Eosinophilic Esophagitis

 

What is eosinophilic esophagitis (EoE)?

Eosinophilic esophagitis is one of many types of esophagitis (inflammation of the esophagus). It is not as common as reflux esophagitis, but has many of the same symptoms. It is caused by an abnormal accumulation of allergy cells, called eosinophils, in the lining of the esophagus (swallowing tube). Eosinophils are a type of blood cell that are seen in allergies of all types. Eosinophils are typically never seen in the esophagus, but can accumulate there in the presence of a food allergy. In this condition they are present at an increased level. The reason for this increased accumulation is due to an abnormal allergic reaction to certain foods. Eosinophilic esophagitis is a chronic condition, meaning it may reoccur or last a lifetime unless the specific food causing the allergy can be identified.

 

What are the symptoms of eosinophilic esophagitis?

Symptoms often include difficulty swallowing or the feeling that food is getting caught or stuck in the esophagus. Symptoms may also include chest pain and heartburn.

 

Who gets eosinophilic esophagitis?

Eosinophilic esophagitis is becoming more prevalent and affects 1 out of 2,000 people. It can occur in any age, gender or ethnicity but is most common in men in their 20-30s. Often individuals with eosinophilic esophagitis also have seasonal allergies or other allergic disorders (i.e. asthma, allergic rhinitis, urticaria, etc.). Children can also be affected.

 

How do you know if you have eosinophilic esophagitis?

The only way to diagnose eosinophilic esophagitis is by upper endoscopy with biopsies (tissue samples) of the esophagus. Upper endoscopy or EGD (esophagogastro-duodenoscopy) is a procedure where a small lighted fiber-optic endoscope is passed through your mouth into your esophagus, stomach, and first portion of your small intestine.  The endoscope allows the doctor to see the lining of your esophagus, stomach, and first portion of your small intestine.  Pictures can be taken and can be part of your medical record.  Biopsies can be taken at the time of endoscopy. There is typically no pain associated with endoscopy or taking biopsies.

 

Findings at the time of endoscopy can show a normal appearing esophagus or an esophagus that appears to have inflammation manifested as esophageal narrowing, rings, exudate or linear depressions.  Biopsies typically show an increase in the number of eosinophils that are present in the esophagus.

 

How is eosinophilic esophagitis treated?

Treatment includes either medication or dietary management. These options will be discussed with your healthcare provider to determine which is most appropriate.  

 

 

 

Dietary management:

The most common allergen causing eosinophilic esophagitis is found in dairy products. Next most common are allergens found in eggs and wheat. Other possible allergens include those found in soy, peanuts/tree nuts, and fish/shellfish. The patient will meet with a dietician who canhelp guide the elimination of all common allergens. Then a series of upper endoscopies with biopsies will be performed as foods are added back in to determine which foods are causing the allergy. This process requires multiple upper endoscopies over several months and strict adherence to the diet regimen.

 

Medication management:

  • First line medication management: Topical steroids are the most effective medications for eosinophilic esophagitis.  Steroids are given either via an inhaler or in a liquid form and are swallowed to coat and treat the esophagus. Side effects of steroids can include the development of a fungal infection in the mouth (thrush), or esophagus. Other typical side effects of steroids are much less common as the steroids are administered topically and are poorly absorbed.
  • Second line medication management: Acid blocking medications called proton pump Inhibitors (PPIs) are almost as effective as topical steroids and are frequently used especially if patients also have acid reflux. High dose PPI medications are started and repeat upper endoscopy with biopsy is performed two months later. About half of people will have adequate treatment with this regimen alone. It is likely the dose of PPI can be reduced in the future if symptoms are well-controlled.
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In some situations, dietary changes and medication management can be used together. For example, a patient who successfully eliminated the food group causing the allergy may remain on PPI medication for treatment of acid reflux.

 

Steroid options:

Steroids administered with an inhaler (example: fluticasone):  Unlike inhaled steroids, where a spacer is used to help get the medication into the lungs, spray the medication without a spacer. This allows for the medication to be delivered to the back of your throat and swallowed and brings the medication in direct contact with your esophagus.  This medication should be taken after meals.

 

To operate the inhaler:

  • Shake the inhaler for 5 seconds.
  • Position the inhaler with the index finger on the top of the medication canister and the thumb supporting the bottom of the inhaler. Position the mouthpiece between your teeth.
  • Close your lips around the mouthpiece. Holding your breath, press down on the top of the medication canister with your index finger to release the medication, and swallow the medication.  Do not breathe in until the medication is swallowed.
  • Wait 15 seconds and repeat if you were instructed to take 2 puffs of the fluticasone. Replace cap on the inhaler when done.
  • After taking the medication you should rinse your mouth with water, without swallowing it, and spit it out.  Rinsing the mouth helps to prevent thrush, an infection that can occur in the mouth and produces white patches.
  • You should avoid eating or drinking for 30 minutes after taking the medication to avoid washing the medication away.

 

Steroids administered in liquid form (example: budesonide):  This medication comes in a single-use plastic vial.  This medication should be taken after meals.

 

  • To start, gently shake the plastic vial with a circular motion.  Then twist and remove the cap of the vial.
  • Partially fill a small cup or teaspoon with honey or syrup and squeeze the liquid from the vial into the honey or syrup. 
  • Swallow the mixture.  The honey or syrup will help the medication “stick” to the esophagus.
  • After taking the medication you should rinse your mouth with water, without swallowing it, and spit it out.  Rinsing the mouth helps to prevent thrush, an infection that can occur in the mouth and produces white patches.
  • You should avoid eating or drinking for 30 minutes after taking the medication to avoid washing the medication away.

 

 

Are there any complications from eosinophilic esophagitis?

The most common complication is food becoming caught in the esophagus due to narrowing. Narrowing of the esophagus can be caused by inflammation and fibrosis of the esophagus.

 

What kind of follow up will I need or when should I seek medical attention?

Routine follow up is required however, if you continue to have problems after you finish the course of medication, call your gastroenterologist. Recurrent or ongoing treatment may be necessary.  If an obstruction causes an inability to swallow or interferes with breathing, call 911 or go to the nearest emergency room.