the disease. In many cases, the esophageal tissue appears completely normal. Because the visual findings are not definitive and the disease may be “patchy,” multiple biopsies are required. Occasionally, contrast barium studies are useful in identifying esophageal strictures (narrowing of the esophagus) and small-caliber esophagus.
What is the role of the gastroenterologist?
Because of gastrointestinal symptoms, patients are typically seen first by a gastroenterologist. When patients have a food impaction, an emergency endoscopy is performed. Otherwise, when EoE is suspected, patients are usually placed on medication for acid blockade and subsequently undergo an upper endoscopy with biopsy. Once EoE is confirmed, patients may be treated with medication and referred to an allergist for allergy testing.
What is the role of the allergist?
While EoE has not been categorized as a “food allergy,” food has been associated with the vast majority of pediatric EoE cases and is becoming increasingly apparent in adult EoE. Therefore, allergists are essential in the management of this disease. Typical allergy tests, such as skin prick tests or blood tests (ImmunoCAP or RAST) may identify immediate allergic reactions, but are not always effective in determining which foods are responsible for EoE. The allergic reaction may be delayed and involve T-cell regulation, so other methods, such as a skin patch test, may be useful.
How is EoE treated?
Currently, there is no single, accepted therapy for EoE. Several medications have been shown to have a positive effect, including proton pump inhibitors, oral and topical corticosteroids, and leukotriene inhibitors. Unfortunately for most patients, these medications need to be taken throughout their lifetimes since the disease returns when prescriptions are discontinued.
Since the underlying cause of EoE is related to food allergies, a large number of pediatric patients and many adult patients must restrict their diets. Foods most commonly associated with allergy include milk, eggs, nuts, beef, wheat, fish, shellfish, corn and soy. Some patients may be allergic to a single food while others may be allergic to many foods.
Allergy tests may not be able to determine the problem foods. In some cases, patients must eliminate all foods from their diet and be placed on a strict, basic formula for between one and three months in order to heal the esophagus. Foods are then slowly reintroduced in an attempt to discover the food(s) causing the allergy. An additional endoscopy with biopsy is often necessary to determine if there is recurrence of EoE after adding certain foods.
Our multidisciplinary approach features:
- Combined evaluation by a gastroenterologist and allergist to diagnose EoE and the potential food allergens triggering the condition, followed by a plan for reintroducing foods in the future.
- Nutritional evaluation by registered dietitians to assess overall nutritional status and to provide dietary education, especially if dietary restrictions and reintroductions are needed.
- Regularly scheduled follow-ups with gastroenterology, allergy and nutrition specialists.
- Second opinions for patients with a history of EoE.