Esophageal eosinophilia, commonly known as Eosinophilic Esophagitis (EoE), is a chronic inflammatory condition affecting the esophagus, the muscular tube that transports food from the mouth to the stomach. This disease involves an abnormal accumulation of specific white blood cells within the esophageal lining. EoE has gained increasing recognition as a significant cause of gastrointestinal issues in both children and adults.
Understanding Esophageal Eosinophilia
Eosinophils are white blood cells involved in the immune system, particularly in allergic reactions. Normally, these cells are not found in esophageal tissue. In individuals with EoE, eosinophils gather in large numbers in the esophagus, releasing chemicals that cause inflammation and tissue damage.
This eosinophil-predominant inflammation is an immune-mediated response, often resembling an allergic reaction. The inflammation can lead to scarring and narrowing within the esophagus. This structural damage impairs the esophagus’s ability to function properly, making swallowing difficult.
Recognizing the Signs and Causes
The symptoms of esophageal eosinophilia vary depending on a person’s age. Infants and young children may experience feeding difficulties, frequent vomiting, abdominal pain, and poor growth or weight gain.
Older children and adults often present with difficulty swallowing solid foods, known as dysphagia. Food impaction, where food gets stuck in the esophagus, is another frequent symptom. Heartburn and chest pain can also occur.
EoE is primarily considered an allergic condition, with food allergens being common triggers. Foods such as milk, wheat, soy, and eggs are frequently implicated, with milk and wheat being the most consistently identified major food triggers. Environmental allergens, like pollen and dust mites, can also contribute to the condition.
Genetic predisposition plays a role in the development of EoE. The condition tends to run in families, and specific genes have been identified that may increase an individual’s susceptibility. People with other allergic conditions, such as asthma, allergic rhinitis (hay fever), or atopic dermatitis (eczema), also have a higher likelihood of developing EoE.
Diagnosis and Management Approaches
Diagnosing esophageal eosinophilia requires a thorough evaluation, as symptoms can overlap with other conditions. The definitive diagnosis relies on an upper endoscopy with biopsies of the esophageal tissue. During this procedure, a thin, flexible tube with a camera is inserted into the esophagus to visually inspect for signs of inflammation, rings, furrows, or white spots.
Regardless of the visual appearance of the esophagus, multiple tissue samples are taken from different areas of the esophagus. These biopsies are then examined under a microscope to count the number of eosinophils present. A count of 15 or more eosinophils per high-power microscopic field is strongly suggestive of EoE. It is also important to rule out other causes of esophageal eosinophilia, such as GERD, often by observing the patient’s response to an eight-week trial of high-dose proton pump inhibitors (PPIs).
Management of EoE involves two primary strategies: dietary therapy and medical therapy. Dietary therapy focuses on identifying and eliminating trigger foods. The 6-food elimination diet, which removes milk, wheat, egg, soy, nuts, and fish/shellfish, is a common approach. After a period of elimination, foods are reintroduced one by one, with repeat endoscopies and biopsies to identify specific triggers.
Another dietary option is an elemental diet, which involves consuming only amino acid-based formulas, completely removing all intact proteins that could cause an allergic reaction. This approach is highly effective, achieving remission in a high percentage of patients, but its restrictive nature and taste can make adherence challenging.
Medical therapy typically involves swallowed topical corticosteroids, such as fluticasone or budesonide. These medications are designed to reduce inflammation directly in the esophagus. Fluticasone is often administered via an inhaler, where the medication is swallowed instead of inhaled, while budesonide can be mixed into a slurry or given as an oral dissolvable tablet. PPIs may also be used, particularly in cases where there is a partial response or to rule out PPI-responsive esophageal eosinophilia.
Living with Esophageal Eosinophilia and Long-Term Outlook
Esophageal eosinophilia is a chronic condition that often requires ongoing management. Regular monitoring is important to assess disease activity and prevent complications. The long-term inflammation can lead to structural changes in the esophagus, such as strictures or narrowing, which can further impede swallowing.
When esophageal strictures develop, endoscopic dilation procedures may be necessary to widen the narrowed areas. This involves using balloons or dilators passed through an endoscope to gently stretch the esophagus. While dilation can alleviate swallowing difficulties, it does not address the underlying inflammation, so continued dietary or medical therapy is usually needed.
Adherence to prescribed dietary restrictions and medical therapies is important for maintaining remission and preventing disease progression. Patients with EoE often benefit from a multidisciplinary care team, which may include gastroenterologists, allergists, and registered dietitians. This collaborative approach helps ensure comprehensive management and support.
While EoE is a chronic condition, proper management generally leads to a good prognosis and improved quality of life. The disease is not currently thought to limit life expectancy or increase the risk of esophageal cancer. Continued research is focused on better understanding the disease and developing more targeted and convenient treatments.