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What is eosinophilic esophagitis (EoE)?
Eosinophilic esophagitis (EoE) is an increasingly common allergic disorder of the esophagus (the tube that moves food from the mouth to the stomach). EoE affects approximately 1 in 2,000 people, and there are now 10 times more people with this disease today than 20 years ago.
This disorder often acts like acid reflux, but these two conditions are quite different. In acid reflux, the esophagus is injured by acid, but in EoE, the esophagus is injured by food. Repetitive exposure to food allergens triggers the immune system in the esophagus to mount an inflammatory response that leads to thickening of the esophagus, changing the way food travels from the mouth to the stomach. Just as eczema and asthma are allergic conditions of the skin and lungs, EoE is an allergic condition of the esophagus. We often think of EoE as “eczema of the esophagus”.
Children with EoE can present with a variety of symptoms including poor or picky eating, abdominal pain, chest pain, vomiting, and trouble swallowing, among others. Difficulty swallowing, or “dysphagia,” is the most common symptom associated with EoE and often causes patients to limit the foods they eat, particularly the foods most difficult to swallow, such as bread, rice, or meat. Some children and young adults may even present with food stuck in their esophagus, requiring an upper endoscopy to remove it.
How is EoE diagnosed?
After the physician completes a thorough history and physical examination, an upper endoscopy is necessary to confirm the diagnosis. Learn more by watching this video. An upper endoscopy is the most reliable test to diagnose EoE. While the patient is asleep, the doctor will use a camera that looks like the tubing of a stethoscope and is about the size of a pinky finger to take tiny biopsies from the lining of the esophagus, stomach, and small intestine. These samples are then examined under a microscope to look for inflammation and the presence of eosinophils.
An eosinophil is a type of white blood cell that is an important part of the immune system. Eosinophils are allergic white blood cells that are typically found in small quantities in the blood and intestine but not normally in the lining of the esophagus. Children with acid reflux may have a few eosinophils in their esophageal biopsies. In EoE, however, large numbers of eosinophils are found in the lining of the esophagus. If more than 15 eosinophils per microscopic field are found in these esophageal biopsies, a diagnosis of EoE is confirmed.
How is EoE treated?
There are a variety of methods used to treat EoE, including:
- Dietary therapy
- Medical therapy
- Endoscopic dilation
Dietary therapy
The six most common food triggers for EoE include milk, soy, egg, wheat, nuts, and seafood. Typically, there are only one or two foods that cause a patient’s EoE.
Dietary therapy is effective approximately 40-90% of the time depending on how many foods are eliminated from a child’s diet. The goal of dietary therapy is to identify and eliminate the specific foods that are driving the inflammation, ultimately allowing the child to have the least restrictive diet possible. However, finding out which foods are causing a child’s EoE remains one of the biggest challenges in EoE as currently available allergy testing cannot reliably determine the right diet for a patient with EoE. We must rely on sequential food exposures followed by repeat testing to know which foods are causing a patient’s EoE.
Given the difficulty of eliminating multiple foods from one’s diet, and knowing that cow’s milk is the most common trigger for EoE, a dairy elimination diet is often recommended first and can be effective up to 50% of the time. But as one can imagine, dietary changes can be difficult for a variety of reasons, including their potential impact on a child’s quality of life, avoidance of nutritional deficiencies, avoidance of cross-contamination, and ensuring that a child adheres to the diet, among others. These challenges are the very reason that patients and their families often benefit from having a dietician and, occasionally, a psychologist as part of their treatment team.
Medical therapy
For various reasons, dietary therapy may not be the optimal approach for all children. In these instances, an alternative treatment option is medical therapy. These medicines can be categorized as (a) acid suppressant therapy, (b) topical steroid therapy, and (c) biologic therapy. Acid suppressant therapy includes medications called proton pump inhibitors that not only reduce acid production but also have anti-inflammatory qualities. Studies have demonstrated that proton pump inhibitor therapy can be effective up to 50% of the time.
Topical steroid therapy involves treating EoE with swallowed anti-inflammatory medications, such as budesonide or fluticasone, to control inflammation. While these medications are considered steroids, they are administered topically and do not have the same side effects as traditional steroids. The purpose of these topical steroids is to coat the esophagus with medication that reduces swelling. Studies have shown that topical corticosteroid therapy can induce remission in up to 80% of patients.
Finally, the FDA has approved a biologic therapy called dupilumab (Dupixent®) for patients older than 1 year and weighing more than 15 kg with EoE. This medication is given as an injection and has been shown to be effective in up to 80% of patients with EoE. More information about Dupixent® can be found on their website.
Regardless of which medication is used for EoE, the ultimate goal is to find the lowest possible dose and frequency that maintains remission.
Dilation therapy
This is a procedure used rarely when the esophagus is too tight (develops a “stricture”) and needs to be stretched. Strictures are more common in adults with long-standing, untreated EoE. But the good news is that long-term and consistent treatment of EoE can effectively prevent the formation of strictures and any future need for dilations.
What can I expect in the future?
The course of this disease is very similar to other allergic diseases like eczema or asthma. Current evidence suggests that most patients do not outgrow this disease or gain tolerance to the foods causing their EoE. EoE is thought of as a relapsing and remitting disease whereby the inflammation will return if therapy is discontinued. It is a condition that may impact the child’s diet, require the use of long-term medication(s), and lead to more frequent doctor’s visits and procedures. Until non-invasive testing methods are readily available, most individuals with EoE will need to undergo follow-up endoscopies to determine if their treatment is working. The impact of this disease on a child’s daily life can vary widely, but most of the time, with dietary changes and/or the use of safe and effective medications, children lead a normal life and return to their usual activities.
Where can I get additional information on EoE?
The course of this disease is very similar to other allergic diseases like eczema or asthma. Current evidence suggests that most patients do
There are a variety of support networks and resources available for children and families impacted by this condition. Patient information and support groups include the following:
- The American Partnership for Eosinophilic Disorders
- The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
- The Food Allergy and Anaphylaxis Network
- View this video and this video for content created for kids on EoE and other eosinophilic disorders.
Together, our team of healthcare professionals will explain this condition and provide available support and resources.
One does not outgrow this disease or gain tolerance to the foods causing their EoE. EoE is thought of as a relapsing and remitting disease whereby the inflammation will return if therapy is discontinued. It is a condition that may impact the child’s diet, require the use of long-term medication(s), and lead to more frequent doctor’s visits and procedures. Until non-invasive testing methods are readily available, most individuals with EoE will need to undergo follow-up endoscopies to determine if their treatment is working. The impact of this disease on a child’s daily life can vary widely, but most of the time, with dietary changes and/or the use of safe and effective medications, children lead a normal life and return to their usual activities.
Discover more about irritable bowel syndrome (IBS) and dyspepsia in children. Call GI Care for Kids in the Greater Atlanta area at (404) 257-0799 or request your appointment now.