Eosinophilic Esophagitis: Symptoms, Diagnosis, Treatment and Prognosis

What is eosinophilic esophagitis? Eosinophilic Esophagitis is an inflammatory disease that is thought to be caused by food or environmental allergies. Eosinophils are a type of white blood cell and a part of the immune system involved in fighting off parasitic infections and creating an allergic inflammatory response. Eosinophils are a very helpful component of the immune system, but too many of them can create a problem. In eosinophilic esophagitis the esophagus (the tube that runs from your mouth to your stomach) is invaded by large numbers of eosinophils and becomes inflamed.

What are the symptoms of eosinophilic esophagitis?

In children, the most common symptoms of eosinophilic esophagitis are nausea, vomiting, abdominal pain and failure to thrive. The most common symptom of eosinophilic esophagitis in adults is difficulty swallowing (dysphagia). Heartburn and chest pain are less common symptoms of eosinophilic esophagitis.

How is eosinophilic esophagitis diagnosed?

Currently, the only way to diagnose eosinophilic esophagitis is by examining biopsies of the esophagus taken via endoscopy. During endoscopy, the patient is sedated while the doctor threads a narrow flexible tube (endoscope) containing a camera through the mouth and down the throat. Concentric rings or white patches seen during visual examination of the esophagus are suggestive of eosinophilic esophagitis, but their presence or absence is not a definitive sign. A pathologist will examine the biopsies and count the number of eosinophils present. In general there should be zero eosinophils present in the esophagus, but the diagnosis of eosinophilic esophagitis is usually made based on a count of more than 15 eosinophils per high power field.

How is eosinophilic esophagitis treated?

Eosinophilic esophagitis is usually treated through both medication and dietary modifications. There are two types of medication primarily used to treat eosinophilic esophagitis. The first type of medication is acid reflux medications called proton-pump inhibitors. Eosinophilic esophagitis often contains a reflux component so the proton-pump inhibitors can be helpful. The second type of medication used to treat eosinophilic esophagitis is swallowed corticosteroids to help reduce the inflammation. For this medication an asthma inhaler is essentially used incorrectly - instead of inhaling the medicine it is swallowed.

Dietary modifications are an important component in the treatment of eosinophilic esophagitis because food allergies are often the root cause of the inflammation. Allergy testing (scratch or patch tests) may be performed to try to determine what food allergies may be causing the eosinophilic esophagitis. The allergy testing may give some indications of allergies, but it does not always find all of the offending foods so an elimination diet is usually necessary.

One elimination diet suggested is the six food elimination diet. In this elimination diet six of the most common allergens - wheat, milk, eggs, soy, peanuts/tree nuts, and fish/shellfish - are eliminated from the diet. If the eosinophilic esophagitis is well-controlled on this diet then food trials may begin in which foods are returned to the diet one at a time. A food trial must be conducted with careful monitoring for the return of eosinophilic esophagitis symptoms.

In some cases the elimination of just those six foods is not enough to control the disease and patients must begin an elemental diet in which all protein sources are removed from the diet. On this diet patients consume an amino acid formula that contains no whole proteins and are allowed oils, salt, and simple sugars. Unfortunately, this formula is very unpalatable and often requires a feeding tube. An elemental diet is more commonly used to treat children with eosinophilic esophagitis than adults. As with the six food elimination diet, food trials may be instituted after the esophagus is given time to heal and the disease is well-controlled.

What is the prognosis for eosinophilic esophagitis?

Eosinophilic esophagitis has not been linked to esophageal cancer and does not appear to decrease life expectancy. Currently, the greatest known risks are food impaction and possible esophageal perforations associated with it, and failure to thrive in children. Eosinophilic esophagitis, however, is a relatively newly-discovered disease so its course has not been fully explored and careful monitoring is necessary.