Eosinophilic Esophagitis (EOE) is a chronic allergic inflammatory disease that affects the esophagus. This condition is driven by an immune response that causes inflammation, leading to symptoms that significantly impact a child’s quality of life and feeding. Parents often hope their child will naturally outgrow the condition over time.
Defining Eosinophilic Esophagitis and Its Cause
EOE is characterized by the accumulation of eosinophils, a specific type of white blood cell, within the lining of the esophagus. Normally absent from this tissue, eosinophils infiltrate the area in response to triggers, causing chronic inflammation. This inflammation can lead to physical changes, such as rings, furrows, or a narrowed esophagus, resulting in difficulty swallowing (dysphagia) or food impaction.
The underlying mechanism is an immune reaction, typically hypersensitivity to food proteins or, less commonly, environmental allergens. EOE is strongly associated with other allergic diseases; 50% to 80% of patients also have conditions like asthma, eczema, or allergic rhinitis. Symptoms vary by age: younger children may experience feeding difficulties, vomiting, or poor weight gain, while older children often report heartburn and abdominal pain.
Prospects for Long-Term Remission
Eosinophilic Esophagitis is a chronic disease requiring ongoing management. The rate of spontaneous remission, where the disease resolves permanently without treatment, is rarely fulfilled, occurring in less than 1% of pediatric patients.
Since a cure is unlikely, the focus is on achieving clinical remission, where symptoms are controlled through consistent treatment. This management stops the inflammatory process, allowing the esophagus to heal and leading to a long-lasting, symptom-free state.
The goal of therapy is to achieve histologic remission, confirmed through biopsy, in addition to eliminating symptoms. Sustained, treatment-induced remission is achievable for the majority of children and prevents the long-term complication of esophageal narrowing. This consistent control allows for a normal quality of life and is the practical equivalent of “outgrowing” the disease.
Key Pillars of EOE Management
Management protocols for EOE suppress inflammation using dietary therapy, pharmacological therapy, or a combination. Dietary therapy eliminates specific food allergens triggering the immune response. The most common approach is the empiric six-food elimination diet, which removes the top allergens:
- Milk
- Wheat
- Egg
- Soy
- Nuts
- Seafood
Milk and wheat are the most frequent culprits among these allergens.
The elemental diet is the most restrictive, replacing all intact proteins with a specialized, amino acid-based formula. This highly effective option is used when elimination diets fail or when multiple food triggers are suspected, as it eliminates all food-based antigens. The effectiveness of dietary elimination is monitored by repeat endoscopy and biopsy to confirm the inflammation has resolved.
Pharmacological management primarily involves swallowed topical steroids, such as fluticasone or budesonide, which reduce inflammation directly in the esophageal lining. Proton Pump Inhibitors (PPIs) are also frequently used, resolving inflammation in a significant subset of patients. If severe narrowing or strictures develop, endoscopic dilation may be performed to stretch the esophagus and allow food to pass more easily.
Monitoring and Ongoing Care
Continuous monitoring is necessary because a child’s symptoms do not always correlate with the level of inflammation present in the esophagus. A patient may feel perfectly well while the disease remains active, potentially leading to progressive tissue damage and fibrosis. Therefore, follow-up endoscopies with biopsies remain the standard of care for tracking the disease and confirming treatment success.
These repeat procedures allow physicians to check for histologic remission, defined as a count of fewer than 15 eosinophils per high-power field, which is the benchmark for successful treatment. Newer, less invasive monitoring techniques, such as transnasal endoscopy or the esophageal string test, are being developed to reduce the need for traditional sedated procedures. The long-term goal of this consistent monitoring is to maintain a state of remission, which prevents the development of irreversible complications like esophageal strictures.