I thought eosinophilic esophagitis (EoE) was only a medical problem for children! If children with EoE can use Neocate, how about adults?
We talk a lot about children, but adults can have food allergies and related conditions as well. This includes eosinophilic esophagitis, or EoE too! In recent years, EoE is being diagnosed more frequently in adults than it was in the past. The most recent estimates point to EoE affecting as many as one in 1,000 people.
We get lots of questions about the role of amino acid-based formulas like Neocate in the diet for people, usually children, with EoE. First, we're going to walk you through the basics of EoE, and also highlight what EoE looks like for adults. Then we'll show how Neocate can be part of living with food allergies as an adult.
What is EoE?
EoE defines an inflammatory disease of the esophagus - the tube from your mouth to your stomach. The inflammation relates to large number of eosinophils - a type of white blood cell - in the tissues of the esophagus. Eosinophils aren’t normally found there!
Here are some digital pictures of eosinophils as seen under an electron microscope. These eosinophils come from blood, which is where they are normally found.
Eosinophils travel in blood throughout the body, primarily the digestive tract, and help fight different types of infections. However, eosinophils are not normally found in the esophagus. When eosinophils are present, this is an indication of inflammation, which may be due to food allergens (e.g. milk, soy, egg) and perhaps environmental allergens (like pollen).
What are the symptoms of EoE?
EoE symptoms can vary - everybody with EoE has a slightly different experience. EoE symptoms can be similar to other conditions, such as gastroesophageal reflux (GER) (acid reflux) and other conditions. This can make it tricky to recognize and diagnosis EoE, which hardly seems fair!
EoE symptoms may include:
- Nausea and/or vomiting
- Heartburn or acid reflux that does not improve after taking prescribed 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)
Children and adults can experience different EoE symptoms. For teenagers and adults with EoE, chest pain and trouble swallowing foods can be especially troublesome.
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. Even if symptoms don't turn out to be related to EoE, it's important to find out the cause! Medical problems that aren't treated can worsen over time or increase your risk for other diseases.
One of the major complications of EoE for adults is the formation of scar tissue in the esophagus. This can cause the esophagus to narrow (called stricture formation). That's the reason why food gets stuck, because the esophagus is too narrow. One study of about 350 patients found that a longer delay in EoE diagnosis was linked to the narrowing of the esophagus. So it's best to get a diagnosis of EoE early to prevent those strictures.
How is EoE diagnosed?
In order for a doctor to diagnose EoE, the first step is to take a thorough medical history for the patient. This allows them to identify potential causes for your symptoms. The most reliable test for EoE is made by endoscopy and biopsy - we'll explain more!
An endoscopy is a medical test that lets your doctor 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 (the start of the small intestine). Patients are sedated for this test. The endoscope lets your doctor view the inside of this area of the body. During the test the doctor also uses the scope to clip small samples of tissue called biopsies.
A pathologist then looks at the biopsy tissues under a microscope. The pathologist counts the number of eosinophils he sees and also checks for signs of tissue damage. A large number of eosinophils in the biopsy tissue may mean that the patient has EoE.
If you or some you know is diagnosed with EoE, tests for food allergies will probably follow. Avoiding certain food allergens can be an effective way to manage EoE.
How is EoE nutritionally or medically managed?
Diet changes and/or medications can help manage EoE symptoms. By keeping the symptoms (and the eosinophils) under control, it's possible to limit further damage to the esophagus. Managing EoE with diet is helpful for many people. There are a couple of different ways to use diet to manage EoE. Adults who choose to try diet for EoE have to be committed, and usually want to get answers for what foods might be triggering their EoE.
Elimination Diet - Healthcare professionals may recommend a “food elimination diet” that removes between four and eight of the most common allergenic foods. The top 8 allergens are milk, soybeans (soy), eggs, tree nuts (e.g., almonds, walnuts, pecans), peanuts, wheat, fish (e.g., bass, flounder, cod) and shellfish (e.g., crab, lobster, shrimp). Some healthcare teams will also eliminate other foods that a patient has positive allergy tests to.
An elimination diet for EoE sound simple on paper, but it can actually be quite a challenge. Removing multiple foods from the diet for EoE can make it hard to dine out, grocery shop, and even cook your own food! On top of that, it can be hard to get enough of each nutrient when you have to avoid multiple foods.
For anyone following an elimination diet for EoE, a Registered Dietitian Nutritionist (RDN) can be a great help. An RDN can help make it easier to avoid multiple foods while also getting enough of each nutrient. For teenagers and adults, this can be especially helpful. Think about it - would you know where to start if someone told you to stop eating any and all foods that contain the top 8 allergens? RDNs to the rescue! It can be tough to find an RDN who specializes in working with EoE patients, especially adults. The good news is that more and more RDNs are working with EoE patients.
Elemental Diet - for some EoE patients, an amino acid-based (or elemental) diet may be needed. An elemental diet means you only consume amino acid-based products, like Neocate. This diet does not contain any whole or partial proteins for the body to react to. An elemental diet is usually liquid formulas that contain amino acids (the building blocks of proteins), fats, sugars, vitamins and minerals.
Elemental formulas are developed to meet all or most nutrient needs. The healthcare team decides the amount of formula needed based on a patient's individual nutrient needs. Most Neocate products are elemental formulas. Neocate Nutra is the only Neocate product that's not a formula - it's an amino acid-based semi-solid food. Neocate Nutra allows people on an elemental diet to keep some texture in the diet.
After 4-8 weeks, it may be possible to start adding foods back into the diet, one or a few at a time, to see which ones don't trigger EoE
After a few weeks of an elimination or elemental diet, the healthcare team will check to make sure the EoE symptoms have improved and that eosinophils have left the esophagus. If things improve, it may be time to start food trials! Food trials are when individual foods or food groups are added back into the diet, one or a few at a time, every 4-8 weeks. This way, the healthcare team can find out which foods trigger EoE.
Not everyone with EoE improves with diet changes, so medications are an option. Some adults choose to skip trying diet changes and go straight to trying medication. Some people with EoE find that their symptoms mostly or fully improve with medication. However drugs don't always work and, if they do, the EoE symptoms return when the drug is stopped.
At this time the Food and Drug Administration (FDA) has not approved any medications for EoE. However, doctors have found that certain types of steroids can help decrease inflammation in the esophagus with EoE. Drugs, such as budesonide or fluticasone propionate, are swallowed so that the drug coats the esophagus to help decrease the inflammation.
We've reviewed some of the basics of EoE as well as how diet can help manage EoE. What questions do you have about EoE and how it impacts adults?
-Kathleen Smith, RDN, LDN
Curious about where we got our facts and figures, or just want to know more? Here are some helpful references:
National Institute of Health, National Institute of Allergy and Infectious Disease. Food Allergy. Available here.
National Institute of Health, National Institute of Allergy and Infectious Disease. Eosinophilic Gastrointestinal Disorders. Available here.
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. Abstract here.
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. Abstract here.
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