Eosinophilic Esophagitis: An Introduction and Overview
Introduction
Eosinophilic esophagitis (EoE) is a chronic, immune system disease that emerged in the medical field in the early 1990s. Over the years, this condition has been increasingly recognized as a significant cause of gastrointestinal disorders. EoE involves a large number of white blood cells, called eosinophils, accumulating in the esophagus, leading to inflammation and various uncomfortable symptoms. This article aims to shed light on EoE by providing detailed insights into its definition, description, and risk factors. It’s designed to empower patients like you with knowledge and understanding of this condition.
Description of Eosinophilic Esophagitis
Eosinophilic esophagitis (EoE) is a condition characterized by a buildup of eosinophils in the lining of the esophagus, the tube that carries food from the mouth to the stomach. This buildup causes inflammation and can result in significant discomfort.
The progression of EoE often begins subtly, with symptoms such as difficulty swallowing or chest pain that can be mistaken for other conditions. As the disease progresses, these symptoms may intensify, leading to food impaction and esophageal stricture.
EoE was once considered a rare condition, but it is now recognized as a major cause of digestive health issues. According to recent statistics, EoE affects approximately 1 in 2,000 individuals globally, with a higher prevalence in Western countries. Both adults and children can develop EoE, but it is most commonly diagnosed in males and people with a family history of the condition.
Risk Factors for Developing Eosinophilic Esophagitis
Lifestyle Risk Factors
EoE is primarily an allergic condition, and certain lifestyle factors may increase the risk of developing it. People with food allergies, particularly to milk, eggs, wheat, soy, peanuts, tree nuts, fish, and shellfish, are at an increased risk. Exposure to environmental allergens like dust mites, animal dander, and pollen can also contribute to EoE.
Medical Risk Factors
Certain medical conditions are linked with an increased risk of EoE. These include other allergic diseases, such as asthma, atopic dermatitis (eczema), and allergic rhinitis (hay fever). Gastroesophageal reflux disease (GERD), a condition in which stomach acid frequently flows back into the esophagus, is also associated with a higher risk of EoE.
Genetic and Age-Related Risk Factors
Research suggests that there’s a genetic component to EoE, as it often occurs in multiple members of the same family. Certain genetic mutations have been associated with an increased risk of the disease. Age also plays a role. While EoE can occur at any age, it’s more commonly diagnosed in children and young adults, particularly males. Older adults are less likely to develop EoE, although it’s not entirely understood why.
Clinical Manifestations
Dysphagia
Dysphagia, or difficulty swallowing, occurs in about 50-60% of adult patients with EoE. This symptom can be especially troubling during meals and may lead to avoidance of certain foods. EoE causes dysphagia by making the esophagus inflamed and rigid, which interferes with the smooth passage of food to the stomach.
Food Impaction
Food impaction, where food becomes lodged in the esophagus, occurs in 33-54% of adult EoE patients. This can be a frightening experience and often requires urgent medical care. It happens because chronic inflammation from EoE narrows the esophagus, making it difficult for food to pass.
Chest Pain
While not as common as other symptoms, chest pain can be experienced by up to 30% of EoE patients. EoE-related chest pain can mimic heartburn, as both are caused by inflammation of the esophagus. However, the chest pain from EoE is due to an immune response rather than acid reflux.
Heartburn
Heartburn is reported in about 15-43% of EoE patients. Though it’s a common symptom of gastroesophageal reflux disease (GERD), EoE can also cause heartburn. This burning sensation happens due to the inflammation and irritation in the esophagus from the eosinophils.
Nausea and Vomiting
Nausea and vomiting are less common symptoms of EoE, affecting roughly 5-15% of patients. These symptoms are typically due to the irritation and narrowing of the esophagus, which can disrupt normal digestion and lead to an upset stomach.
Abdominal Pain
About 9-20% of EoE patients experience abdominal pain. This is thought to be due to the same inflammatory process that causes other symptoms of EoE, but in this case, the inflammation and irritation may affect nerves that transmit pain signals from the esophagus.
Failure to Thrive (in children)
In children with EoE, ‘failure to thrive’ or poor growth can be seen in about 6-33% of cases. This occurs due to feeding difficulties, food aversion, and malabsorption of nutrients because of the inflammation in the esophagus.
Poor Appetite
Poor appetite is another manifestation of EoE, particularly in children, with around 25% of young patients reporting this symptom. The discomfort associated with eating can lead to a reluctance or fear of eating, thus resulting in poor appetite.
Diagnostic Evaluation
Diagnosing Eosinophilic esophagitis involves a combination of clinical evaluation, consideration of symptoms, and specific diagnostic tests. Let’s examine the key diagnostic evaluations:
Upper Gastrointestinal (GI) Endoscopy
An upper GI endoscopy is a procedure where a flexible tube with a camera at the end (an endoscope) is used to examine the esophagus, stomach, and the first part of the small intestine. For EoE, this test is crucial as it can reveal physical changes in the esophagus associated with the disease, such as rings, furrows, and narrowing. If the results indicate these changes, further evaluation for E
oE is usually pursued.
Results that might suggest EoE include inflammation, white patches (eosinophilic exudates), longitudinal furrows, concentric rings, or narrowing (strictures) of the esophagus. However, a negative result does not completely rule out EoE, especially if symptoms persist. Additional tests may be recommended.
Esophageal Biopsy
During an endoscopy, an esophageal biopsy may be performed. This involves taking small samples of the esophagus tissue for examination under a microscope. The biopsy can confirm the presence of eosinophils, which is a hallmark of EoE.
In EoE, the biopsy would typically show a high number of eosinophils in the esophagus tissue (more than 15 eosinophils per high power microscopic field). If the biopsy does not show this, but symptoms continue, further diagnostic tests or a review of the biopsy might be needed.
Blood Tests
Blood tests are sometimes used to assess the overall number of eosinophils and to perform allergy testing. Elevated eosinophils in the blood can support the diagnosis of EoE, although it’s not a definitive diagnostic criterion. Allergy testing can help identify potential triggers for EoE, aiding in management strategies.
An elevated eosinophil count or positive allergy test results could suggest EoE. However, negative results do not exclude the disease, particularly if clinical symptoms persist.
Barium Swallow
A barium swallow is an imaging test that checks for abnormalities in the esophagus. The patient swallows a liquid containing barium, which coats the esophagus and shows up on X-rays. It can reveal structural changes such as strictures, rings, or a narrow esophagus often seen in EoE.
Results indicating EoE include narrowing of the esophagus, the presence of rings, or strictures. However, a normal barium swallow does not rule out EoE, and further testing may be necessary if symptoms persist.
Esophageal Manometry
Esophageal manometry measures the rhythmic muscle contractions in your esophagus when you swallow, the coordination and force exerted by the esophagus muscles, and how well your lower esophageal sphincter works. It can help identify motility problems that might contribute to symptoms like dysphagia.
Abnormal results can indicate a motility problem that might be contributing to EoE symptoms. However, normal manometry doesn’t rule out EoE and further testing may be needed if symptoms continue.
pH Monitoring
pH monitoring measures the amount of acid in your esophagus over 24 hours. This test is often done when GERD is suspected alongside EoE, as controlling acid reflux can be an important part of managing EoE symptoms.
An abnormal pH monitor indicating acid reflux doesn’t confirm EoE but suggests that acid reflux may be contributing to symptoms. Normal pH monitoring doesn’t exclude EoE, and further testing may be needed if symptoms persist.
Skin Prick Testing, Elimination Diets, and Patch Testing
Skin prick testing, elimination diets, and patch testing are all methods of identifying food allergies that might be triggering EoE. Skin prick testing involves introducing potential allergens into the skin and observing for a reaction. An elimination diet involves removing suspected food triggers from the diet
and monitoring for symptom improvement. Patch testing involves placing potential allergens on the skin and monitoring for delayed reactions.
Positive results from these tests may suggest certain food triggers that could be contributing to EoE. However, even if these tests are negative, EoE could still be present if symptoms persist.
What if all Tests are Negative but Symptoms Persist?
If all tests are negative but symptoms continue, it can be frustrating. However, don’t lose hope. Some patients might have a less typical presentation of EoE, or other conditions may be contributing to the symptoms. It’s crucial to communicate openly with your healthcare provider about the severity and persistence of your symptoms. Further diagnostic testing or referrals to a specialist might be appropriate.
Health Conditions with Similar Symptoms to Eosinophilic esophagitis
Gastroesophageal reflux disease (GERD)
Gastroesophageal reflux disease, or GERD, is a condition where stomach acid frequently flows back into the esophagus, causing irritation. GERD can cause symptoms like heartburn, regurgitation, and difficulty swallowing, similar to EoE.
However, unlike EoE, GERD typically responds to antacids or proton pump inhibitors (PPIs), and symptoms can be triggered by certain foods or lying down after eating. The gold standard for diagnosing GERD is a 24-hour pH monitoring test, which measures the acidity in your esophagus. A high level of acidity would suggest GERD rather than EoE.
Esophageal Stricture
An esophageal stricture is a narrowing of the esophagus that can cause swallowing difficulties. It can result from chronic inflammation, like in EoE, or from other causes such as acid reflux or radiation therapy.
The symptoms are similar to EoE, but in the case of strictures, a barium swallow test or endoscopy usually shows a specific narrowed area in the esophagus. Also, strictures often respond to dilation (stretching) procedures, while EoE often requires more comprehensive treatment strategies.
Achalasia
Achalasia is a rare disorder affecting the esophagus, making it difficult for food and liquid to pass into the stomach. Dysphagia, or difficulty swallowing, is a common symptom in both EoE and achalasia.
Achalasia, however, usually involves a problem with the lower esophageal sphincter not relaxing properly. A test called esophageal manometry can show this problem and help distinguish achalasia from EoE.
Peptic Ulcer Disease
Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or the first part of the small intestine, the duodenum. This condition can cause abdominal pain, nausea, and vomiting, similar to EoE.
However, peptic ulcer disease often comes with burning stomach pain that feels better when you eat or drink and gets worse on an empty stomach. A test called an upper gastrointestinal (GI) endoscopy can visualize the ulcers and help differentiate this condition from EoE.
Eosinophilic Gastroenteritis
Eosinophilic gastroenteritis is an uncommon condition where eosinophils, a type of white blood cell, build up in the stomach and small intestine. Like EoE, this condition can cause abdominal pain and nausea.
Eosinophilic gastroenteritis, however, usually affects other parts of the gastrointestinal tract beyond the esophagus. An endoscopy and biopsy of the stomach or intestine can help identify this condition.
Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) refers to conditions characterized by chronic inflammation in the gastrointestinal tract, such as Crohn’s disease and ulcerative colitis. IBD can cause abdominal pain, similar to EoE.
However, IBD often involves other symptoms such as diarrhea, rectal bleeding, weight loss, and fatigue. A colonoscopy and biopsy are often used to diagnose IBD, while an upper endoscopy and biopsy are used for EoE.
In
fectious Esophagitis
Infectious esophagitis is an infection and inflammation in the esophagus, which can be caused by viruses, bacteria, or fungi. This condition can cause painful swallowing, similar to EoE.
However, infectious esophagitis often occurs in people with weakened immune systems and may present with fever. An endoscopy can often identify the infectious agent and differentiate this condition from EoE.
Esophageal Cancer
Esophageal cancer is a serious and often fatal condition where malignant cells form in the esophagus. Like EoE, this condition can cause difficulty swallowing.
However, esophageal cancer is typically accompanied by weight loss and often occurs in older adults. An endoscopy and biopsy are needed to confirm a diagnosis of esophageal cancer.
Structural Abnormalities (e.g., rings, webs)
Structural abnormalities like esophageal rings or webs can cause narrowing of the esophagus and lead to swallowing difficulties. These are physical changes in the structure of the esophagus, not inflammatory conditions like EoE.
Esophageal webs or rings can be seen on a barium swallow test or endoscopy. Unlike EoE, these conditions do not involve eosinophil infiltration and usually respond to dilation procedures.
Treatment Options
Medications
Topical Corticosteroids (e.g., fluticasone, budesonide)
Topical corticosteroids are medications that help reduce inflammation in the esophagus. They are often the first-line treatment for EoE. These medications are swallowed rather than inhaled, allowing the drug to coat the esophagus. Improvement in symptoms and esophageal inflammation can be expected within weeks to months.
Proton Pump Inhibitors (e.g., omeprazole)
Proton pump inhibitors (PPIs) reduce the production of stomach acid. They are used in EoE treatment to rule out GERD and because some people with EoE respond to PPI therapy. It may take a few weeks to see improvement in symptoms with PPI therapy.
Systemic Corticosteroids (e.g., prednisone)
Systemic corticosteroids are powerful anti-inflammatory drugs used to treat severe EoE or in cases where topical steroids are not effective. While systemic corticosteroids can provide quick symptom relief, long-term use can lead to side effects.
Antihistamines (e.g., loratadine, cetirizine)
Antihistamines are drugs used to treat allergic reactions. They may be used in EoE to help manage symptoms associated with allergies, but they do not treat the underlying inflammation in the esophagus. Relief of allergy symptoms can be expected soon after taking these medications.
Mast Cell Stabilizers (e.g., sodium cromoglycate)
Mast cell stabilizers are drugs that prevent mast cells from releasing inflammation-causing chemicals. These medications are sometimes used in EoE, although their effectiveness is still being studied. If effective, symptom relief can be expected in weeks to months.
Leukotriene Inhibitors (e.g., montelukast)
Leukotriene inhibitors are drugs that block the actions of
leukotrienes, chemicals that cause inflammation in asthma and allergic reactions. They are occasionally used in EoE, especially when asthma or allergies are also present. If effective, symptom relief can be expected in weeks to months.
Immunomodulators (e.g., azathioprine, cyclosporine)
Immunomodulators are drugs that modify the body’s immune response, reducing inflammation. They are used in severe EoE or when corticosteroids are not effective or cannot be used. They can take several months to become fully effective.
Prokinetic Agents (e.g., metoclopramide)
Prokinetic agents are drugs that stimulate the muscles in the gastrointestinal tract to move food along. They are occasionally used in EoE to help with symptoms of dysphagia or food impaction, but do not treat the underlying inflammation. They typically start to work within an hour of ingestion.
Acid-suppressing Medications
Acid-suppressing medications, such as H2 blockers and proton pump inhibitors, reduce the production of stomach acid. They are used in EoE treatment to rule out GERD and because some people with EoE respond to this therapy. Improvement in symptoms can be expected within a few weeks.
Procedures
Elimination Diet Therapy
Elimination diet therapy involves removing certain foods from the diet that are commonly associated with allergies, such as milk, soy, eggs, wheat, nuts, and seafood. This can be effective in treating EoE in many patients, particularly in children. It typically takes a few weeks to months to see improvement in symptoms.
Endoscopic Dilation
Endoscopic dilation is a procedure where a small balloon or dilator is used to stretch the esophagus. This procedure can help alleviate dysphagia caused by strictures or narrowing of the esophagus due to EoE. Symptom relief is typically immediate, but the procedure may need to be repeated over time.
Topical Corticosteroid Therapy
Topical corticosteroid therapy involves swallowing corticosteroid medication in a viscous form to coat the esophagus and reduce inflammation. This therapy can effectively treat EoE in many patients, leading to symptom improvement in weeks to months.
Esophageal Balloon Dilation
Esophageal balloon dilation is similar to endoscopic dilation, but uses a balloon to stretch the esophagus. It can help alleviate dysphagia caused by strictures or narrowing of the esophagus due to EoE. Symptom relief is typically immediate, but the procedure may need to be repeated over time.
Esophageal Stent Placement
Esophageal stent placement is a procedure where a tube is placed in the esophagus to keep it open. This procedure is usually reserved for severe cases of EoE where there is significant narrowing. It can provide immediate relief of symptoms, but there can be complications, and the stent usually needs to be removed after a period of time.
Esophageal Dilation with Bougies
Esophageal dilation with bougies involves using a series of increasingly larger dilators to gradually stretch the esophagus. This can help with dysphagia caused by EoE. Symptom relief is typically immediate, but the procedure may need to
be repeated over time.
Note: Always consult with a healthcare provider for the diagnosis and treatment of medical conditions. This information is for educational purposes and should not be used as a substitute for professional medical advice.
Improving Eosinophilic Esophagitis and Seeking Medical Help
Managing Eosinophilic esophagitis (EoE) can be accomplished through a combination of medical treatments and lifestyle changes. Here are some helpful home remedies to alleviate symptoms and improve the condition:
- Elimination diets (under medical supervision): Certain foods can trigger EoE. A supervised elimination diet, where suspected foods are removed and then gradually reintroduced, can help identify these triggers.
- Avoidance of trigger foods or allergens: Once triggers have been identified, avoiding these foods or allergens can help manage symptoms.
- Small, frequent meals: Eating smaller meals more frequently can help ease the strain on the esophagus.
- Adequate hydration: Drinking plenty of fluids, particularly while eating, can assist in moving food down the esophagus.
- Chewing food thoroughly: Thoroughly chewing food can ease its passage down the esophagus.
- Maintaining an upright position after eating: Gravity can help keep food and stomach acid down, reducing symptoms.
- Stress reduction techniques: Stress can worsen EoE symptoms. Techniques like deep breathing, meditation, and yoga may be beneficial.
- Allergen-proofing the home environment: Reducing exposure to environmental allergens, like dust mites or pet dander, can also help manage EoE.
- Nutritional supplementation: In severe cases, or where food restrictions are necessary, nutritional supplements may be recommended to ensure adequate nutrition.
If symptoms persist despite these measures, it is important to seek medical help. Telemedicine can provide a convenient and accessible platform to discuss your concerns with a healthcare professional.
Living with Eosinophilic Esophagitis: Tips for Better Quality of Life
Living with EoE may require some adjustments, but with the right care and management, individuals can lead a healthy and fulfilling life. Regular follow-ups with healthcare professionals, a willingness to make necessary dietary changes, and learning how to manage stress can greatly improve quality of life. Telemedicine services can provide a convenient way to manage your EoE, allowing you to consult with healthcare professionals from the comfort of your own home.
Conclusion
Eosinophilic esophagitis is a chronic condition that requires ongoing management. Early diagnosis and treatment are vital to prevent complications and improve outcomes. Lifestyle changes and medical treatments can help manage symptoms and improve quality of life. Our primary care telemedicine practice is here to support you through every step of your EoE journey, providing accessible, high-quality healthcare whenever and wherever you need it.
Brief Legal Disclaimer: This article is for informational purposes only and not intended as medical advice. Always consult a healthcare professional for diagnosis and treatment. Reliance on the information provided here is at your own risk.