Eosinophilic Esophagitis

Eosinophilic esophagitis, commonly known as EoE, is a chronic allergic condition impacting the esophagus—the vital tube connecting the mouth to the stomach. In this disorder, the esophageal lining harbors abnormally increased eosinophils, a type of infection-fighting cell. These eosinophils cause inflammation and damage the esophageal tissue, resulting in symptoms like heartburn, nausea, and difficulty swallowing. Notably, EoE symptoms closely mimic those of gastroesophageal reflux disease (GERD), although their treatments differ significantly.

Causes

EoE emerges from a complex interplay of genetic and environmental factors:

• Immune System Reaction: An abnormal immune response leads to the accumulation of eosinophils in the esophagus, causing inflammation. This reaction often stems from allergens in foods or environmental sources like pollen.

• Food Triggers: Certain foods, including milk, wheat, eggs, soy, peanuts, tree nuts, and seafood, can spark this heightened immune response, leading to symptoms such as difficulty swallowing and chest pain due to inflammation and tissue damage over time.

• Environmental Factors: Although the exact reasons remain unclear, a correlation exists between increasing EoE cases and broader environmental changes.

• Genetic Predisposition: A family history of allergic conditions like asthma, eczema, and allergic rhinitis raises the risk of developing EoE, suggesting a genetic link.

Despite its rarity, affecting about 150,000 people in the United States, the incidence of EoE is rising across all age groups, including infants, children, and adults.

Symptoms

EoE is an inflammatory condition targeting the esophagus, with symptoms varying between children and adults.

• Infants and Young Children may exhibit:

• Difficulty feeding

• Discomfort or pain while feeding

• Vomiting

• Abdominal pain

• Delayed growth or not gaining weight, known as failure to thrive

• Adults may experience:

• Difficulty swallowing, medically termed dysphagia

• Food impaction, where food gets stuck in the esophagus

• Heartburn

• Chest pain unresponsive to antacids

• Regurgitation, with undigested food returning to the mouth

Inflammation-induced swelling and narrowing of the esophagus primarily cause these symptoms, making food passage challenging. Persistent inflammation might lead to scar tissue (fibrosis), worsening symptoms. Consultation with a healthcare provider is crucial if symptoms occur frequently or severely to ensure proper management and prevent complications.

Diagnosis

Diagnosing EoE can be challenging due to symptom overlap with other gastrointestinal issues like heartburn or vomiting. Healthcare professionals must first rule out other common causes. A primary diagnostic tool is an upper endoscopy, or esophagogastroduodenoscopy (EGD), performed by a gastroenterologist. This involves inspecting the esophagus for signs of inflammation, tissue rings, or narrowing. Biopsies obtained during endoscopy help confirm the diagnosis by detecting eosinophils within the tissue. Blood tests may also be conducted to identify associated allergic reactions, and occasionally, an esophageal sponge test might be used to collect tissue samples without endoscopy.

Treatments

Managing EoE involves addressing esophageal inflammation through dietary changes, medications, or procedures like esophageal dilation. Dietary modifications often involve removing foods that trigger allergic responses, such as dairy or wheat, from the diet. Medications may include acid blockers like proton pump inhibitors, topical steroids such as Fluticasone or Budesonide, and monoclonal antibodies like dupilumab to reduce inflammation. In severe cases, dilation may be necessary to alleviate swallowing difficulties by widening the esophagus. The aim of these treatments is symptom control and complication prevention, requiring ongoing management.

Medications

Various medications are employed to manage EoE effectively:

• Proton Pump Inhibitors (PPIs): These drugs reduce stomach acid production, easing esophageal inflammation. While chiefly used for GERD, they benefit EoE patients by preventing acid exposure to the esophagus.

• Steroids: Topical corticosteroids like Fluticasone and oral Budesonide target esophageal inflammation. Administered via inhaler or liquid form, they alleviate symptoms such as difficulty swallowing in both children and adults.

• Immune System Modulators: Dupilumab (Dupixent), a monoclonal antibody for patients aged 12 and older, directly targets the immune system, effectively controlling EoE-induced inflammation, leading to significant symptom improvement.

Regular medical check-ups are essential to monitor and adjust medications as needed for effective symptom management. Discontinuing treatment may cause symptom recurrence.

Prevention

Consider these strategies to prevent EoE symptoms:

• Identify and avoid food triggers causing esophageal inflammation, including dairy, eggs, nuts, soy, wheat, and seafood.

• Some studies suggest eliminating only animal milk could be as effective as cutting multiple food groups for condition management.

• Minimize allergen exposure by creating an environment with fewer allergens, particularly seasonal or environmental ones like pollen, for sensitive individuals.

• Regular consultations with a gastroenterologist and collaboration with a nutritionist can help develop a personalized plan to reduce flare-ups and effectively manage EoE over time.