Eosinophilic esophagitis or “EE,” and also known as “EoE”, is an allergic reaction that causes inflammation and damage to the esophagus, the muscular tube that connects mouth to stomach. EoE is characterized by inflammation and accumulation of a specific type of immune cell, called an eosinophil, in the esophagus.
Eosinophils are a special type of white blood cell. Eosinophils help us fight off certain types of infections, such as parasites or hookworms. However, eosinophils also are involved in other conditions, including allergies, cancer and other problems. The eosinophil is a cell that serves many roles. Some roles are specific and some not specific, which means that there are a number of different processes in the body that can cause eosinophils to be present. An eosinophilic disorder may be present when eosinophils are found in high numbers in the blood or part of the body for a long period of time without a known cause. Generally, this means more than 6 months.
Eosinophilic disorders can occur in different areas of the gastrointestinal (GI) tract. For instance, eosinophilic esophagitis (EoE) means abnormal numbers of eosinophils in the esophagus. Eosinophils are not normally present in the esophagus. Eosinophils are normally found in small numbers in other areas of the GI tract.
The exact prevalence in adults is uncertain, but it is estimated to affect 1 per 10,000 children and approximately 1 per cent of adults in the US.
Causes
Eosinophilic esophagitis is caused by the presence of a large number of eosinophils in the esophagus. The production and accumulation of eosinophils may be caused by many factors such as particular foods or environmental irritants in some affected individuals. Some individuals with this condition have been found to have an unusually high expression of a particular gene called eotaxin-3 and an abnormal eotaxin-3 gene. This gene codes for a protein that is important in controlling the accumulation of eosinophils. Eosinophilic esophagitis can run in families but the mode of genetic transmission has not yet been determined.
Foods reported to be the cause of EE have included milk, eggs, peanuts, shellfish, peas, beef, chicken, fish, rye, corn, soy, potatoes, oats, tomatoes and wheat. Of these, the most common food triggers are milk, egg, wheat, rye and beef.
Environmental allergens, such as pollens, molds, cat, dog and dust mite allergens may also be involved in the development of EE.
Risk Factors
Climate – Living in a cold or dry climate.
Season – May be more likely diagnosed between the spring and fall, probably because levels of pollen and other allergens are higher and people are more prone to be outdoors.
Sex – More common in males than in females.
Family history – If family members have eosinophilic esophagitis, there may be a greater chance of being diagnosed.
Allergies and asthma – If a person has food or other allergies, or asthma, he or she isare more likely to be diagnosed.
Age – Originally thought to be a childhood disease, but now is known to be common in adults as well. However, the symptoms differ somewhat.
Symptoms
Symptoms vary from one person to the next. The symptoms may differ depending on age. Symptoms in young children may include problems with eating, vomiting and poor weight gain. Older children and adults may experience reflux, chest pain and difficulty swallowing. The symptoms can occur days or even weeks after eating a food allergen. However, symptoms may wax and wane, meaning they are not always present. This can be confusing. Common symptoms include =
- Reflux that does not respond to usual therapy (this includes proton pump inhibitors, a medicine which stops acid production in the stomach)
- Difficulty swallowing (dysphagia)
- Food impactions (food gets stuck in the throat)
- Nausea and vomiting
- Failure to thrive (poor growth or weight loss)
- Abdominal or chest pain
- Poor appetite
- Malnutrition
- Difficulty sleeping
Complications
Complications associated with EE include –
- Choking
- Food impaction (getting food stuck in the throat) that requires a trip to the emergency room
- Eating disorders can develop if eating is painful
- Scarring and narrowing of the esophagus that may require surgery to fix
- Feeding aversion may develop in toddlers, so that even if their EE is being managed, they may still not want to eat because they associate eating with feeling uncomfortable
Treatment
Medication – Medication to reduce acid production will reduce acid reflux and the scarring that can result. Topical asthma steroid puffers 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 disease. Montelukast (Singulair) is an asthma tablet that reduces inflammation by blocking the effects of inflammatory chemicals known as leukotrienes released by white cells. Other medicines are also being studied.
Steroids are the most commonly used medication for both the control of the inflammation and the direct suppression of the eosinophils. These medications can be taken orally (in pill form) or topically. Steroids may need to be taken long term, though their long-term use for eosinophilic esophagitis has not been well studied. What is known is that for some patients, continued swallowed use of steroids can result in Candida infections (yeast infections of the mouth and esophagus) as a side effect.
Dilation – Sometimes if the oesophagus is very narrow, an endoscopy and a procedure known as dilation may be required to open up the oesophagus to allow food to pass more easily.
Diet manipulation – Dietary manipulation should be undertaken under the direction of a medical specialist and supervision of a specialist dietitian. Dietary manipulation may assist both adults and children. 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 symptom recurring.
Reference –
http://www.orpha.net/consor/cgi-bin/OC_Exp.php?Lng=GB&Expert=73247
https://www.niaid.nih.gov/topics/foodallergy/understanding/Pages/eoe.aspx
http://allergies.about.com/od/foodallergies/a/ee.htm
https://my.clevelandclinic.org/health/diseases_conditions/hic_eosinophilic_esophagitis
http://www.webmd.com/a-to-z-guides/eosinophilic-esophagitis
http://www.cincinnatichildrens.org/health/e/eosinophilic-esophagitis-ee/
http://umm.edu/programs/childrens/services/pulmonology-and-allergy/eosinophilic-esophagitis
http://emedicine.medscape.com/article/1610470-overview