Eosinophilic esophagitis
What is eosinophilic esophagitis?
Eosinophilic esophagitis (EoE) is an inflammation of the esophagus (the tube connecting the mouth to the stomach), caused by a specific white blood cell – the eosinophil. Nearly three-quarters of affected cases occur in white males. This is a relatively newly recognized disease that has been increasingly diagnosed in adults and children over the past decade.
Diagnosis of eosinophilic esophagitis
Currently, eosinophilic esophagitis is diagnosed by upper endoscopy and biopsy. The endoscopy sometimes reveals rings, white plaques (patches), or furrows in the esophagus; however, EoE may be present even if the esophagus looks normal. That’s why we take biopsy samples. Biopsy samples look for an overabundance of eosinophils in the esophageal tissue.
Outlook for patients with EoE
Based on what is known to date, eosinophilic esophagitis does not cause cancer of the esophagus and is not thought to limit life expectancy in any way. Current information suggests if left untreated, EoE may lead to esophageal narrowing over time.
Treatment at Penn Medicine
There are two main treatment approaches to eosinophilic esophagitis: steroid medications and dietary management. There is also a third approach for some patients, called esophageal dilatation.
Steroids are the most commonly used medication for both the control of inflammation and the direct suppression of the eosinophils. These medications are typically taken topically and in severe cases may need to be taken orally (in pill form). Steroids may need to be taken long term, although their long-term use for eosinophilic esophagitis has not been well-studied. Occasionally, continued swallowed use of steroids can result in Candida infections (yeast infections of the mouth and esophagus) as a side effect. A drug class that is currently being investigated for future use is biologic agents. These drugs would specifically target the white blood cell itself, the eosinophil.
Food allergies contribute to EoE; however, no one has yet to determine which foods might be the cause. The more common foods associated with food allergies are milk, eggs, peanuts and tree nuts, beef, wheat, fish, shellfish, corn and soy. In the case of EoE, a single food may be problematic for some people, while many foods may be the cause for others.
With this in mind, we can try several dietary approaches. In a "targeted" approach, foods are eliminated from the diet one at a time, as best indicated by allergy testing. Unfortunately, typical allergy tests, such as skin prick or blood tests, are not usually effective for determining the problematic foods responsible for EoE. Therefore, we often use another type of elimination diet, the six food elimination diet, instead.
The six food elimination diet excludes six foods (dairy, eggs, nuts, wheat, fish, and soy), and you slowly add them back into your diet until you find the culprit.
A third approach, an "elemental diet" consists of removing all sources of protein from the diet. This is a very strict, tasteless amino acid formula-based diet that may require a feeding tube hooked up directly to the stomach to obtain enough nourishment. In this diet, only amino acids (the building blocks of proteins) are supplied to patients. This is, however, the most effective diet for people with EoE.
With any of these food trial diets, foods are slowly reintroduced in an attempt to discover which ones are causing the allergic reaction. Repeat biopsies and endoscopic examinations are necessary to determine which foods are not problematic.
Another treatment that has been tried for some patients is esophageal dilatation, which is specifically for patients who get food stuck in their esophagus.