Eosinophilic Esophagitis

Eosinophilic esophagitis (“EE”) is one of many types of esophagitis (inflammation of the esophagus). It is not as common as acid reflux esophagitis but has many of the same symptoms. In many cases, in fact, there is a combination of acid reflux and “EE”. EE is caused by an abnormal accumulation of eosinophils in the lining of the esophagus (swallowing tube). Eosinophils are a type of blood cell that can be seen in the esophagus lining, but usually very few are visible under the microscope. In EE these cells are present at an increased level. The reason for this increased accumulation is unknown. Often individuals with eosinophilic esophagitis have allergies or an allergic disorder (i.e. asthma, allergic rhinitis, urticaria, eczema etc., sometimes only as a child). Eosinophilic esophagitis is a rare condition. Of those adults affected with EE, the majority are men in their 20-30s. Children can also be affected..

Causes

Eosinophilic gastroenteritis may be due to allergies to an as yet unknown food allergen in many cases, people who have this kind of esophagitis are allergic to one or more foods. Some foods that may cause eosinophilic esophagitis include milk, eggs, wheat, soy, peanuts, beans, rye, and beef. However, conventional allergy testing does not reliably identify these culprit foods. People with eosinophilic esophagitis may have other nonfood allergies. For example, inhaled allergens, such as pollen, may be the cause in some cases.

Signs and Symptoms

Symptoms often include heartburn and more commonly difficulty in swallowing, or the feeling that food is getting caught or stuck in the esophagus. Chest pain that isn’t typically heartburn can occur. Children get nausea and may fail to grow normally but nausea is uncommon in adults.

Diagnostic Methods

The only way to diagnose eosinophilic esophagitis is by upper endoscopy with biopsies (tissue samples) of the esophagus. Upper endoscopy or EGD (esophagogastroduodenoscopy) is a procedure performed with intravenous (IV) sedation given to accomplish very good comfort levels, and then a small lighted tube is passed through your mouth into your esophagus, stomach and the first portion of your small intestine. The tube that is used as a camera within it and is connected to a computer. This test allows the doctor to see the lining of your esophagus, stomach and the first portion of your small intestine. Pictures can be taken and can be part of your medical record. Biopsies can be taken at the time of endoscopy. There is no pain associated with taking biopsies. Findings at the time of endoscopy can show a normal-appearing esophagus or an esophagus that appears to have many rings (somewhat like a spring). Biopsies show an increase in the number of eosinophils that are present.

Treatment

There are various forms of treatment for EE. They are as follows:

  • Acid blocker medication These are called PPI or proton pump inhibitor medications (like generics for Prilosec, Prevacid, Nexium, Aciphex, Protonix). Many patients with EE do have acid reflux, which can cause its own damage and blockage points, and likely the acid backwash weakens the resistance of the upper parts of the esophagus to the allergic inflammation.
  • Further treatment involves the use of a steroid inhaler of the medication budesonide (such as Fluticasone). This is usually done for 4-12 weeks and sometimes longer during a single course. The treatment can be repeated periodically as necessary. If recurrent use is needed, additional anti-allergy medications can be used. Sometimes, patients are referred to an allergist for additional testing or treatment, but allergy testing has a poor ability to find specific foods that are involved. Unlike inhaled steroids where a spacer is used to help get the medication into the lungs, you are to spray the medication without a spacer. This allows for the medication to be delivered to the back of your throat and swallowed. This brings the medication in direct contact with your esophagus.

To operate the inhaler:

  1. Shake the inhaler for 5 seconds.
  2. Position the inhaler with the index finger on the top of the medication canister and the thumb supporting the bottom of the inhaler. Position the mouthpiece between your teeth. Close your mouth around the mouthpiece. Press down on the top of the medication canister with your index finger to release the medication.
  3. The medication should be taken after meals. After taking the medication you should rinse your mouth with water and spit it out. You should avoid eating for 30 minutes after taking the medication to avoid washing the medication away.

Side effects of steroid inhalers can include the development of a yeast infection in the mouth (thrush), esophagus or respiratory tract. Other typical side effects of steroids can occur, but with a much-lessened incidence as compared to oral medication like Prednisone, because so little of the medication is absorbed.
If an individual just can’t manage an inhaler, a liquid suspension of medication can be made up, usually at greater cost and only by a compounding pharmacy.

Complications of EE

The most common complication is food becoming caught in the esophagus. This can lead to erosions (irritation) or ulcerations on the wall of the esophagus.

What kind of follow up will I need or when should I seek medical attention?

Routine follow-up is not required once we know that treatment is working well and you have clear guidance about how much of the time to be using the acid blocker (usually LONG TERM) and using the steroid inhaler (usually intermittently if symptoms relapse). However, if you continue to have problems despite following the recommendations, call your gastroenterologist. Go to the nearest emergency department if an obstruction causes an inability to swallow which won’t clear up within a couple of hours, or call 911 if this blockage interferes with breathing.