What is Eosinophilic Esophagitis and How Is It Treated?

Let’s say you have been having difficulty swallowing, chest pain and heartburn. At the same time, you have noticed you keep getting food stuck in your esophagus, which is called food impaction.  You share this with a friend who tells you that her brother was having the same trouble and it turned out to be eosinophilic esophagitis (EoE).

That’s a real mouthful to say. What does it mean if you have it? Why do you have it? And what is the treatment? How worried should you be about this? In this article, we will walk you through all these questions and more.

What is eosinophilic esophagitis?

To get us on firm footing, let’s define some basic terms.

The esophagus is the tube that carries food and water from the throat to the stomach.

“Esophagitis” means that the esophagus is inflamed.

Eosinophils are one of the several types of white blood cells that help us fight infections.

Eosinophilic esophagitis occurs when too many of these white blood cells gather in the esophagus and cause inflammation, swelling, and scarring.

Because white blood cells are part of our immune systems, EoE is called a chronic immune system disease. It is more common in men than women.

Causes of eosinophilic esophagitis

EoE is looked at as a type of allergy triggered by certain foods or other causes. The body’s allergic reaction is to send eosinophils to your food pipe. Doctors don’t fully know the root cause of this problem. It could be a combination of genetic, environmental, and immunological factors. Several genes that help regulate immune responses and inflammation have been linked to EoE. And it’s believed that allergens and pollutants might trigger or worsen the symptoms. A related condition is called esophageal eosinophilia, which means more eosinophils are drawn to the esophagus than normal. But this doesn’t necessarily lead to esophagitis or cause any symptons.

How do doctors diagnose eosinophilic esophagitis?

You told your friend that you sometimes find it hard to swallow foods and often feel chest pain, heartburn, regurgitation, and food impaction. These symptoms resemble those of gastroesophageal reflux disease (GERD). Other symptoms for EoE include

  • Stomach pain.
  • Unexpected weight loss. In children this appears as poor weight gain or stunted growth.
  • Vomiting

Your doctor will check your medical history to see if any risk factors for EoE apply to you, including:

  • Family history of EoE.
  • Personal history with atopic dermatitis or asthma.
  • Environmental or food allergies.
  • Living in a cold or dry climate.

The doctor might first try proton pump inhibitors (PPIs), which also are the go-to treatment for gastroesophageal reflux. If you don’t respond to PPI therapy, that’s a clue that you need further evaluation.

A doctor might perform an upper endoscopy—inserting a flexible tube with a camera through your mouth to look at the esophagus. If you have EoE, the esophageal lining might look inflamed, with white patches, rings, or narrowing of the esophagus. But everything could look normal even if you have EoE.

To confirm a diagnosis, a doctor will take small tissue samples from the esophageal epithelial cells. Then someone will count the number of eosinophils present and look for other features. If it’s over a certain number, your doctor can begin treatment for EoE.

Treatment of eosinophilic esophagitis

Because this is a chronic condition, there is no cure for EoE. The goal is to reduce inflammation and ease the symptoms. Your age and the severity of the disease will help determine the treatment strategy.

Diet therapy

Your doctor might recommend food allergy testing to see if diet therapy would help. The most common trigger foods for EoE are milk, wheat, soy, eggs, peanuts, tree nuts, fish, and shellfish.

So, after allergy testing you might be placed on a food elimination diet. No potential trigger foods are allowed for a certain period—usually several weeks. During this elimination diet, foods are reintroduced one by one to try to identify the triggers for the esophageal dysfunction. Dietitians can help EoE patients plan a healthy diet with no trigger foods. Two of the standard approaches are the six-food elimination diet and the targeted elimination diet. In some cases, an elemental diet is recommended, limiting the patient to ingesting only a liquid amino acid formula. For very young children, a feeding tube might be necessary because they can’t drink enough of the formula on their own.

Topical steroids

Topical corticosteroids are swallowed to allow for direct contact with the esophagus to control inflammation. Budesonide or fluticasone are commonly used in this treatment. The patient usually takes the steroid for several weeks and then the symptoms, and possibly the esophageal tissue, are reassessed. If necessary, another round of treatment is ordered.

Systemic corticosteroids

These steroids are taken orally or injected to reduce inflammation throughout the body. Prednisone is commonly prescribed for severe cases and when other methods are not helping. Systemic corticosteroids flow throughout the body, while the topical steroids referred to above generally do not enter the bloodstream. For that reason, the side effects are more severe with systemic corticosteroids than with topical steroids. The side effects include:

  • Swelling in the lower legs due to fluids.
  • High blood pressure.
  • Weight gain.
  • Mood swings and other psychological problems.
  • Upset stomach.

Other treatments

Medications that affect your immune system are sometimes used to treat EoE. One of these, Dupixent (dupilumab), was approved in May 2022 by the FDA, making it the first federally approved treatment for EoE. The medication, which is injected weekly, is known as a monoclonal antibody. However, the drug can cause allergic reactions and its dampening effect on the immune system can cause cold sores to reappear.

Doctors might also use endoscopic therapy to help with esophageal narrowing. It’s generally reserved for patients with severe symptoms and complications involving food impaction and bleeding. Using an endoscope, a doctor can remove strictures, or narrowings, and place a stent to keep the esophagus open.

Besides medical treatment, people with EoE can take other steps to ease their symptoms and make their lives better, including:

  • Chew food thoroughly to make it easier to swallow.
  • Eating small, more frequent meals to reduce the amount of food in the esophagus must process at one time.
  • Don’t eat within a few hours of bedtime. This reduces the chances of acid reflux.
  • Elevate the head of your bed—again to reduce acid reflux.
  • Don’t wear tight-fitting clothing that puts pressure on the esophagus and stomach.

Getting help if you have eosinophilic esophagitis

Living with the chronic inflammation of EoE can be challenging, but the physicians at Florida Medical Clinic can help you manage things. If you are experiencing symptoms of EoE, it is important to get an accurate diagnosis and the right treatment.

Then you can treat the condition and lead a full and active life. Also, early intervention can help you avoid complications and get better outcomes.

Meet David R. Heiman, MD

Dr. Heiman has lived in the Tampa area most of his life and serves as the Endoscopy Medical Director in North Tampa. He is married and enjoys spending time with family and playing golf and tennis.

He is a member of the American Board of Internal Medicine, American College of Physicians, American Society of Gastrointestinal Endoscopy, American College of Gastroenterology, and National Board of Medical Examiners.

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Gastroenterology

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