Eosinophilic Esophagitis (EoE)

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WHAT IS EOSINOPHILIC ESOPHAGITIS (EOE)? Eosinophilic Esophagitis (EoE), an allergic inflammatory condition in the esophagus, involves eosinophils. This is a type of white blood cell. In healthy people, white blood cells are typically devoid of eosinophils. In EoE, white blood cells called eosinophils build up in the esophagus, the tube that connects the mouth to the stomach. Read More

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Eosinophilic Esophagitis (EoE)

What is Eosinophilic Esophagitis? 

Eosinophilic Esophagitis (EoE), an allergic inflammatory condition in the esophagus, involves eosinophils. This is a type of white blood cell. In healthy people, white blood cells are typically devoid of eosinophils. In EoE, white blood cells called eosinophils build up in the esophagus, the tube that connects the mouth to the stomach.   

Eosinophilic Esophagitis

Causes

The presence of a large number of eosinophils in the esophagus causes eosinophilic esophagitis. Many factors might have contributed to this production and buildup of eosinophils. Such factors may include immune hypersensitivity responses to particular foods or environmental proteins (allergens) in certain affected persons. 

Genetically, some people with EoE have been found to have an extraordinarily high expression of a particular gene (known as eotaxin-3) that codes for a protein that controls the accumulation of eosinophils. Many genes have been found to contribute to EoE, including CAPN-14 and TSLP.

In normal health conditions, the esophagus is usually devoid of eosinophils. The buildup of eosinophils in the esophagus is a reaction to foods, allergens, or acid reflux. 

Eosinophils are a type of disease that fights against white blood cells. They respond to conditions indicating a parasitic infection, an allergic reaction, or cancer. The patient can have high levels of eosinophils in tissues at the site of an infection or inflammation, apart from the blood. 

Eosinophilic functions include:

  • The movement to inflamed areas.
  • Trapping substances.
  • Killing cells.
  • Anti-parasitic and bactericidal activities.
  • Participating in immediate allergic reactions.
  • Modulating inflammatory responses.

The accumulation of eosinophils in the esophagus (to fight allergens) can inflame or injure the esophageal tissue. The damaged esophagus can lead to difficulty in swallowing food or making food get stuck while swallowing, as well as other EoE symptoms.

What are the risk factors associated with eosinophilic esophagitis?

Eosinophilic Esophagitis risk factors
Picture Courtesy: frontiersin

The frequency of occurrence of eosinophilic esophagitis (EoE) is approximately 1 in 2,000 people (a percentage of 0.05%). EoE is a relatively newly recognized disease. Once, it was thought that it was a childhood illness. However, it has been discovered that adults do get EoE, which persists from their childhood to their adulthood. But rarely, some people first experience EoE as adults.

Certain people are more likely to get eosinophilic esophagitis. Although anyone can get EoE, boys tend to develop it more often than girls, in the proximity of 3:2. Some EoE patients have high expression of a particular gene; eotaxin-3. Many genes have been associated with EoE, including CAP-14 and TSLP. EoE may be more common in families. Exposure to “unsafe foods” or pollen may risk an individual allergy. Gardeners and workers in factories where grains are packaged in sacks, or cleaners in warehouses, are at risk of getting EoE. Employees in road construction sites are also at high risk. People living in cold or dry climates and asthmatic patients are more likely at risk. Eosinophilic esophagitis is diagnosed more in spring and autumn. 

Symptoms

EOSINOPHILIC ESOPHAGITIS SYMPTOMS
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The signs of EoE vary with age. However, most of them are the same for both children and adults. They include:

  • Swallowing difficulty (dysphagia).
  • Food impaction (food getting stuck in one’s esophagus).
  • Vomiting (mainly in children).
  • Chest pain.
  • Pains in the upper abdomen.
  • Nausea.
  • Undergrowth (mainly in children).
  • Weight loss.
  • Lack of appetite.
  • Malnutrition (poor or unhealthy feeding).
  • Backflow of undigested food (regurgitation).

From the above information given, it is quite evident that the symptoms of EoE overlap with those of gastroesophageal reflux disease (GERD). 

Many EoE patients are initially thought to have GERD when diagnosed, only to be found that they do not typically respond to anti-GERD therapies. People with eosinophilic esophagitis often have allergic disorders (such as asthma or eczema). 

Other related disorders with almost similar symptoms to EoE include ulcerative colitis (an inflammatory bowel disease of unknown causes) and Crohn’s disease (an inflammatory bowel disease of unknown causes too).

How is eosinophilic esophagitis diagnosed?

EOSINOPHILIC ESOPHAGITIS DIAGNOSIS
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The following tests may have to be carried out to diagnose someone with eosinophilic esophagitis (EoE):

  • Upper Endoscopy
Upper Endoscopy EoE
Picture Courtesy: mayoclinic

Here, a long narrow tube (endoscope) with light and a camera is inserted through the mouth and down the esophagus to detect inflammation, swelling, horizontal rings, vertical furrows, narrowing, and white spots in the esophagus.

  • Biopsy

Multiple tissue samples are taken from the esophagus and examined with a microscope for eosinophils.

  • Blood Tests

These look for higher eosinophil counts or total immunoglobulin E (IgE) levels.

  • Esophageal Sponge Test

Here, a capsule that is tied to a string is swallowed. When the capsule dissolves in the stomach, a sponge is released that is pulled out of the mouth with the string. The pulled-out sponge will have a sample of esophageal tissue and allow the doctor to determine the degree of inflammation in the esophagus without having to undergo an endoscopy. 

  • Food patch test

It is a type of allergy test. During this test, a small amount of fresh food is placed in a small aluminum chamber called a Finn chamber. The Finn chamber is placed on the person’s back area. The food which is present in the Finn chamber is in contact with the skin for 48 hours. It is then removed, and the doctor reads the result at 72 hours [1].

How is eosinophilic esophagitis treated?

EoE is a chronic relapsing disease; hence most patients will require ongoing treatment to control their symptoms. The treatments of eosinophilic esophagitis (EoE) include one or more of the following:

Dietary Therapy

The doctor may recommend the patient stop eating certain foods after conducting tests for food allergies. This can be considered an eosinophilic esophagitis natural treatment. Eosinophilic esophagitis diet such as dairy or wheat products may be restricted from the meals to relieve their symptoms. These may include:

  • Eggs.
  • Fish.
  • Soy.
  • Nuts.
  • Milk.
  • Wheat.
  • Shellfish.

Medications 

These include:

  • Proton Pump Inhibitor

PPI is an acid blocker. It is the easiest medication to use when treating eosinophilic esophagitis (EoE). It can be used as a first-line treatment.

  • Topical Steroids

Steroids are only recommended if the patient doesn’t respond to PPI. Topical steroids (which can be applied to the skin), such as fluticasone or budesonide, are liquids that are swallowed to treat eosinophilic esophagitis (EoE). There are usually no side effects associated with steroids.

  • Monoclonal antibodies

Monoclonal antibodies are used in treating eosinophilic esophagitis in adults and children 12 years and older. Dupilumab is a monoclonal antibody that blocks the action of certain proteins in the body that causes inflammation [2].

  • Dilation

If the use of steroids is not helpful enough (or at all), then the doctor may recommend dilation if the patient experiences severe narrowing (structures) in the esophagus. 

Note the sequence, starting with PPIs→ and topical steroid dilation. 

What is the prognosis of eosinophilic esophagitis?

Eosinophilic esophagitis (EoE) is a rare chronic disease that requires further intense research, ongoing monitoring, and management. EoE does not appear to limit life expectancy, and so far, there is no data suggesting EoE causes cancer of the esophagus.

What are the complications of eosinophilic esophagitis?

Eosinophilic esophagitis, if left untreated, complications may occur, such as:

  • Scars in the esophagus.
  • Narrowing of the esophagus

This makes swallowing more difficult and more likely for the food to get stuck, thus creating an emergency. Sometimes, the patient complains of vomiting.

  • Damage to the esophagus

The buildup of eosinophils can result in esophageal injuries and inflammation. Because of the inflammation of the esophagus, endoscopy can cause perforation or tears in the lining tissues. 

FAQ

What triggers eosinophilic esophagitis?

Eosinophilic esophagitis (EoE) is caused by the presence of a large of eosinophils in the esophagus. The production and pileup of eosinophils may be caused by many factors, like immune hypersensitivity to certain foods or allergens, in some EoE patients.

What happens if eosinophilic esophagitis is left untreated?

If left untreated, the patient can eventually result in scarring and narrowing of the esophagus, which makes the symptoms even worse over a period of time. Treatment of EoE begins with acid-blocking medication. These drugs can reduce acid reflux symptoms and inflammation in the esophagus.

How rare is Eosinophilic Esophagitis?

EoE is a rare disease, increasing in prevalence (with approximately 1 out of 2,000 persons affected per year). EoE affects people of all ages and ethnic compositions but tends to affect males more than females.

What foods does one have to avoid if they are diagnosed with Eosinophilic Esophagitis?

The six-food elimination diet (SFED) is the most frequently employed in patients with EOE. This diet usually excludes wheat, eggs, milk, soy, nuts, fish, or shellfish.

Do antihistamines help eosinophilic esophagitis? 

Antihistamines are frequently used for the treatment of gastroesophageal reflux disease and allergic disorders, and these drugs will be effective in the treatment of eosinophilic esophagitis as well. The two common antihistamines are loratadine and famotidine.

Can eosinophilic esophagitis cause shortness of breath?

Eosinophilic esophagitis can cause food impaction and difficulty in breathing. The patient may require immediate care in a medical emergency [3].

Does stress cause eosinophilic esophagitis?

Stress and disease anxiety subscales are important contributors in adult eosinophilic esophagitis patients [4]. 

Is eosinophilic esophagitis an autoimmune disorder?

Eosinophilic esophagitis is a chronic immune system disorder. During this condition, a type of white blood cell called an eosinophil builds up in the lining of the tube (esophagus) that connects the mouth to the stomach [5].

References

  1. https://www.aaaai.org/conditions-treatments/related-conditions/eosinophilic-esophagitis
  2. https://www.mayoclinic.org/diseases-conditions/eosinophilic-esophagitis/diagnosis-treatment/drc-20372203
  3. https://www.verywellhealth.com/eosinophilic-esophagitis-coping-5207800#:~:text=Eosinophilic%20esophagitis%20can%20cause%20food,emergencies%20and%20require%20immediate%20care.
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6910091/#:~:text=The%20disease%20anxiety%20and%20choking,HRQOL%20in%20adult%20EoE%20patients.&text=In%20fact%2C%20a%20separate%20study,HRQOL%20in%20the%20EoE%20population.
  5. https://www.mayoclinic.org/diseases-conditions/eosinophilic-esophagitis/symptoms-causes/syc20372197#:~:text=Eosinophilic%20esophagitis%20(e%2Do%2Dsin%2D,your%20mouth%20to%20your%20stomach.