Eosinophilic Esophagitis (EoE) is a chronic allergic/immune condition recently recognized that involves inflammation or swelling of the esophagus, caused by large numbers of white blood cells in the tissue of the esophagus.
The condition can occur at any age but is most commonly found in Caucasian males. Symptoms of EoE vary with age:
- Infants and toddlers may refuse their food or may not be growing properly.
- School age children often complain of abdominal pain and may have trouble swallowing.
- Teens and adults frequently have difficulty swallowing.
A medical emergency that can occur with EoE is food impactions, where the esophagus can constrict to the point that food gets trapped. Allergists and gastroenterologists nationwide are seeing more patients with EoE, probably due to greater physician awareness. Other diseases can result in eosinophils in the esophagus, particularly acid reflux (GERD).
Diagnosis of EoE
EoE can currently be diagnosed with an endoscopy and biopsy of the esophagus. An endoscopy is a medical procedure that lets your doctor see in your esophagus; a biopsy involves taking tissue samples for lab analysis.
Eosinophilic Esophagitis is diagnosed by both a gastroenterologist and pathologist. The physicians will look for the patient’s history to be consistent with EoE, and will carefully examine the esophagus during the endoscopy and evaluate the tissue samples from the biopsy.
Eosinophilic Esophagitis and Allergies
A majority of patients with EoE are atopic, or have a family history of allergies or asthma and symptoms of more or more allergic disorders. These allergic disorders include allergic rhinitis, atopic dermatitis (hives), food allergy, and asthma.
After the diagnosis has been made by an gastroenterologist, the next step is allergy testing to provide the physicians with information so that any allergic aspects of EoE can be properly treated.
EoE can be affected by environmental allergies such as dust mites, molds, animals, and pollen. Some patients seem to experience worsening symptoms during pollen seasons. Testing for these common environmental allergies is often part of the EoE evaluation.
The main cause of EoE in a large number of patients is adverse immune response to food.
Our physicians are experts in evaluating and treating EoE related to food allergies. The relationship between food allergies and EoE is complex. In many types of food allergy, the allergy triggers are easily diagnosed by a history of severe reaction like hives after ingestion of certain foods.
In EoE, it is more difficult to establish the role caused by foods since reactions are slower, and a single food may be harder to pinpoint.
Allergists may do a series of allergy tests to identify the foods causing EoE. Dairy products, wheat, soy and eggs are typically the primary causes of EoE. Allergies to these foods often can be easily proven by conventional allergy testing like skin tests, blood tests or patch tests. However, once a food has been removed from a patient’s diet, symptoms tend to improve within a few weeks.
Prick Skin Testing
Prick skin testing introduces a small amount of allergen into the patient’s skin with a small puncture with a prick device with a drop of allergen. Allergy skin testing provides our allergists with specific information on what substances the patient is allergic to.
Immunoglobulin E (IgE) is an allergic antibody that Patients with allergies have an allergic antibody called Immuoglobulin E(IgE); patients with IgE for a particular allergen will see an area of swelling and redness where the skin prick test was done, about 15 minutes after the test.
Sometimes our allergists may perform a blood test for specific allergies, and may be helpful in certain conditions linked to food allergies, especially EoE. Blood test results are not as conclusive as skin prick testing in EoE and are usually not recommended for the evaluation of food allergy in EoE.
Food Patch Tests
Another type of allergy test that can be helping in diagnosing EoE is food patch testing, which determines if the patient has a delayed reaction to a particular food.
The patch test is performed by placing a small amount of a fresh food in a small aluminum container called a Finn chamber, which is taped to a patient’s back and stays in contact with the skin for 48 hours. The chamber is removed and the allergist reads the results at 72 hours; areas of skin that are inflamed indicate a positive delayed reaction to that food. Results from a food patch test will help your doctor conclude if there are foods you should avoid.
TREATMENT of EoE
Food Testing Directed Diets
If the patient is diagnosed with specific food allergies after skin prick testing and patch testing, your allergist may remove those specific foods from your diet.
Eliminating major food allergens from the patient’s diet before any food allergy testing is conducted is also a common treatment of EoE. Excluded foods often include dairy, wheat, peanut, tree nuts, fish and eggs. Although they tend to be difficult to follow, this type of diet has been shown to be very helpful in treating EoE. Foods are re-introduced one at a time with follow up endoscopies to ensure that EoE remains in control.
This approach is usually reserved for children with multiple food allergies who have not responded well to other forms of treatment.
All sources of protein are removed from the diet; the patient receives their nutrition from an amino acid formula and simple sugars and oils. All other food is removed.
There are currently no medications approved specifically to treat EoE. Swallowing small doses of glucocorticosteroids is the most common treatment. Higher doses may be needed initially to control the inflammation but pose a greater risk of side effects.
Proton pump inhibitors that help control the amount of acid produced have been used to treat EoE. They improve EoE symptoms without improving the inflammation, so careful monitoring by your physician is very important.
Partnering with Your Physicians
It is very important for patients to listen to their gastroenterologist for advice on managing their EoE, since it’s a complex disorder. Patients must also work closely with their allergist/immunologist to determine if allergies are playing a role in their condition. You allergist may recommend a consultation with a dietitian to help the patient avoid foods that are triggers for EoE.
It’s important that the patient’s team of physicians work closely to treat EoE.