Eosinophilic Esophagitis: Symptoms and Causes

Jan 30, 2020

Modern medicine is a train that keeps rolling along, and this means that new discoveries are made every day and new understandings are around every corner. This can be good news for many people because it means that diseases that once had a dire prognosis are now curable or able to be successfully mitigated. Still, as amazing as modern medicine is, there are still new conditions that emerge and pose new challenges for doctors. One example of a recently identified disease that is still not very well understood is eosinophilic esophagitis.

What is eosinophilic esophagitis?

Besides being a difficult name to pronounce, eosinophilic esophagitis is a disease that was only first recognized as a distinct clinical problem in 1993. Also sometimes referred to as allergic oesophagitis, the condition is characterized by allergy-related inflammation of the epithelial lining of the esophagus. Eosinophilic esophagitis is still fairly rare, but incidences of diagnosis have been increased slightly in recent years as more doctors are becoming aware of it; it is estimated that it afflicts 1-4 people in 10,000.

At a basic level, the inflammation central to eosinophilic esophagitis is a reaction to an allergen; the current prevailing thought is that food allergies are the primary trigger. The difference between eosinophilic esophagitis and other types of inflammation is a type of white blood cell called eosinophil that is not typically found in the esophagus. In patients with eosinophilic esophagitis, large numbers of eosinophils are sent to the esophagus by the immune system and cause inflammation as a part of their regular immune response.

Although it is located in the esophagus and can have a significant impact on the digestive system, eosinophilic esophagitis is classified as an autoimmune disorder, a type of condition where the immune system inadvertently attacks the body itself. It is considered a chronic condition and is not “curable” in a conventional sense, but there are treatments that can encourage it to become inactive.

What are the symptoms of eosinophilic esophagitis?

The inflammation caused by the build-up of eosinophils in the esophagus is ultimately similar to other inflammatory immune responses elsewhere in the body; it is meant as a defense in order to remove foreign elements from the body. In eosinophilic esophagitis, however, this inflammation can have a number of side effects that are common symptoms of the condition in adults:

Dysphagia: the technical term for difficulty swallowing
Impaction: food stuck in the esophagus after swallowing
Regurgitation: backflow of undigested food
Persistent heartburn
Centrally-located chest pain that is non-responsive to antacids

Though eosinophilic esophagitis has now become just as common in adults, the disease was first diagnosed in children. The symptoms in children can present slightly differently:

Vomiting
Abdominal pain
Difficulty swallowing
Difficulty eating (or feeding, in infants)
Malnutrition and weight loss
Impaired growth

Before eosinophilic esophagitis was first identified, the symptoms were almost always assumed to be the same as those of gastroesophageal reflux disease (GERD). GERD is similar in that eosinophils are present in the esophagus as the result of an immune response, and the resulting symptoms are typically also similar. One of the notable differentiators of eosinophilic esophagitis is that one of the standard treatments for GERD (the prescription of proton pump inhibitors) are ineffective with eosinophilic esophagitis.

What causes eosinophilic esophagitis?

The main cause of eosinophilic esophagitis is simply the presence of an abnormally large quantity of eosinophils in the esophagus; as noted earlier, the eosinophils cause inflammation, and the inflammation leads to the various symptoms. But what causes the initial influx of eosinophils? This area of research is still actively being pursued, but there are several possibilities that might explain the immune response:

Food Allergens: Recent research has shown that food allergies may be one of the key factors in eosinophilic esophagitis, but it is difficult to diagnose because the allergic response is different when compared to other conditions; for example, many food allergies cause an immediate reaction (like hives), but in eosinophilic esophagitis, the reaction is delayed. It appears, however, that foods like eggs, dairy products, wheat, and soy may be the main culprits.

Aeroallergens: Aeroallergens are airborne substances that cause an allergic reaction. In patients with eosinophilic esophagitis, pollen, mold, dust mites, or animals may be the agents responsible for the immune response that leads to eosinophils gathering in the esophagus.

Genetics: Some recent research has found that a gene known as eotaxin-3 might make individuals genetically predisposed to getting eosinophilic esophagitis; the eotaxin-3 gene is responsible for a protein that controls the accumulation of eosinophils. There are also a number of other genes being studied, including those involved in the regulation of the esophageal barrier that would normally protect against excessive inflammation.

How does eosinophilic esophagitis cause dysphagia?

As discussed earlier, there are numerous symptoms involved in eosinophilic esophagitis, but dysphagia is often the most prevalent. Defined as having difficulty or discomfort when swallowing, dysphagia in eosinophilic esophagitis patients can be anywhere from mild to severe. The inflammation that is triggered because of the presence of too many eosinophils can stiffen the lining of the esophagus; when this happens, it is significantly more difficult for a food bolus (a mass of chewed, solid food) to proceed down the esophagus. The same stiffening can also cause impaction, a situation where food that cannot pass actually gets stuck in the esophagus.

Diagnosis of Eosinophilic Esophagitis

The similarity to GERD in terms of symptoms makes the diagnosis of eosinophilic esophagitis somewhat dependent on first ruling out GERD. In order to confirm eosinophilic esophagitis, though, the doctor will typically utilize several tests:

Upper Endoscopy: An endoscope is a long, flexible tube with a camera on one end that is used to examine, among other parts of the body, the gastrointestinal tract. The doctor will insert the endoscope in the patient’s mouth and inspect the esophageal lining. Telltale signs of eosinophilic esophagitis include inflammation, swelling, strictures (narrowing), white spots, or horizontal rings.
Biopsy: While performing an endoscopy, the doctor may also take a biopsy, a small cutting of tissue that can then be analyzed. The presence of eosinophils typically confirms eosinophilic esophagitis.
Blood Test: A blood test is one of the final procedures that can confirm eosinophilic esophagitis as well as point to the potential allergens that might be causing the problem. Besides eosinophil count, total immunoglobulin E levels can also point to allergy-related eosinophilic esophagitis.

Treatments for Eosinophilic Esophagitis

As a chronic condition, eosinophilic esophagitis cannot be strictly cured. There are, however, a number of treatment methods doctors can employ to mitigate the symptoms or even make the diseases essentially inactive:

Diet Therapy: Since food allergies appear to be one of the primary triggers of the initial inflammation, a dietary approach is typically the first step. However, since people are different and have different allergies, a doctor will order a series of allergy tests to determine which foods are actually the problem. A restricted diet that avoids these foods (often dairy or wheat products) can sometimes more or less eliminate or substantially reduce the inflammation.
Medication: Proton pump inhibitors (PPI) are often prescribed initially; though they have an unreliable record at treating eosinophilic esophagitis, the lack of responsiveness to PPI can actually help confirm the diagnosis. Another medication that may be used is a topical steroid like fluticasone or budesonide, a liquid that when swallowed can coat the inner lining of the esophagus and reduce inflammation.
Dilation: In some cases of eosinophilic esophagitis where there is a narrowing of the esophagus, the doctor may use endoscopy to mechanically stretch out the esophagus. While it doesn’t address the inflammation, dilation can make the passage of food bolus more smooth.

Gastroenterologist Appointment Eosinophilic esophagitis is still a somewhat little-known disease, though doctors are as yet unsure if that is because it is a modern disease or simply one that has been misdiagnosed consistently up until now. If you recognize the symptoms discussed here and would like to talk with a gastroenterologist about your digestive health, contact Carolina Digestive Health Associates to make an appointment.