Eosinophilic Esophagitis

Up until the 1990s, when patients complained that they were having difficulty swallowing and they were shown to have inflammation and swelling in the esophagus, it was assumed the patient had gastro-esophageal reflux disease (GERD). But GERD medication didn’t improve the condition. Then in the 1990s, doctors discovered that the inflamed, swollen esophagus was due to a chronic immune system disease whose symptoms were identical to GERD, difficulty swallowing and chest pain. This disease occurs when white blood cells, called eosinophils, build up in the patient’s esophagus. This causes inflammation and swallowing problems and can cause food to lodge in the throat when the patient swallows.

The disease is called eosinophilic esophagitis. We perform upper endoscopy at Concorde Gastroenterology to diagnose this disease.


What is eosinophilic esophagitis?

Eosinophilic esophagitis is a chronic immune system disease. The disease was only identified about 20 years ago, so research is ongoing into the best way to diagnose and treat it. When first discovered, it was considered a children’s disease, but since then it has been shown to affect both children and adults.

The immune function that causes the problem is an over-response to allergens in the esophagus. The white blood cells common in the digestive tract, eosinophils, stay in the digestive tract normally. But the allergic reaction causes them to move up into the esophagus. As they build up in the esophagus, the tissues become inflamed and may swell. This creates the swallowing problems that are the main symptom of eosinophilic esophagitis.


What are the symptoms of eosinophilic esophagitis?

Symptoms are similar for adults and children with eosinophilic esophagitis, but there are some variations:

Adult symptoms

  • Difficulty swallowing
  • Food getting stuck in the esophagus after swallowing
  • Centrally located chest pain that doesn’t respond to antacids
  • Persistent heartburn
  • Upper abdominal pain
  • No response to gastro-esophageal reflux disease (GERD) medication
  • Backflow of undigested food

Children symptoms

  • Difficulty feeding, in infants
  • Difficulty eating, in children
  • Vomiting
  • Abdominal pain
  • Difficulty swallowing
  • Food getting stuck in the esophagus after swallowing
  • No response to GERD medication
  • Poor growth, malnutrition, weight loss

What causes eosinophilic esophagitis?

The digestive tract normally contains the eosinophils that cause eosinophilic esophagitis, but in this case the patient has an allergic reaction to an outside substance. This is thought to be the progression of eosinophilic esophagitis, although it is still being studied.

  1. Reaction in the esophagus — The lining of the esophagus reacts to allergens, such as food or pollen.
  2. Multiplication of eosinophils — The white blood cells, the eosinophils, move into the esophagus and multiply, and they produce a protein that leads to inflammation.
  3. Damage to the esophagus — The inflammation can cause scarring, narrowing, and the formation of excessive fibrous tissue in the lining of the esophagus.
  4. Difficulty swallowing — Due to the narrowed esophagus, the patient now has trouble swallowing and with food becoming caught.
  5. Additional symptoms — From the swallowing issues, other symptoms, such as stomach pain and central chest pain, develop.

How is eosinophilic esophagitis diagnosed?

When diagnosing eosinophilic esophagitis, one of the first things to do is rule out whether the patient has gastro-esophageal reflux disease. From there, the main diagnostic tool is an upper endoscopy. Biopsy and blood tests may also be used.

Upper endoscopy — This involves a long narrow tube (endoscope) with a light and a tiny camera on the end. The endoscope is inserted through the patient’s mouth and down the esophagus. The images from the endoscope play on a video monitor next to the examination table. The doctor will check the lining of your esophagus, looking for inflammation and swelling, horizontal rings, vertical furrows, narrowing, and white spots.

Biopsy — The endoscope can also take small samples of tissue from your esophagus for biopsy. The tissue is examined under a microscope for eosinophils.

Blood tests — If eosinophilic esophagitis is suspected, blood tests may be used to confirm diagnosis and look for the sources of your allergic reaction. Blood showing higher than normal eosinophil counts or total immunoglobin E levels points to allergy.


How is eosinophilic esophagitis treated?

There is no cure for eosinophilic esophagitis; it is considered to be a chronic relapsing disease.

These are the current treatments used:

Dietary therapy

The patient’s diet may be limited to avoid certain types of foods. Depending on the tests for any food allergies, you may need to eliminate certain foods from your diet, things such as dairy or wheat products, which could reduce your allergic reaction and inflammation. Dietary therapy is usually the treatment used with children. This can be a trial and error process, working to find the exact food that is triggering the allergic reaction.

Medication

Acid blocker — The first medication usually tried is an acid blocker, such as proton pump inhibitor. This is successful on a limited number of patients.

Topical steroid — Topical steroids are delivered in a liquid that is swallowed. This calms the eosinophilic esophagitis, but the steroid is not absorbed into the bloodstream, so the patient can avoid the typical steroid side effects. Most patients respond to treatment with topical steroids.

Dilation

If the patient has severe narrowing of the esophagus, dilation (stretching) could be recommended. This stretches the esophagus, making swallowing easier. Dilation is used when patients aren’t responding to more conservative treatments.


Will I need surgery on my esophagus?

At this time, surgery is not used as a treatment for eosinophilic esophagitis.

Are there risks to these treatments for eosinophilic esophagitis?

Nutritional deficiencies — Restricting a patient’s diet, such as the six-food elimination diet often used for eosinophilic esophagitis, must be done in coordination with a nutritionist because of the restrictions on calories and, more importantly, nutrients. Without proper supervision or diligence on the part of the patient, nutritional problems can arise.

Steroid side effects — Topical steroids are usually successful, but they do have various possible side effects.

Dilation — Dilation is effective for relieving the esophagus narrowing, but it does not address the underlying inflammation. Plus, this stretching is associated with deep mucosal tears and esophageal perforation.


What happens if I don’t treat my eosinophilic esophagitis?

Eosinophilic esophagitis is a chronic disease that comes and goes. If you choose not to treat your condition, it won’t likely get any worse, but it won’t get better, either. You’ll continue to have swallowing problems, food will still get caught in your esophagus, and you have chest and upper abdominal pain. Between dietary therapy and topical steroids, relief is possible.

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If you think you may have eosinophilic esophagitis and would like to schedule a consultation, call us today at 212-889-5544.
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