Eosinophilic Esophagitis: A Growing Allergic Disease
Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease characterized by high numbers of a type of white blood cell called eosinophils in the esophagus. The exact causes are not fully understood, but it is believed to be triggered by certain foods and environmental allergens. EoE is becoming increasingly common, and its prevalence is estimated to be 1 in 2,000 individuals. In this article, we will explore what is known about the causes, symptoms, diagnosis and treatment of this complex condition.
What Causes EoE?
Research indicates that EoE is an immune/allergic-mediated disease of the esophagus. Genetic susceptibility plays a role, as EoE tends to run in families. Environmental factors like allergens also contribute to the development and severity of the disease. The main triggers identified so far are:
- Food allergens: The top food allergens associated with EoE include milk, wheat, soy, eggs and nuts. Eliminating foods from the diet based on allergy testing can help reduces symptoms for many patients.
- Aeroallergens: Indoor and outdoor allergens like dust mites, pollen, and pet dander can exacerbate EoE inflammation in sensitized individuals. Exposure to these allergens makes symptoms worse for some patients.
- Proton pump inhibitors (PPIs): There is an association between long-term PPI use and development of EoE. PPIs are thought disrupt the normal protective mechanisms in the esophagus, allowing allergens to more easily penetrate and trigger inflammation.
The exact interplay between genetic susceptibility, environmental exposures, and the immune response is complex and actively being studied. EoE seems to occur when an allergen crosses the defective esophageal epithelium in a susceptible individual, activating their oversensitive eosinophilic immune system.
Symptoms of EoE
The most common symptoms of EoE include one or more of the following:
- Dysphagia (difficulty swallowing): This is the core symptom of EoE and usually worsens with time as the disease progresses. Patients may experience painful swallowing of certain foods.
- Food impaction: Large pieces of poorly chewed or swallowed food can become temporarily stuck in the esophagus, requiring intervention to dislodge. This is a risk as the esophagus begins to narrow.
- Chest pain: A feeling of chest pain, pressure or discomfort when swallowing is common. Pain is usually localized to the upper chest area.
- Heartburn and acid reflux: These symptoms may occur, however, they do not typically respond to acid suppression therapy like PPIs.
- Vomiting: This can happen periodically due to blockage from food or difficulty swallowing large bites.
- Failure to thrive in children: Pediatric patients have difficulty consuming enough calories due to dysphagia, leading to poor growth.
While individuals exhibit variable symptom patterns, dysphagia tends to be the most troublesome and persistent complaint in EoE. Symptoms may come and go or gradually worsen over time without treatment.
Diagnosing EoE
Since the symptoms of EoE can mimic other conditions, a high level of suspicion is needed from doctors. A thorough medical history and physical exam will help identify patients who need further investigation. The gold standard confirmatory test is esophagogastroduodenoscopy (EGD), during which biopsies are taken from multiple sites in the esophagus for microscopic evaluation. Diagnosis requires ≥15 eosinophils per high-power field upon microscopic examination of biopsy tissues by a pathologist. Additional testing like allergy testing may be used to identify specific food triggers. Radiographic imaging with barium studies can evaluate any structural changes to the esophagus caused by EoE. Overall, making an accurate diagnosis requires correlating the clinical history and examination with the endoscopic and histologic findings.
Treating EoE with Diet and Medications
A multifaceted treatment approach tailored to the individual is usually needed to effectively treat eosinophilic esophagitis. The two main treatment modalities are:
Food elimination diets: These involve identifying and removing the specific foods triggering the allergic inflammatory response, usually based on allergy testing. The most common diets used are the Elimination Diet (removing 6 foods), the Elemental Diet (eliminating all foods using an elemental formula), and the Six-Food Elimination Diet. Up to 80% of patients experience symptom improvement this way.
Topical corticosteroids: For patients where diet therapy does not control symptoms or is not practical long-term, topical swallowed corticosteroids like fluticasone and budesonide are mainstays of pharmacological treatment. These act locally on the esophagus to reduce inflammation without systemic side effects. However, maintenance therapy may be needed.
Other adjunctive measures such as acid suppression with PPIs, endoscopic dilation of strictured areas, and allergen immunotherapy can be utilized depending on the specific individual’s presentation and treatment response. The prognosis for EoE patients is generally good with long-term management, though it typically requires a lifelong multifaceted approach. With advances in diagnosis and treatment, outcomes continue to improve for this difficult-to-treat esophageal condition.
Eosinophilic esophagitis is an increasingly recognized immune/allergic disorder affecting the esophagus. It presents with a variety of symptoms relating to difficulty swallowing and requires coordination between allergists and gastroenterologists for proper diagnosis and management. While its exact causes are still under investigation, diet therapy, medications, and environmental control have shown efficacy at reducing inflammation and improving quality of life for EoE patients. With further research into the complex interplay between genetics and environmental triggers, more targeted treatment approaches hold promise. Increased awareness, early diagnosis, and a tailored long-term care plan are important to achieving optimal outcomes for this challenging disease.
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