Eosinophilic Esophagitis

1 What Is Eosinophilic Esophagitis?

Eosinophilic esophagitis (EoE) is a condition caused by the proliferation of eosinophils in the lining of the esophagus, or food pipe. The build-up of these white blood cells in the esophagus inflames or injures the esophageal tissue, which causes food to get caught when swallowing.

The eosinophil is a type of white blood cell commonly involved in causing allergic reactions like swelling and inflammation. The inflammation causes stiffening or narrowing of the esophagus, which causes food to get stuck there. Thus, eosinophilic esophagitis causes difficulty swallowing and blockage in the esophagus. Eosinophilic esophagitis is a chronic relapsing condition, which means it is characterized by long periods of normal health with episodes of inflammation.

If the stomach acid content relaxes into the esophagus, it can cause inflammation in the esophagus. Even after treatment of acute reflux, the eosinophils remain present in eosinophilic esophagitis. Eosinophils exist in the gastrointestinal tract of a normal, healthy person, but if they are present in the esophagus, this condition is considered to be abnormal. One of the common causes of eosinophils in the esophagus is eosinophilic esophagitis, but other conditions, such as gastro-esophageal reflux disease, inflammatory bowel disease, and parasitic diseases, also cause a build-up of eosinophil in the esophagus. The body sends out eosinophils in response to an allergic reaction. This made experts believe that food allergies cause EoE. Some patients with EoE may also have hay fever, asthma, or eczema. EoE can occur in children as well as adults.

Eosinophilic esophagitis is a newly-identified condition. It was formerly thought to be rare, but recent studies show this condition is longstanding and a major cause of digestive illnesses. Eosinophil esophagitis is a common cause of difficulty with swallowing food in young adults. There have been many reported cases of this condition on five continents. This disease is increasing like asthma and rhinitis. One to three adults per 10,000 people may have this condition. This information is based on patient statistics from Australia and Switzerland. Some studies have suggested the condition is common in Caucasians. However, there have been cases in people of Asian, American, African, and Hispanic descent. Males are three times more likely to be affected than females. Studies are ongoing to fully determine the process of eosinophilic esophagitis.

The types of EoE are:

  • Reflux esophagitis: This is known as GERD. It occurs when the stomach contents go back into the esophagus.
  • Drug-induced esophagitis: This can occur when certain medications are taken with insufficient water.

2 Symptoms

The most common symptom is difficulty swallowing food. It also causes food impactions, wherein food accumulates in the esophagus and does not pass into the stomach. To relieve the obstruction, often, an endoscopy is needed. Mostly, adults between ages twenty and forty show these symptoms, although there have been cases where adults show symptoms at later ages. Heart burn and chest pain are less common symptoms.

In adults, eosinophilic esophagitis may cause the following symptoms:

  • Impaction of food in the esophagus
  • Difficulty swallowing
  • Heartburn or pain in the upper abdomen that often persists despite treatment
  • Hyperacidity that often does not respond to antacids
  • Vomiting
  • No response to medications used to treat GERD (gastroesophageal reflux disease)

In children, the condition may cause:

  • Frequent vomiting
  • Marked difficulties in feeding
  • Difficulty swallowing
  • Abdominal pain
  • No response to medications used to treat GERD (gastroesophageal reflux disease)
  • Poor growth and malnutrition

You need to see a doctor if you experience chest pain with other problems like shortness of breath and pain in the arms or shoulders, which are all symptoms of a heart attack that requires immediate medical intervention.

Severe and frequent symptoms of suspected eosinophilic esophagitis require a doctor’s attention. You need to see a doctor if you take medications for heartburn, GERD, or hyperacidity and do not see improvement within two weeks.

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3 Causes

Recently, eosinophilic esophagitis is a distinct condition caused by an allergic reaction of the esophagus. Doctors previously thought it may be a consequence of gastroesophageal reflux disease (GERD). Typical things like pollen or allergenic food cause the allergic reaction in the esophagus.

Eosinophils are a normal component of white blood cells found throughout the body. They play an important role in the function of the immune system. The number of eosinophils increases greatly during viral or parasitic infections, or in conditions such as rheumatoid arthritis. Because of its similar disease process to allergies, eosinophilic esophagitis often affects individuals with strong food allergies or allergic conditions like asthma, atopic dermatitis, and chronic lung diseases.

Eosinophils become a problem if they end up in the esophagus and multiply. This causes inflammation, scarring, and narrowing of the esophagus. It also causes the formation of fibrous tissue, causing the esophagus to lose its flexibility. Chewed food cannot pass easily through the stiff esophagus, causing difficulty swallowing and blockage.

There could also be a genetic cause of EoE in some patients. Studies have found that patients with EoE have an increase in gene coding for a protein called eotaxin-3. Some studies have revealed a genetic link in some adults with a family history of allergic disorders and a family history of EoE. Almost seventy percent of patients with EoE have conditions such as asthma, rhinitis, eczema, or food allergies. In a recent study, EoE was treated with dietary elimination, but when certain foods were added back into the diet, it recurred, suggesting that food allergens could be the cause of EoE.

Eosinophilic esophagitis is an increasingly common disease, and the number of patients with it has increased significantly.

4 Making a Diagnosis

To make a proper diagnosis of eosinophilic esophagitis, your primary doctor will likely refer you to a gastroenterologist. A gastroenterologist specializes in diseases of the digestive tract while an allergist focuses on treating allergies.

You can do certain things to improve your care. Here are some important preparations to make before the doctor’s appointment:

  • Ask your doctor if there are any restrictions needed before the appointment.
  • If you already underwent tests like an endoscopy with another doctor, bring the results with you.
  • List down your symptoms and their onset, as well as any medicines and supplements you are taking.
  • Include important personal information like major stresses and recent life changes.
  • Bring a family member or your spouse to help you remember all the information and give assistance.

Although time may be limited, feel free to ask your doctor questions. Some good questions to ask are:

  • What are the causes of my symptoms?
  • What tests do I need? Do I have to undergo an endoscopy?
  • Is my condition temporary or will it last for a long time?
  • What are the available treatments for my condition?
  • What would be the best option if I have other health problems?
  • What are the restrictions I have to follow?
  • What are the schedules of the follow-up visits?
  • Does my case require a specialist? What would be the cost?
  • Do my medications have generic alternatives?
  • Can you share printed materials or online sources to help me understand my condition?

Your doctor may discuss several things with you during the appointment. You need to answer as honestly as possible so the diagnosis will be accurate. You will need to answer questions on topics such as:

  • Your symptoms, their onset, and their severity
  • Things that seem to improve or worsen your symptoms
  • Any concerning symptoms, such as symptoms that wake you up at night, worsening of symptoms after eating or lying down, difficulty swallowing, and regurgitation of food or stomach contents
  • Your medical history
  • Any symptoms that seem to worsen during certain seasons
  • Your present and past allergies
  • Medications you take, especially antacids or anti-reflux medicines

Performing an upper endoscopy with a biopsy of the esophagus is the current method of diagnosis for EoE. In an endoscopy, a thin, flexible tube with a camera is inserted into the esophagus while the person is sedated. This enables the doctor to see the inside of the esophagus. From the lining of the esophagus, a biopsy is taken and later inspected under the microscope. Pathologists look for characteristic changes of EoE. There can be signs of inflammation in the esophageal tissue and a large number of eosinophil build-up in the superficial portion of the tissue biopsy. Sometimes, in the deeper portion of the tissue, scarring or fibrosis can be seen. The eosinophils in EoE are not found in the stomach or duodenum; they are restricted to the esophagus. The gastroenterologist can look for the following characteristic features:

  • Linear furrows or creases in the esophagus
  • Concentric rings in the superficial layer of the esophagus
  • Narrow esophagus
  • White spots on the tissue of the esophagus
  • Strictures (short, very narrow segments of esophagus)

However, the presence of these characteristic features alone cannot be used to diagnose this condition. Even an adult patient with EoE may show a normal esophagus. It is important to distinguish gastro-esophageal reflux disease (GERD) from EoE, since both conditions’ symptoms overlap. GERD is also more common in adults, and it even causes EOE, so it is important to distinguish between the two. It is thus suggested to start taking acid reducers if, on tissue biopsy, eosinophils are found in the esophagus. After the reflux is treated, another endoscopy is done to check if the eosinophils have gone away. If they are still there even after the reflux treatment, it means the patient likely has EoE. Another test is called an esophageal pH test. This tests whether the acid in the esophagus is contributing to the eosinophils. A thin tube is placed through the nose into the esophagus and stomach or in the esophagus via endoscopy, and a temporary sensor is placed. The level of acid can be monitored for twenty-four to seventy-two hours. If the levels are high, it could be GERD causing the eosinophils to be in the esophagus. Some patients might have both conditions and so would need treatment for both.

5 Treatment

Eosinophilic esophagitis is characterized by relapses, so treatment is focused on controlling symptoms.

  • Diet therapy: If tests show you have allergies, the doctor may prescribe diet therapy, which may help relieve symptoms of swelling and inflammation. You would need to avoid allergenic foods like dairy and wheat. If your allergies are particularly strong, you may be referred to an allergist and put on a more restrictive diet for several weeks:
  • “Six-food-elimination diet,” or a “targeted-elimination diet”: This is a part of dietary treatment. It usually lasts for six weeks. If there is an improvement in the disease, the foods are reintroduced one at a time in order to identify the food trigger. The six-food-elimination diet consists of a diet with no milk, wheat, eggs, nuts, soy, or sea food, as these are the common food allergens in EoE patients. Foods found to be positive in allergy testing are eliminated in a targeted-elimination diet.
  • Elemental diet: An amino acid-based formula is taken for six weeks. But the poor taste of elemental formula and its cost could make it a less preferable option.
  • Medications: The doctor may give you an acid blocker (like PPI) to reduce acid production in the stomach and address hyperacidity and heartburn. If that does not address symptoms, you will be prescribed steroids, such as fluticasone or budesonide. Budesonide is administered orally. A fluticasone inhaler, used for asthma, is inhaled without the usual spacer so the medicine deposits in the mouth, which is then swallowed with a small amount of water to send it to the esophagus. These steroids allow the esophagus to heal, reduce inflammation, and break down in the body quickly to prevent systemic effects. You may need to take steroids on a regular basis. Proton pump inhibitors are also used to treat EoE. These include lansoprazole (Prevacid) and omeprazole (Prilosec). They help reduce acid reflux and relieve irritation in the esophagus. Other medications include corticosteroids, which help reduce inflammation. In order to keep symptoms under control, some people need to be on medications long-term.
  • Dilation of the esophagus: If eosinophilic esophagitis already caused severe narrowing of the esophagus, and if steroids fail to work, the doctor may recommend a dilation procedure. This procedure carries the risk of bleeding and tearing of the esophagus, but, in most cases, it brings relief from symptoms and improves swallowing. In the short-term, dilation is helpful, but repeated dilations to control symptoms may be needed. Usually, patients treated with medical or dietary therapy can be treated with this method as well. The risks of this method include chest pain. Dilation needs to be done with caution. After the failure of medical or dietary therapy, this method may be performed. However, dilation alone does not relieve inflammation.

If your present therapies fail to improve your symptoms, you may want to try experimental therapies. You can ask your doctor if there are available programs or trials for experimental treatment of eosinophilic esophagitis.

6 Alternative and Homeopathic Remedies

There are no approved alternative remedies for eosinophilic esophagitis.

Some alternative treatments promise to work, but you should ask your doctor first:

  • Herbal remedies like licorice, marshmallow, chamomile, and slippery elm are often touted to relieve heartburn. However, these medicines may cause side effects and may interfere with medicines used to treat eosinophilic esophagitis.
  • Relaxation therapies like progressive muscle relaxation and guided imagery may help improve well-being and reduce stress. These are non-invasive and may help relieve anxiety caused by the condition.
  • Acupuncture is often advertised to relieve regurgitation and heartburn, but there is little evidence to support this.

7 Lifestyle and Coping

Lifestyle modifications are necessary in order to cope with eosinophilic esophagitis.

Eosinophilic esophagitis may cause frequent, but painful problems, such as heartburn.

You can adopt certain lifestyle measures to address symptoms:

  • Lose weight if overweight or obese: Excessive body weight puts you at risk for heartburn. If you are overweight or obese, losing weight can improve heartburn symptoms. Ask your doctor about safe and effective strategies to lose weight. If you are in the normal weight range, work to maintain it.
  • Elevating the head off the bed: This may help reduce the likelihood of the stomach contents going up the esophagus and causing heartburn, especially at night. You need to raise the head off the bed six to nine inches, and the entire upper body must be elevated, not just the head. Use wood or cement blocks to raise the head off the bed, or simply insert a wedge between the mattress.
  • Avoid certain foods that trigger heartburn: Culprit foods include fatty and fried foods, alcohol, chocolate, tomato sauce, mint, onions, garlic, and caffeine.

8 Risks and Complications

Eosinophilic esophagitis tends to be common in people with the following risk factors:

  • Family history of eosinophilic esophagitis
  • Having allergies, asthma, or both
  • Being male
  • Adult age, as the condition is more common in adults than in children
  • Living in cold or dry climates
  • Spring and fall seasons

Long-Term Consequences

EoE is a chronic, recurring condition. The level of eosinophils in the esophagus may keep changing over time, but the patient will continue to have symptoms. Complications involving esophageal stricture and food impactions may occur. Rarely, the esophagus may tear or get perforated due to forceful vomiting, food impactions for prolonged time, or dilation of the esophagus. This complication requires immediate medical attention. Currently, treatment aims at controlling symptoms, decreasing the levels of eosinophils in the tissue, and preventing complications, such as food impactions.

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