I thought eosinophilic esophagitis (EoE) was only a medical problem for children!
We write a lot about children, but adults can have food allergy-associated disorders as well. One such medical problem that can occur in adults, as well as children, is eosinophilic esophagitis (EoE), which is now more frequently diagnosed as a disease in adults. EoE may affect up to one in 1,000 people.
What is EoE?
EoE defines a specific inflammatory disease of the esophagus (the tube from your mouth to your stomach) that is characterized by the infiltration of a large number of eosinophils, a type of white blood cell, in the lining of the esophagus. Eosinophils aren’t normally found there!
These are digital pictures of stained eosinophils from an electron microscope. The top two pictures are eosinophils from circulating human blood (where eosinophils are normally found). The bottom two pictures are eosinophils in mouse bone marrow and culture.
Eosinophils travel to various structures of the body, primarily the digestive tract, and function to help fight different types of infections. However, eosinophils are not normally found in the esophagus. When they are present, this is an indication of inflammation, which may be due to food allergens (e.g. milk, soy, egg) and perhaps environmental allergens.
What are the symptoms of EoE?
EoE symptoms can vary between individuals and can be similar to other conditions, such as gastroesophageal reflux disease (GERD) (acid reflux) and other conditions.
These symptoms may include:
Nausea and/or vomiting
Heartburn or acid reflux that does not improve after taking appropriate medications
Chest and/or abdominal pain
Dysphagia (difficulty and/or pain with swallowing)
Feeling that food is stuck in the throat or chest
Food impaction (food that gets stuck in the throat)
When should I visit the doctor if I think I have problems with my esophagus?
Always see your doctor sooner vs later, if you think you have any medical problems. Medical problems can worsen over time or increase your risk for other diseases.
One of the major complications of EoE is stricture formation (extreme narrowing) of the esophagus. One study of about 350 patients found that a longer delay in EoE diagnosis was linked to the occurrence of esophageal strictures. Thus the risk of developing esophageal strictures is significantly associated with the length the time period from appearance of first symptoms to establishment of EoE diagnosis.
How is EoE diagnosed?
In order for your doctor make a diagnosis, a thorough history will need to be taken to determine potential causes for your symptoms. The most reliable test for EoE is made by endoscopy and biopsy.
An endoscopy is a medical procedure that allows your doctor to look inside the digestive tract. A thin, flexible, lighted tube called an endoscope is guided into the mouth and throat, then into the esophagus, stomach and duodenum (start of the small intestine). The endoscope allows your doctor to view the inside of this area of the body, as well as to insert instruments through a scope for the removal of small tissue samples called biopsies. A pathologist reviews the biopsies to determine the quantity of eosinophils and signs of tissue damage. A high level of eosinophils could indicate that you have EoE.
If you are diagnosed with EoE, you will probably be tested for food allergies. In some situations, avoiding certain food allergens will be an effective treatment for EoE.
How is EoE nutritionally or medically managed?
Diet changes and/or medications can help with the EoE symptoms and prevent further damage to the esophagus.
Nutrition management of EoE is helpful for many people. Healthcare professionals may recommend a “food elimination diet” that removes between four and eight of the most common allergenic foods, which includes milk, soybeans (soy), eggs, tree nuts (e.g., almonds, walnuts, pecans), peanuts, wheat, fish (e.g., bass, flounder, cod) and crustacean shellfish (e.g., crab, lobster, shrimp). A Registered Dietitian Nutritionist (RDN) can be of great help with the “elimination diet” and nutrition management of EoE. Some healthcare professionals eliminate the foods that tested positive through allergy tests.
In some cases, an elemental diet is required; this diet does not contain any whole or partial proteins for the body to react to. An elemental diet is usually a liquid formula that contains amino acids (the building blocks of proteins), fats, sugars, vitamins and minerals. Elemental formulas are developed to meet all or most individual’s nutritional needs; the amount of formula recommended is based on your specific nutritional requirements. These elemental formulas include products such as Neocate® Junior, Neocate® Junior with Prebiotics and Neocate® Splash or E028 Splash. Neocate® Nutra is an amino acid-based semi-solid food that allows people on an elemental diet to keep some variety in the diet.
If there are improvements of symptoms and/or decreased eosinophils in the esophagus after the elimination diet or elemental diet, food trials with reintroduction of individual foods begins.
Some individuals do not respond fully to nutrition management, so medications are an option. Although the Food and Drug Administration (FDA) had not approved any medications for management of EoE, doctors have found that certain types of steroids can help decrease the esophageal inflammation. Drugs, such as budesonide or fluticasone propionate, are swallowed so that the drug directly touches the esophagus to help decrease the inflammation. Some individuals find that EoE symptoms completely resolve, but if the drug is discontinued the symptoms return.
What other questions do you have about EoE?
-Kathleen Smith, RDN, LDN
National Institute of Health, National Institute of Allergy and Infectious Disease. Food Allergy. Available from http://www.niaid.nih.gov/topics/foodAllergy/understanding/Pages/eoe.aspx Accessed March 19, 2015.
National Institute of Health, National Institute of Allergy and Infectious Disease. Eosinophilic Gastrointestinal Disorders. Available from http://www.niaid.nih.gov/topics/EosinophilicDisorders/understanding/Pages/gastro.aspx Accessed March 19, 2015
Schoepfer AM, Safroneeva E, Bussmann C, Kuchen T, Protmann S, UweSimon H, Straumann A. The Delay in Diagnosis of Eosinophilic Esophagitis Increases Risk for Stricture Formation in a Time-Dependent Manner. Gastroenterology 2013 Dec; 145 (6): 1230-1236.e2. Published Online: August 15, 2013 DOI: http://dx.doi.org/10.1053/j.gastro.2013.08.015 Accessed March 19, 2015
Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis, PA, et al. Eosinophilic esophagitis: Updated consensus recommendations for children and adults. Journal of Allergy and Clinical Immunology 2011;128:3-20.e6.