Eosinophilic Oesophagitis

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Eosinophilic oesophagitis (EoE) results in an inflamed oesophagus, which is the muscular tube that connects the mouth to the stomach. Most cases are seen in people with other allergies such as allergic rhinitis (hay fever) and asthma. It is estimated to affect arround one in 2,000 people (children and adults) and the frequency of EoE appears to be increasing. The reasons are unclear, but it is known that allergies of all types have become more common.

What is EoE

Eosinophils are a type of white blood cell that cause allergic inflammation seen in allergic rhinitis and asthma.

In EoE the lining of the oesophagus is infiltrated with eosinophils. This can result in abnormal function of the oesophagus and symptoms summarised below.

Symptoms of EoE

The symptoms of EoE are different in children compared to adults, as shown in the table below.

CHILDREN

ADULTS

Slow eating.

Trouble swallowing.

Food sticking on the way down the oesophagus.

Food getting stuck on the way down the oesophagus.

Choking or gagging on food.

Regurgitation of foods.

Regurgitation of foods.

Severe acid reflux (heartburn) that does not respond to medications.

Abdominal (stomach) pain.

Chewing longer and drinking more water with solid food/s.

An estimated 30-50% of both children and adults will eventually have food impaction, which means that food becomes stuck in the oesophagus, does not go down and may have to be removed in hospital.

If left untreated, EoE can result in permanent scarring and narrowing of the oesophagus which makes it more likely that food will get stuck. It should be noted that mild reflux and vomiting are common in children and adults, and most do not have EoE.

How is Eosinophilic oesophagitis diagnosed?

If a diagnosis of EoE is suspected by the treating doctor, they will usually confirm this by looking at the oesophagus using an endoscope. A tissue sample (biopsy) will be taken at the same time and examined to look for eosinophils. Endoscopy and biopsy is normally performed by a gastroenterologist (stomach/bowel medical specialist). 

EoE may result from drug, food allergy or pollen inhalants

Around 75% of people with EoE have other allergic conditions such as allergic rhinitis or asthma. When allergy testing is performed, many people will have positive skin prick tests or patch tests to foods, even when there are no obvious symptoms after they are consumed. When food is involved, staples such as cow's milk (dairy products), wheat, meats, soy and egg seem to be the most common triggers. Some researchers have found that people benefit if these foods are removed from the diet. Other people with EoE have found that symptoms appear only during springtime when they are exposed to pollens.

Who treats EoE?

Most people with EoE are managed by gastroenterologists, and co-managed with clinical immunology/allergy specialists and specialist dietitians.

EoE Treatment options

Time
Symptoms in infants may resolve in the first few years of life, particularly when only one or two foods are involved. When symptoms arise in older children and adults, they usually last for many years. Current follow up studies indicate that symptoms do not seem to resolve in these groups.

Medication

  • Anti-acid medications that reduce acid production can reduce acid reflux, and tissue scarring. In many cases these also reduce inflammation.
  • Topical asthma steroid puffers or steroid liquid made up as a paste can reduce inflammation in the oesophagus. These are swallowed instead of inhaled, are low dose, poorly absorbed, and extremely unlikely to cause cortisone/steroid tablet like side effects. They help reduce inflammation and the scarring that can result from untreated EoE.
  • Montelukast is an asthma tablet that reduces inflammation by blocking the effects of inflammatory chemicals known as leukotrienes, that are released by white cells. Trials show that it may help reduce symptoms, but has little impact on inflammation.
  • Other medications are being studied.

Dilation

If the oesophagus is very narrow, an endoscopy and a procedure known as dilation may be required to open the oesophagus to allow the food to pass easier.

Diet manipulation

Dietary manipulation may assist both adults and children, but should be undertaken under the direction of a medical specialist, and supervised by a specialist dietitian. When undertaking dietary manipulation, the foods are removed for a period of time and then re-introduced one at a time to see which foods result in symptoms.

Types of dietary manipulation used include:

  • Common food allergen elimination diets. These usually include the removal of cow’s milk, soy, egg, wheat, peanuts, tree nuts, fish and shellfish. Allergy testing or patient history may result in the removal of additional foods.
  • Step-up diets. These are used instead of removing many foods at the same time. For example, one to two foods are removed at first, to see if symptoms improve, then repeating a biopsy if they do, but removing more foods at intervals if symptoms persist. This method is probably of greatest use when symptoms are regular, as improvement can be seen over a few weeks.
  • Directed diets. Foods are removed based on the history of trigger foods and allergy testing. The problem with this approach is that food allergy test results are negative in most people with EoE.
  • Amino acid based diets. These are based on amino acid formula and are impractical in adults and older children.

Endoscopies and repeat biopsies may be needed to monitor the response to treatment. It is important to note that:

  • Diagnosis of EoE should always be confirmed by endoscopy and biopsy.
  • Dietary manipulation should be temporary, initiated by a medical specialist and supervised by a specialist dietitian to avoid the risk of malnutrition.

EoE is a developing area of research

There are currently questions about the role of allergy and diet manipulation (and best approach when doing so), that need to be answered by research.

In some people symptoms may improve with diet manipulation, but the underlying inflammation can persist. It is unclear whether the aim should be to settle symptoms, and/or try to control the underlying inflammation completely.

People with Eoe who report symptoms that worsen during the pollen season may be triggered by swallowed pollen, and could benefit from pollen allergen immunotherapy to reduce the severity of pollen allergy.

© ASCIA 2019

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand.

ASCIA resources are based on published literature and expert review, however, they are not intended to replace medical advice. The content of ASCIA resources is not influenced by any commercial organisations.

For more information go to www.allergy.org.au

To donate to immunology/allergy research go to www.allergyimmunology.org.au

Updated May 2019

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