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Eosinophilic Esophagitis

What Is Eosinophilic Esophagitis?
Eosinophilic (ee-oh-sin-oh-fill-ick) esophagitis (EE for short) is an allergic reaction in the esophagus, the tube that carries food from the mouth to the stomach.  Although it is a relatively rare disease, a growing number of cases have been diagnosed in recent years. Like food allergies, EE is caused by a defect in the body’s immune response.  However, while food-allergic reactions are triggered by immunoglobulin E (IgE), white blood cells called eosinophils are the culprits in EE.  Eosinophils are important players in the immune system and usually do their primary job—fighting parasites and other infections—without causing any problems.  But when abnormally large numbers of eosinophils gather in your esophagus, they cause inflammation.  In this case, the inflammation resembles a skin rash in the lining of the esophagus, which makes it difficult for food to go down.

Symptoms of EE
Common symptoms of EE include:

• Heartburn or acid reflux symptoms that do not go away with medication
• Difficulty swallowing
• Food impactions (food gets stuck in the throat)
• Nausea and vomiting
• Poor growth or weight loss
• Abdominal or chest pain
• Poor appetite
• Malnutrition

It is important to remember that not everyone with EE has all of these symptoms.  A recent study in the journal Gastroenterology found that children usually complain of nausea or cramps, while older adults tend to experience difficulty swallowing.  Some symptoms may cause only mild discomfort, while others can be more problematic.  If a patient has difficulty swallowing when he eats, he may gag frequently, have trouble eating thicker bites of food, or regurgitate (bring the food back up).  If food becomes impacted, he may have to visit the hospital for treatment.

Food Allergy and EE

A food allergy usually is the underlying cause of EE, but not always. Some studies suggest that environmental allergies are another possible cause, but others have not been able to identify a specific allergen. This condition is often misdiagnosed as acid reflux, since the symptoms are similar, but medications used to treat acid reflux are not effective in EE.

Thirty years ago, EE was unknown. Over the past five years in particular, diagnoses of EE have risen dramatically, but researchers have not yet determined whether the disease has become more common or is just easier to recognize due to improved diagnostic techniques.  Most likely, it’s a combination of both, but EE is still a rare disorder.  The disease is most prevalent in children.  Most adults who develop EE are diagnosed between 30-40 years of age, and males are three times more likely to be affected than females.  EE usually affects people who have a family history of the disease and/or a history of food allergies or other allergy-related diseases, such as eczema and asthma.  

EE in Children
EE is a special concern in children because it can deprive them of the nutrients they need to grow and develop.  According to the Center for Pediatric Eosinophilic Disorders at the Children’s Hospital of Philadelphia, approximately 1 in 3,000 children is diagnosed with EE, and about 10% of children with acid reflux actually have EE.  Some children fully outgrow EE, just as they outgrow other allergies. Others partially outgrow it—the number of foods that trigger the disease decrease over time.  Unfortunately, some children don't outgrow EE at all, and will need to learn to manage the disease as a lifelong, chronic condition. 

Diagnosis
Diagnosis requires an endoscopy, performed by a gastroenterologist.  During the test, you are sedated, and the gastroenterologist inserts an endoscope (a thin, flexible tube with a light at the end) into your mouth and through your esophagus, stomach, and the upper part of your small intestine.  This instrument allows him to view your intestine and to take biopsies (small tissue samples).  Sometimes the gastroenterologist can see signs of EE, such as "rings" or "white spots.” But in many cases, the esophagus looks normal, so the biopsies, which allow the physician to examine your tissue under a microscope, are the key to an accurate diagnosis.   

Food allergy blood tests and prick skin tests cannot accurately identify the foods that may be triggering EE, and most often several foods are problematic.  However, allergy tests can help guide therapy to some extent.  Since many foods may be suspect, an elimination diet is often used to discover the problem allergen. Your allergist will ask you to eliminate foods that contain suspect allergens for about 4-8 weeks, until your symptoms disappear.  Then, under the allergist’s supervision, you will gradually add certain foods back into your diet.  If a food causes symptoms to reappear, it is likely to be the guilty party.  Repeated endoscopies and biopsies are needed to monitor progress.   

Treatment
The good news is, once all your food allergies have been properly diagnosed, avoiding the allergens that trigger the eosinophilic reaction will be an effective treatment in most cases.  Medications such as oral or inhaled steroids also may be given to help reduce the inflammation in the esophagus.  Sometimes an elemental formula—a liquid diet that provides vital nutrients—is required to help heal the esophagus as foods are slowly added back into your diet.

For More Information on EE
Since so many people have been diagnosed with EE in recent years, scientists are working to find out more about the disorder and how to best treat it.  As with food allergies, the symptoms of EE can range from mild to severe, and educating yourself about the disease is the key to living a full and productive life.  For more tips on coping with EE, please visit the American Partnership for Eosinophilic Disorders Web site at www.apfed.org.