Definition of Eosinophilic esophagitis
In eosinophilic esophagitis (e-o-sin-o-FILL-ik uh-sof-uh-JIE-tis), a type of white blood cell (eosinophil) builds up in the lining of the tube that connects your mouth to your stomach (esophagus). This buildup, which is a reaction to foods, allergens or acid reflux, can inflame or injure the esophageal tissue. Damaged esophageal tissue can lead to difficulty swallowing or cause food to get caught when you swallow.
Eosinophilic esophagitis is a chronic immune system disease. It has been identified only in the past two decades, but is now considered a major cause of digestive system (gastrointestinal) illness. Research is ongoing and will likely lead to revisions in its diagnosis and treatment.
Symptoms of Eosinophilic esophagitis
Signs and symptoms include:
- Difficulty swallowing (dysphagia)
- Food impaction
- Chest pain that is often centrally located and does not respond to antacids
- Persistent heartburn
- Upper abdominal pain
- No response to gastroesophageal reflux disease (GERD) medication
- Backflow of undigested food (regurgitation)
- Difficulty feeding
- Abdominal pain
- Difficulty swallowing (dysphagia)
- Food impaction
- No response to GERD medication
- Failure to thrive (poor growth, malnutrition and weight loss)
When to see a doctor
Seek immediate medical attention if you experience chest pain, especially if you have other signs and symptoms, such as shortness of breath or jaw or arm pain. These may be signs and symptoms of a heart attack.
Make an appointment with your doctor if you experience severe or frequent eosinophilic esophagitis symptoms. If you take over-the-counter medications for heartburn more than twice a week, see your doctor.
Previously, doctors thought eosinophilic esophagitis symptoms were caused by gastroesophageal reflux disease (GERD), but they now recognize it as a distinct condition with very different causes. Eosinophilic esophagitis is an allergic reaction in which the lining of your esophagus reacts to allergens, such as food or pollen.
Eosinophils are a normal type of white blood cells present in your digestive tract, but in eosinophilic esophagitis they multiply in your esophagus. The eosinophils produce a protein that causes inflammation, which can lead to scarring, narrowing and formation of excessive fibrous tissue in the lining of your esophagus. As a result, you may have difficulty swallowing (dysphagia) or have food become stuck when you swallow (impaction), as well as other symptoms.
People with eosinophilic esophagitis may also have food allergies, environmental allergies, asthma, atopic dermatitis or chronic respiratory disease. Doctors also think some people are genetically more likely than others to develop eosinophilic esophagitis.
There has been a significant increase in numbers of people diagnosed with eosinophilic esophagitis in the past decade. At first researchers thought this was due to the increase in awareness among doctors and greater availability of upper endoscopy. However, studies now suggest that the disease is becoming increasingly common, parallel to the increase in asthma and allergy.
Conditions that can increase your risk of eosinophilic esophagitis include:
- 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, you have a greater chance of being diagnosed.
- Allergies and asthma. If you have food or other allergies, or asthma, you are 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.
Complications of Eosinophilic esophagitis
In some people, eosinophilic esophagitis can lead to the following:
- Scarring and narrowing of the esophagus. This makes it difficult to swallow and more likely that you will have food get stuck.
- Damage to the esophagus. Because of inflammation of the esophagus, endoscopy can cause perforation or tears in the esophageal lining tissue. Sometimes tearing happens spontaneously.
Preparing for your appointment
If you think you have eosinophilic esophagitis, you’re likely to start by seeing your family doctor or a general practitioner. Your doctor may recommend you see a specialist in treating digestive diseases (gastroenterologist) or an allergist.
Because appointments can be brief, and because there’s often a lot of ground to cover, it’s a good idea to be well-prepared. Here’s some information to help you get ready, and what to expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet.
- Bring test results. If you are seeing a new specialist after you’ve had an endoscopy from another doctor, bring the results with you.
- Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, vitamins or supplements that you’re taking.
- Consider taking a family member or friend along. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For eosinophilic esophagitis, some basic questions to ask your doctor include:
- What is likely causing my symptoms?
- What kinds of tests do I need?
- Do I need an endoscopy?
- Is my condition likely temporary or chronic?
- What is the best course of action?
- What are the alternatives to the primary approach that you’re suggesting?
- I have other health conditions. How can I best manage them together?
- Are there any restrictions I need to follow?
- Should I see a specialist? What will it cost?
- Is there a generic alternative to the medicine you’re prescribing for me?
- Are there brochures or other printed material I can take with me? What websites do you recommend?
- Should I schedule a follow-up visit?
In addition to the questions you’ve prepared, don’t hesitate to ask questions during your appointment.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may allow more time later to cover points you want to address.
- What are your symptoms?
- When did you first notice them?
- Have they been continuous or occasional?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
- Do your symptoms wake you up at night?
- Are your symptoms worse after meals or after lying down?
- Do you have difficulty swallowing?
- Have you ever had food get stuck while you are swallowing?
- Does food or sour material ever come up in the back of your throat?
- Do you have chest pain or stomach pain?
- Have you had an esophageal dilation?
- Have you been treated with a topical steroid or food elimination diet?
- Have you gained or lost weight?
- Do you experience nausea or vomiting?
- Are your symptoms worse at certain times of the year?
- Do you have asthma or any chronic respiratory disease?
- Do you have any allergies to foods or to anything in the environment, such as pollen?
- Does anyone in your family have allergies?
- Have you tried taking antacid or anti-reflux medication? What was the result?
If you are a parent of a young child, the doctor may also ask if your child has trouble feeding or has been diagnosed with failure to thrive.
Tests and diagnosis
Your doctor will consider both your symptoms and test results to diagnose eosinophilic esophagitis. This will include determining whether you have:
- Gastroesophageal reflux disease (GERD), in which eosinophils usually are not present
- Proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE), in which eosinophils are present, but symptoms improve with proton pump inhibitor (PPI) medication
Tests to diagnose eosinophilic esophagitis include:
- Upper endoscopy. Your doctor will use a long narrow tube (endoscope) containing a light and tiny camera and insert it through your mouth down the esophagus. He or she will inspect the lining of your esophagus for inflammation and swelling, horizontal rings, vertical furrows, narrowing (strictures) and white spots. Some people with eosinophilic esophagitis will have an esophagus that looks normal.
- Biopsy. Your doctor will perform a biopsy of your esophagus, likely taking two to four samples of cells from two locations.
If doctors suspect eosinophilic esophagitis, you may be given some additional tests to confirm the diagnosis and to begin to look for the sources of your allergic reaction (allergens).
- Blood tests. You may be given a blood test to look for higher than normal eosinophil counts or total immunoglobulin E (IgE) levels, suggesting allergy.
- Medication trials. You may be given anti-reflux medication, specifically proton pump inhibitors (PPIs), to see if your symptoms improve. After 8 weeks, you will have a repeat endoscopy to see how healing has progressed.
- Dietary treatment trials. Your doctor may have you participate in a food elimination diet. This will include taking biopsies from your esophagus to learn how the disease responds to these dietary changes.
- Food-patch test. In this test, food is placed in a small container, which is then taped on your back, touching your skin. The doctor looks for inflammation on that spot.
Treatments and drugs
Eosinophilic esophagitis is considered a chronic relapsing disease, meaning that most people will require ongoing treatment to control their symptoms. Treatment will involve one or more of the following:
Depending on your response to tests for food allergies, your doctor may recommend that you stop eating certain foods, such as dairy or wheat products, to relieve your symptoms and reduce inflammation. A more limited diet is sometimes required. Your doctor may refer you to an allergist for specific recommendations.
Your doctor will likely first prescribe an acid blocker such as a PPI. This treatment is the easiest to use, but most people’s symptoms don’t improve. If you do not respond to the PPI, your doctor will then likely prescribe a topical steroid, such as fluticasone or budesonide, which is taken orally to treat eosinophilic esophagitis.
This type of steroid is not absorbed into the bloodstream, so you are unlikely to have the typical side effects often associated with steroids. If a topical steroid is not effective or you need more immediate symptom relief, you may be prescribed prednisone.
Steroids may decrease the buildup of eosinophils in the esophagus, reduce the inflammation associated with an allergic reaction, and allow your esophagus to heal. Some people may need to take steroids on an ongoing basis.
If you experience severe narrowing (strictures) of your esophagus, your doctor may recommend dilation to help make swallowing easier. Dilation may be used if steroids are not helpful.
Because people with eosinophilic esophagitis can have bleeding or tearing of their esophagus, doctors have been concerned about the safety of dilation, especially of perforation during the procedure. Studies have found that dilation is safe and may provide symptom relief for some people — though it may initially be painful. However, it does not improve the underlying inflammation.
Lifestyle and home remedies
If you often have heartburn, these lifestyle changes may help reduce the frequency or severity of symptoms.
- Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus. If your weight is at a healthy level, work to maintain it. If you are overweight or obese, work to slowly lose weight — no more than 1 or 2 pounds (0.5 to 1 kilogram) a week. Ask your doctor for help in devising a weight-loss strategy that will work for you.
- Avoid foods and drinks that trigger heartburn. Common triggers, such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine, may make heartburn worse. Avoid foods you know will trigger your heartburn.
- Elevate the head of your bed. If you regularly experience heartburn at night or while trying to sleep, put gravity to work for you. Place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches. If it’s not possible to elevate your bed, insert a wedge between your mattress and box spring to elevate your body from the waist up.
No alternative medicine therapies have been proved to treat eosinophilic esophagitis. Still, some complementary and alternative therapies may provide some relief from heartburn or reflux symptoms when combined with your doctor’s care. Talk to your doctor about what alternative treatments may be safe for you. Options may include:
- Herbal remedies. Herbal remedies sometimes used for heartburn or reflux symptoms include licorice, slippery elm, chamomile, marshmallow and others. Herbal remedies can have serious side effects, and they may interfere with medications. Ask your doctor about a safe dosage before beginning any herbal remedy.
- Relaxation therapies. Techniques to calm stress and anxiety may reduce signs and symptoms of heartburn or reflux. Ask your doctor about relaxation techniques, such as progressive muscle relaxation or guided imagery.
- Acupuncture. Acupuncture involves inserting thin needles into specific points on your body. Limited evidence suggests it may help people with regurgitation and heartburn, but major studies have not proved a benefit. Ask your doctor whether acupuncture is safe for you.