About Eosinophilic Esophagitis (EoE)
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 2000 people and there are 10 times as many people with this disease today than 20 years ago. In fact, the number of new diagnoses each year is now approaching that of Inflammatory Bowel Disease (including Crohn’s Disease and Ulcerative Colitis). 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 and/or environmental allergies. These allergens trigger the immune system to mount an inflammatory response in the esophagus that leads to swelling of the esophagus and ultimately results in a patient’s symptoms. Just as eczema and asthma can be allergic conditions of the skin and lungs, EoE is an allergic condition of the esophagus. In fact, we often think of EoE as “eczema of the esophagus” and treat it with medicines traditionally used for asthma. 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 those foods most difficult to swallow like breads, rice or meat. There are even some children and young adults who present with food stuck in their esophagus, requiring an upper endoscopy to remove this food.
How is EoE Diagnosed?
After your doctor completes a thorough history and physical examination, an upper endoscopy is necessary to confirm the diagnosis. Currently, endoscopy is considered the only reliable diagnostic test for EoE. While your child is asleep, your doctor will use a camera that looks like the tubing of a stethoscope to take tiny pinch biopsies from the lining of the esophagus, stomach and small intestine. These specimens 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 can be thought of as allergic 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. But, in EoE, there are larger numbers of eosinophils found in the lining of the esophagus. After excluding acid reflux, large numbers of esophageal eosinophils make a diagnosis of EoE.
How is EoE Treated?
There are a variety of methods used to treat EoE as currently there is no single accepted therapy. Treatment can be categorized as 1) dietary therapy or 2) topical steroid therapy.
Dietary therapy can be further classified as a) skin test-directed elimination dietary therapy, b) six food elimination diet (SFED) therapy, or c) elemental dietary therapy. For those patients who test positive for food allergies, exclusion of these foods (so called “skin test-directed elimination”) permits 50-70% of patients to have complete resolution of their symptoms and esophageal inflammation (referred to as “inducing remission”). In some patients without identifiable food allergies, another option may include the “six food elimination diet,” where the six most common foods associated with EoE (milk, soy, egg, wheat, nuts and seafood) are excluded. Similar to skin test-directed elimination therapy, the SFED also induces remission in 50-70% of children. Finally, in children with severe and unresponsive disease, a third dietary option is an elemental diet. With this diet, all sources of protein are eliminated and patients are supported with a broken-down (so called “elemental”) formula. Children on an elemental diet often require a feeding tube, but this therapy induces remission in nearly 100% of patients. In most cases, dietary therapy is coordinated with an Allergist to help determine the optimal approach. An Allergist may use skin testing (called “skin prick” and “atopy patch” testing) to best determine the foods that need to be eliminated from your child’s diet. Then, through a process of sequential food reintroductions, the goal is to find the specific food(s) that are driving the inflammation, ultimately allowing your child to have the least restrictive diet possible. As one can imagine, dietary changes can be difficult for a variety of reasons including knowing which foods to eliminate, avoiding nutritional deficiencies, ensuring small amounts of allergic foods are not hidden in other foods and making sure your child is sticking 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.
For a variety of reasons, dietary therapy may not be the optimal approach for all children. In these instances, an alternative treatment option includes topical steroid therapy, where patients are treated with swallowed anti-inflammatory medications (budesonide or fluticasone) to control the inflammation. While these medications are considered steroids, they are given topically and do not have the same frequency of side effects as traditional steroids. The purpose of these topical steroids is to coat the esophagus with a medication that reduces the swelling in the esophagus. Studies have shown that topical corticosteroid therapy can induce remission in 50-80% of patients. The goal is to find the lowest possible dose that continues to maintain remission. Until non-invasive testing methods are developed, most individuals with EoE will need to undergo follow-up endoscopies to determine if their treatment is working. The frequency of these endoscopies can be discussed with your physician.
What can I expect for the future?
The course of this disease is very similar to other allergic diseases like eczema or asthma. Current evidence suggests that patients do not outgrow this disease. EoE is thought of as a relapsing and remitting disease whereby the inflammation will likely return if therapy is discontinued. It is a condition that may affect your child’s diet, cause the need to take daily medication(s), and lead to more frequent doctor’s visits and procedures. There is certainly a wide range of how this disease will affect a child’s daily life, but most of the time, with the use of safe and effective medications and/or dietary changes, children ultimately live a normal life and return to their usual activities.
Where can I get additional information on EoE?
There are a variety of support networks and resources available for families affected by this condition. Patient information and support groups include The SEED Center of Atlanta, Inc (www.seedcenteratl.org), The American Partnership for Eosinophilic Disorders (www.apfed.org), the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (www.naspghan.org), the Food Allergy and Anaphylaxis Network (www.foodallergy.org), and GAeos.org (www.gaeos.org).
Together, your team of healthcare professionals will help you better understand this condition and connect you with the available support and resources that will help your child and family thrive.