Allergy Capital

Eosinophilic Oesophagitis (Eosinophilic Esophagitis)

Eosinophilic oesophagitis (eosinophilic esophagitis) results in inflammation the oesophagus, the muscular tube that connects the mouth to the stomach. Most cases are seen in people with allergies such as hay fever and asthma. There is some evidence that this may be an unusual form of food allergy.

Updated 25 March 2006

IMPORTANT The information provided is of a general nature and should not be used as a substitute for professional advice. If you think you may suffer from an allergic or other disease that requires attention, you should discuss it with your family doctor.

What is eosinophilic oesophagitis?
The oesophagus is a muscular tube that connects the mouth to the stomach. In this condition, the lining of the oesophagus is inflamed with eosinophils, a type of white cell that causes the inflammation seen in hay fever and asthma.

Eosinophilic oesophagitis affects mainly children and young adults
This condition occurs in males more often than females and mainly in children and young adults. It should be suspected when a person complains of:

foods sticking on the way down, sometimes completely;
choking on food;
regurgitation of foods, and sometimes;
severe acid reflux that does not respond to medicines used to suppress stomach acid production

It should be noted that mild reflux and vomiting are common in children and adults, and most do not have eosinophilic oesophagitis. The condition has often been present for many years before diagnosis.

How is eosinophilic oesophagitis diagnosed?
The diagnosis can be suspected by your treating doctor, but confirmation needs an examination of your oesophagus using an instrument known as an endoscope. A tissue sample (biopsy) will be taken at the same time. This procedure is normally performed by a gastroenterologist (stomach/bowel specialist). Sometimes a blood sample will show a higher than normal levels of eosinophils in the blood as well.

Eosinophilic oesophagitis may result from pollen or food allergy
Around 80 per cent of patients with this condition suffer from allergic conditions such as hay fever or asthma. When allergy testing is performed, many will have positive skin prick tests or patch tests to foods, even when there are no obvious symptoms after they are consumed. Some researchers have found that patients benefit if these foods are removed from the diet, suggesting that this condition may be an unusual form of food allergy. Others have found that symptoms can appear only during Springtime when patients are exposed to pollen. When food is involved, staples such as dairy products, wheat, soy, meats, chicken and egg seem to be the most common triggers.

Eosinophilic oesophagitis may be increasingly
Eosinophilic oesophagitis was first described in 1978, but reports of cases were few until the 1990's. This condition appears to have become more common, not just because doctors are getting better at diagnosing it. The reasons are unclear, but it is known that allergies of all types have become more common then they were a generation or two ago.

Who treats eosinophilic oesophagitis?
Most people are managed by gastroenterologists. With the recognition that allergy may also play a role in some patients, some are managed by allergy/immunology specialists and specialist dietitians as well.

Why treat eosinophilic oesophagitis?

In adults, the condition lasts for many years if not indefinitely. Treatment is recommended to reduce the risk of permanent scarring that may results from untreated inflammation and uncontrolled acid reflux. So far, there is no evidence that this condition increases the risk of cancer. Babies with severe reflux often outgrow the problem, but whether older children do so is currently unclear.

How is eosinophilic oesophagitis treated?
Time
Symptoms in infants often resolve in the first few years of life, particularly when only 1 or 2 foods is involved. Unfortunately, when symptoms arise in older children and adults, they usually last for many years. Followup studies so far indicate that they may never resolve completely n patients of this age.

Medication

Medication to reduce acid production will reduce acid reflux and the scarring that can result.
Topical asthma steroid puffers can reduce inflammation in the oesophagus. These are "swallowed" instead of inhaled, are low dose, poorly absorbed, and extremely unlikely to cause cortisone/steroidtablet-like side-effects. They help reduce inflammation and the scarring that can result from untreated disease.
Montelukast (Singulair) is an asthma tablet that reduce inflammation by blocking the effects of inflammatory chemicals release by white cells known as "leucotrienes".
Other medicines are also being studied. Swallowed cortisone tablets with the property of being poorly absorpbed (like budesonide) have been helpful in some studies, but are not available currently in Australia.

Dilatation of the Oesophagus
Some times if the oesophagus is very narrow, you might need an endoscopy and a procedure known as "dilatation" to open up the oesophagus to allow food to pass more easily.

Diet manipulation
In recent reported studies, some groups claimed that a combination of skin prick testing and food patch testing with staple foods, will identify potential food allergens. If avoided, they claim that improvement is seen in around 3 out of 4 patients. The general approach is to avoid the foods for which there is evidence of sensitization. If improvement in symptoms occur, foods are introduced one food at a time, starting with the foods that are least likely to cause problems. It is important to note that:

the diagnosis of EES should always be confirmed first, and
that dietary manipulation should be temporary and supervised by a skilled dietitian to avoid the risk of malnutrition.

Not all eosinophilic oesophagitis is related to allergy
Around a quarter of sufferers have no evidence of allergy. Some have underlying conditions that can cause similar inflammation in the gut. These people will not respond to diet manipulation, but may respond to medication. Even when people who feel better with avoiding certain foods, the inflammation may still persist.

This is a developing area of study

More is being discovered about this condition. There are controversies as to the role of allergy and diet manipulation, and how many people are actually helped by diet. Furthermore, sometimes symptoms may improve with diet manipulation, but the underlying inflammation may still persist. At this time it is not clear how aggressive treatment should be in all cases; should we aim to settle the symptoms, or try to control the underlying inflammation as well? More patients are being reported with symptoms during the pollen season, suggesting that inhaled allergen (or perhaps swallowed pollen) may cause problems in some people. One study in late 2005 (Clinical Experimental Allergy 2005; 35: 1421-31) found eosinophils in the oesophagus of people with hay fever WITHOUT symptoms (although at a lower levels than in eosinophilic oesophagitis).

Patient Support Groups (USA)

American Partnership for Eosinophilic Disorders

Patient Web links

Allergy Health Online

Cincinnati Childrens Hospital Research Unit (need to search on this condition) Also Eosinophil FAQ

Health Professional Links

Pediatrics 2002 article

Allergy 2004 article

World Allergy Organisation

Cochrane Review of Medical Therapies 2004

Gut 2003 Review

Journal of Allergy and Clinical Immunology and Allergy (search for articles on "eosinophilic esophagitis"

eMedicine review

Clinics in Gastroenterology and Hepatology 2004

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