The Association of Allergists and Immunologists of QuébecEosinophilic esophagitis
What is eosinophilic esophagitis?
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition that affects the esophagus, the part of the digestive system that connects your mouth to your stomach. It is an increasingly prevalent disease and can affect people of all ages, both children and adults. This inflammation is associated with the presence of eosinophils lining the esophagus. Eosinophils are a type of white blood cell that increases with allergic responses and causes inflammation.
Who are those most likely to suffer from eosinophilic esophagitis?
EoE can present at any age, however, young adolescent males and men in their 20-30s are more likely to be affected. Many patients have additional allergic diseases including asthma, allergic rhinoconjunctivitis (seasonal allergies), eczema and food allergies. Moreover, there is often a member of the family who also has eosinophilic esophagitis or other allergic diseases.
What are the symptoms of eosinophilic esophagitis?
Symptoms vary among children and adults. Children may present with feeding difficulties, abdominal pain, vomiting, a burning sensation in the stomach and insufficient weight gain whereas adults typically present with difficulty swallowing (dysphagia) and/or food obstruction. However, any of these symptoms can present at any age.
Those with EoE also often change their eating habits to reduce their symptoms, such as drinking large volumes of liquids during meals, cutting their food into small pieces and avoiding certain textures like meat that can be difficult to chew.
If EoE is left untreated, long-term uncontrolled inflammation of the esophagus can lead to damage of the esophagus such as hardening (fibrosis). This can cause narrowing of the esophagus leading to difficulty swallowing, food getting stuck (food impactions) and in rare cases, perforation of the esophagus.
What are the possible triggers of eosinophilic esophagitis?
In most patients, certain foods are identified as possible triggers. The most common food triggers include milk, wheat, egg, soy, peanuts, tree nuts, fish and shellfish. Studies have shown that milk, followed by wheat, are the two most common food triggers. Other studies also suggest that allergens in the environment (such as tree and grass pollen) may also play an important role in the development of EoE and increased inflammation of the esophagus.
It is important to note that these food triggers are different from immediate food allergies. Food allergies can affect different organs such as the skin and airways, whereas EoE is limited to the esophagus. In severe cases, food allergies can lead to immediate life-threatening reactions like anaphylaxis, whereas EoE does not. Epinephrine intramuscular injections are not used in the treatment of EoE.
How is eosinophilic esophagitis diagnosed?
In someone who presents with typical symptoms of the disease (difficulty swallowing, food obstruction, heartburn, abdominal pain, etc), the diagnosis is made by examining the number of eosinophils on a biopsy of tissue taken from the esophagus. This biopsy is taken during an endoscopy performed by a gastroenterologist, which involves placing a small camera in the esophagus to obtain small samples of tissue. An elevated number of eosinophils in the esophageal biopsy (>15 eosinophils/HPF) confirms the diagnosis of EoE in someone with compatible symptoms.
What is the treatment of eosinophilic esophagitis?
There are three first-line treatment options currently available to treat EoE by reducing inflammation in the esophagus.
- Proton-pump inhibitors (PPI)
- Examples include pantoprazole and dexlansoprazole. They are also used to treat heartburn/reflux.
- Topical corticosteroids
- There are three forms available for the treatment of EoE:
- Budesonide orodispersable tablet is designed to treat EoE by coating the esophagus.
- Budesonide slurry requires mixing the liquid in the nebule with either honey or apple sauce.
- Fluticasone swallow, which is an inhaler used to treat asthma. It is swallowed instead in EoE to coat the esophagus.
- These forms all stay in the esophagus with no significant absorption in the blood known to date. They are effective and generally safe treatments.
- There are three forms available for the treatment of EoE:
- Food elimination diets
- Sometimes, specific foods that trigger the disease may be identified. However, unfortunately, food allergy skin testing is not reliable to identify responsible food triggers in EoE, therefore we do not proceed with food skin testing in EoE.
- Cow’s milk is likely the most common food trigger. Some patients may choose to try a milk elimination diet, which consists of eliminating all animal milk products including cow’s milk, cheese, butter, yogurt and ice cream.
- All forms of diets must be undertaken under supervision, so as not to cause nutritional deficiencies.
If the esophageal inflammation is not well controlled despite these treatments, a biologic medication that targets the allergic pathway of the immune system can be considered. Dupilumab is currently the only approved biologic for the treatment of EoE. It is approved in adults and children as of 1 year of age in Canada. It is given as an injection under the skin.
If the esophagus is very narrow, balloon dilatations which are performed by a gastroenterologist during the endoscopy may be required.
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Ariana Mustillo, MD
Natacha Tardio, MD, FRCPC
mis-à-jour 10/2024