Eosinophilic Esophagitis - Gastroenterology
What is Eosinophilic Esophagitis?
Eosinophilic Esophagitis is a mouthful of a phrase. It is a disease that we are seeing more and more frequently. It is a common cause of swallowing difficulty, as well as heartburn that does not respond to conventional medications.
To understand Eosinophilic Esophagitis, we need to discuss each of the words in its name. First let’s consider the word esophagitis. The esophagus is the food tube that connects our mouth to our stomach. Any time an organ in the body becomes inflamed, we attach an "-itis" to its name. Thus, esophagitis is inflammation of the esophagus. There are many things that can cause inflammation of the esophagus such as acid reflux or certain infections.
The second word to understand is eosinophilic. It is based on a type of white blood cell named the eosinophil. White blood cells are part of the immune system and circulate through the body to help fight infection. The eosinophil is involved in our body's allergic reactions. For example, eosinphils are activated in people with asthma. When a disease causes the buildup of too many of a certain cell, we attach the ending "-ilic" to its name. Thus, eosinophilic means a disease where there are too many eosinophils.
So, when we put these two words together; Eosinophilic Esophagitis is an inflammation of the esophagus generated by eosinophils. The eosinophils infiltrate into the wall of the esophagus where they cause inflammation and disease. Eosinophilic Esophagitis has also been referred to as Allergic Esophagitis or Asthma of the Esophagus. This condition is seen throughout the world. It is more often seen in children but is now occurring with increased frequency in adults. It appears to be more common in males than females.
Common symptoms of Eosinophilic Esophagitis are difficulty swallowing food, heartburn that doesn't respond to typical therapy with antacids, or food getting lodged in the esophagus. Very young children may develop weight loss and difficulty feeding. Rarely, it can also cause chronic abdominal pain.
We do not fully understand Eosinophilic Esophagitis. We suspect it is an allergic reaction. Some people speculate that the eosinophils are left over from a more acute infection, or that there is some environmental exposure such as pollen. Others believe it is an allergic response to certain foods. Finally, some speculate that food additives or pesticides may be a factor. Regardless, the most common symptoms tend to be food that either becomes stuck or gives a sense of getting stuck after it is swallowed. Some people have even had complete impaction of food where a piece of food lodges in the esophagus like a cork in a bottle top.
The diagnosis is most often suggested by a history of difficulty swallowing, particularly in a younger person. Endoscopy is usually done to confirm the diagnosis. Endoscopy is a procedure where a small, flexible scope is passed into the mouth and down the esophagus while the person is asleep. When a biopsy of the esophagus is taken during endoscopy in someone with Eosinophilic Esophagitis the pathologist sees an increase in the number of eosinophils in the tissues of the esophagus. Other disorders can produce eosinophils of the esophagus, such as reflux disease and inflammatory bowel disease. The patients history and the location of the biopsies helps to sort this out.
There is still much to learn about the best treatment for Eosinophilic Esophagitis. It is important to find an underlying cause if allergy is suspected. Sometimes, a person will have a known food allergy and this food should be avoided until it is clear if the particular food allergy is associated with the symptoms. Common foods associated with Eosinophilic Esophagitis include eggs, milk, soy, wheat and corn. Because of these potential associations, often times these foods are eliminated from the diet and slowly reintroduced to determine if there is a correlation between the food and the symptoms. Allergy testing can also be carried out to help guide diet changes. Acid suppression with any number of medications is often a first line approach. It is often inffective but is generally safe and may help some people. When there is a narrowing in the esophagus seen during endoscopy, a dilation is often performed. Dilation needs to be done carefully as the esophagus can be quite stiff and narrow in Eosinophilic Esophagits and there is a risk of tearing or perforating the esophagus.
When people do not respond to diet changes or acid suppression, steroid medication is often used. Fluticasone (Flovent) is an inhaled steroid that is used in asthma. It can also be used for patients with Eosinophilic Esophagitis. Instead of inhaling the steroid, however, the steroid is swallowed with a small amount of water. Oral steroids, such as prednisone, have also been found to be effective but the risks and benefits of this approach need to be weighed individually and discussed with your physician.
There is still much to learn about Eosinophilic Esophagitis, but it appears to be occurring more frequently and is a common cause for people, young and old, to have difficulty swallowing food. The symptoms may be controlled with either acid suppression or by identifying a triggering food. Endoscopy is often used to confirm the diagnosis by obtaining biopsies of the esophagus. Endoscopy can also be used to follow a response to treatment. Elimination diets can be effective but referral to an allergist is often helpful to guide the diet changes. Finally, topically applied steroid medication in the form of swallowed Fluticasone has been shown to be effective in some patients.