Eosinophilic Esophagitis (EoE)

Do you have trouble swallowing food? Does food sometimes get stuck in your throat? Do you have to drink a large amount of liquid just to get food down? A yes to any of these questions suggest you may have a chronic condition called eosinophilic esophagitis (EoE).

EoE affects about one in 2,000 people, according to the American College of Allergy, Asthma & Immunology (ACAAI). EoE can be triggered by a food allergy. Some people who think they have gastroesophageal reflux disease (GERD) may actually have EoE.

In addition, people with EoE often have other allergic conditions such as asthma and atopic dermatitis.

What is eosinophilic esophagitis?

EoE is a chronic condition. It occurs when an increased number of cells called eosinophils cause inflammation and swelling in the esophagus. This can make it difficult to swallow food.

What are symptoms of eosinophilic esophagitis?

Symptoms will depend on age.

In infants and young children, symptoms may include:

• refusal to eat
• abdominal pain
• reflux
• vomiting
• poor growth

In teenagers and adults, symptoms may include:

• difficulty swallowing
• reflux
• chest pain
• food getting slightly stuck in the throat

If you have any of these symptoms, you may have eosinophilic esophagitis.

People with EoE tend to cut their food into tiny pieces, over-chew food, or drink excessive amounts of liquid to get food down.

It’s important to note that if food does get stuck in the throat, this is a potential medical emergency and people should go to the hospital immediately.

What causes eosinophilic esophagitis?

Doctors and researchers are not sure what causes it. In some people, EoE is triggered by food or by environmental allergens such as pollen and mold.

Who develops eosinophilic esophagitis?

EoE occurs in both children and adults. It’s common to see it in more males than females. It’s prevalent in families that have a history of allergic disease.

How is EoE diagnosed?

A doctor will perform a biopsy. This involves inserting a small tube, or endoscope, through the mouth to examine the esophagus and stomach. The doctor then takes small tissue samples. There may be visible swelling, lacerations, ulcers or nodules in the esophagus.

Many people experience EoE symptoms for years and never see a doctor. They may come to think it’s normal to have food get slightly stuck in the throat or experience pain as they swallow.

How is EoE treated?

There are three ways to manage and treat eosinophilic esophagitis:

• diet therapy
• medication
• a combination of both

Diet therapy

Your diet can trigger or worsen EoE symptoms. Sometimes the food is obvious and you can avoid that food. Sometimes it is tough to pinpoint exactly which food or category of foods is causing symptoms.

Diagnostic tests such as skin tests, blood tests and patch tests to identify EoE trigger foods are no longer recommended. The results are difficult to interpret for EoE and do not always match symptoms.

Instead, diet therapies are recommended. There are two types of diet therapies.

• Elimination diet
• Elemental diet

Elimination diets are commonly used for EoE. Talk with your doctor about which therapy is best for you.

Elimination diet

A food elimination diet is just what it sounds like. You remove certain foods from your diet that may be causing symptoms. Once EoE is in remission, the foods are re-introduced one at a time to see if symptoms return. Repeat endoscopies are done at 6-12 weeks to look for signs of inflammation.

For older children and adults, an elimination diet may involve common food allergens: milk, peanut, tree nuts, eggs, wheat, soy and all seafood. For infants and young children, the diet may be limited to a non-allergenic, amino acid-based formula at first. Then other foods are slowly added to the diet. This is followed by observation for worsening EoE.

There are several types of food elimination diets.

• 6-Food Elimination Diet (6FED). This eliminates cow’s milk, wheat, egg, soy, peanuts/tree nuts, and all seafood. It has shown to achieve remission in 74% of patients.
• 4-Food Elimination Diet (4FED). This eliminates cow’s milk, wheat, egg, and soy. It has shown to achieve remission in 64% of patients.
• 1-Food Elimination Diet (1FED). It eliminates cow’s milk. Studies results vary, but remission is typically between 43-65% of patients.

Elimination diets should only be done under the guidance of a physician. Adhering to diet therapy is critical. It may be helpful to see a nutritionist or dietician to find replacement foods and ensure nutritional needs are met.

Elemental diet

In an elemental diet, people with EoE drink an amino acid formula and avoid protein. People often find it difficult to drink enough of the formula to get enough nutrition. They are evaluated after a week on the diet to see if they are drinking enough of the formula. If they are not getting enough, a nasogastric tube is given so the formula is delivered through the tube.

After 8-12 weeks on the formula, a repeat endoscopy with biopsy is done to look for disease remission. If the endoscopy shows remission, then foods are reintroduced one at a time or in small groups. People who use a nasogastric tube may transition to a gastronomy tube (g-tube). This allows for long-term nutritional supplements.

As new foods are introduced, repeat endoscopies and biopsies are done every 8-12 weeks. This process can take 9-12 months or even several years.

Elemental diets are very effective at achieving disease remission. Up to 95% of people who do elemental nutrition are able to achieve remission of EoE. But elemental diets can be challenging in terms of adherence.

An elemental diet is not a short-term process. It can take years to figure out the triggering foods and achieve remission. Plus, it can be difficult to drink the same formula all day, every day. Side effects of the elemental diet include abdominal cramps and constipation. It may also lead to the development of food allergies due to food avoidance.

In addition, elemental diets are expensive. Some states require insurance to cover the cost of the formula.

Medications

Since EoE is an inflammatory disease, the mainstay of therapy is to decrease inflammation in the esophageal tissue. Your doctor may prescribe:

Proton pump inhibitors (PPIs)

These reduce acid production in the stomach. They have been found to also reduce esophageal inflammation in some EoE patients. PPIs are often used as a first treatment for EoE. Some respond well to PPIs and see a decline in the number of eosinophils and inflammation. However, not all EoE patients respond to PPIs.

Corticosteroids

These medications help control inflammation. They can be given as an inhaled medication or as a liquid that is swallowed. As the esophageal tissue heals, the dosage can decrease.

Biologics

Dupilumab (brand name: Dupixent®) is currently the only FDA-approved treatment for EoE. Dupilumab works by blocking proteins called interleukin-4 and interleukin-13. This decreases eosinophils in the body. It can reduce inflammation or stop inflammation before it can start. The medication can also improve patients’ ability to swallow food.

Dupilumab is an injectable medication that is administered weekly. It’s prescribed to adults and children ages 12 and older weighing at least 88 pounds.

Patient Resources

• American Partnership for Eosinophilic Disorders (APFED)
• Campaign Urging Research for Eosinophilic Disorders (CURED)

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Reviewed by:

Jacqueline Eghrari-Sabet, MD, FACAAI, is board-certified in allergy, immunology and pediatrics. She serves as the Medical Director of Telehealth for Allergy & Asthma Network. Dr. Eghrari-Sabet is the founder of Family Allergy & Asthma Care and the FAAR Institute in the Washington, DC area, where she has been in private practice since 1994. Dr. Eghrari-Sabet is Assistant Clinical Professor at George Washington University School of Medicine and Health Sciences. She is also President of White Coat Resources, a health education consulting service.

Matthew Greenhawt, MD, FACAAI, is a board-certified pediatric allergist and immunologist. He serves as associate professor of pediatrics-allergy/immunology at the University of Colorado School of Medicine. He is also director of the Food Challenge and Research Unit at Children’s Hospital Colorado. Dr. Greenhawt went to medical school at Tufts University School of Medicine and earned a Masters of Science degree at University of Michigan.