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Eosinophilic Esophagitis (EoE)

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What is Eosinophilic Esophagitis?

Eosinophilic Esophagitis (EoE) is an inflammatory, allergic condition that affects the esophagus (food pipe) in which excess numbers of white blood cells called “eosinophils” accumulate there. Eosinophils are part of the allergic response and they create inflammation, so having too many of them in the esophagus can cause damage to the tissue; swelling which may result in difficulty swallowing or even food getting stuck; nausea or vomiting; chest pain, heartburn or abdominal pain and rarely even esophageal tears or rupture.

How do we diagnose Eosinophilic Esophagitis?

EoE is diagnosed by taking a biopsy (tissue sample) from the esophagus during an upper endoscopy procedure and examining it under a microscope. If there are eosinophils present in the sample(s), the pathologist will count how many are visible. Having more than 15 eosinophils present in the microscopic field of view is usually diagnostic of EoE.

What causes Eosinophilic Esophagitis?

EoE shares a root cause with other types of allergic diseases: an abnormal immune system response, usually (but not always) to specific foods. Just as we don’t fully understand why some people develop food allergies and others do not, there is no clear ‘cause’ for EoE. Research suggests there are certain genes involved with EoE. Many people with EoE have other known food or environmental allergies, asthma and/or eczema, as well. It is often seen in children and in young adults, but may also develop later in life.

How is Eosinophilic Esophagitis treated?

There are several treatment options for EoE.

  • Diet: For patients who wish to seek out a possible allergic food trigger for their EoE, an elimination diet protocol is available under careful guidance of one of our GI dietitians. Research suggests that somewhere in the 70% range of people with EoE are triggered by one or more foods, and the most common triggers are milk, wheat, eggs, soy, peanuts/tree nuts, fish/shellfish. Milk is by far the most common trigger, followed by eggs and wheat. Unfortunately, triggers cannot be identified by blood or skin testing for food allergy, so to identify possible triggers, patients will work with a dietitian to systematically eliminate one or more of these foods from their diet for 6-8 weeks at a time, have new biopsies taken, and compare their baseline levels with those post-elimination. The process can take many months and involve multiple repeat endoscopies. However, it offers the possibility that a person can avoid the need to rely on medications in order to control disease activity.

Medication

  • Proton pump inhibitors: Proton pump inhibitors (PPIs) are a common first-line treatment for the inflammation caused by EoE. These drugs decrease acid production by the stomach and also probably have a direct anti-inflammatory action. Research suggests that between 50-75% of EoE cases respond to PPI medications.
  • Topical corticosteroids: Certain steroid medications taken through an asthma inhaler can be used to treat EoE that is neither food nor PPI responsive. With the approach, an aerosol pump is used, but the agent is swallowed into the esophagus rather than inhaled into the lungs. The steroid exerts a direct topical anti-inflammatory action on the esophagus.
  • Emerging medications: Research over the past two decades has pinpointed specific ‘chain reactions’ that lead to the development of EoE. Based on this new understanding, laboratory scientists have created “smart” medications which specifically block these pro-inflammatory pathways. It is expected that these medications will reach the US market soon.
  • Endoscopic dilation: In some cases, EoE will lead to narrowing (“stricture”) of the esophagus. If this occurs, food can get stuck on the way down. Fortunately, dilation (stretching out) of the narrowed area using inflatable balloons passed through a scope is usually effective and safe. Several treatments may be required.

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