Eosinophilic Esophagitis (EoE)
Eosinophilic esophagitis, also known as EoE, is a relatively newly recognized disease that is characterized by eosinophils (allergy cells) building up in the lining of the esophagus, causing inflammation and other symptoms.
At CHOC, our multidisciplinary gastroenterology and allergy teams work together to diagnose and treat EoE so that our patients can reduce or eliminate their symptoms, prevent future complications and live a happy life.
Symptoms of EoE
The eosinophils cause inflammation in the esophagus, which may cause the following symptoms:
- Difficulty feeding, including feeding refusal and feeding intolerance
- Poor weight gain
- Decreased appetite
- Chest pain
- Abdominal pain
- Reflux-like symptoms
- Vomiting
- Trouble swallowing
- Food impaction (when food gets stuck in the throat)
Symptoms of EoE are generally similar in infants, toddlers, teens and adults. Infants may experience growth problems. Older babies may have issues transitioning to solid foods. Older kids may have trouble swallowing food or feel that food gets stuck in their esophagus.
Many patients with EoE also experience gastroesophageal reflux disease (GERD), a chronic digestive disorder that is caused by the abnormal flow of gastric acid from the stomach into the esophagus. It is not uncommon for a patient to receive treatment for GERD while also undergoing treatment for EoE.
What causes EoE?
The reasons why some people have EoE are not fully understood. What we do know is that EoE is a chronic disease that can be managed through diet and/or medical treatment. EoE is not life threatening; however, if left untreated it may cause permanent damage to the esophagus.
How is EoE diagnosed?
Currently, only an endoscopy and biopsy (small tissue sample) of the esophageal tissue can provide a definite diagnosis of EoE. A child’s symptoms and medical history can strongly suggest EoE, but the endoscopy and biopsy are required. Greater than 15 eosinophils throughout the esophagus confirms the diagnosis. The endoscopist may mention seeing trachealization (rings) or furrowing (linear white lines) in the esophagus, which is also suggestive of EoE.
How is EoE treated?
For children with EoE, the primary goal of treatment is to ensure normal growth and development. Proton pump inhibitors (PPIs) and/or dietary modifications are the most common therapies. Steroids and other medications are sometimes used. Treatment regimens are often difficult to maintain and must be individualized according to each family’s concerns and lifestyles.
What medications help EoE?
Many children benefit from taking swallowed steroids. Fluticasone propionate and budesonide are steroid medicines that were developed for asthma. Instead of inhaling these medicines like asthma patients, children with EoE swallow them. When patients take the medicine on a daily basis, it “coats” the esophagus with the steroid medicine, destroys the eosinophils and helps the esophagus heal. These medications are safe for growing children, as after it is swallowed, it passes through the body and is eliminated without dangerous side effects. These medications are different than anabolic steroids.
Steroid medications destroy the eosinophils in the esophagus so they cannot cause inflammation or tissue damage but do not solve the root of the EoE problem. Because food allergies are believed to be a major cause of EoE symptoms, when a patient stops taking the steroid medication, the eosinophils almost always return.
A biologic called Dupixent has been approved for EoE and is showing promising results. Dupixent is not a cure but can be helpful in controlling inflammation.
Some patients with EoE may also have allergy symptoms that require daily medications. Not every patient with EoE will need allergy and asthma medicine.
EoE can resemble other medical conditions. Eosinophils may be seen in the esophagus in lower numbers in GERD patients. Both GERD and EoE patients may respond to acid blocker therapy with proton pump inhibitors.
EoE and Food
For some kids with EoE, certain foods can exacerbate symptoms. A food elimination diet may be recommended after discussing the child’s medical and food history. A food elimination diet removes specific foods or food groups from the diet that are known to be the most common triggers for EoE. Endoscopies are performed after both eliminating and reintroducing foods, to determine which foods are associated with the presence of eosinophils in the esophagus.
What happens if someone with EoE is exposed to an “unsafe” food?
EoE reactions do not happen immediately. Usually, if a child is exposed to an “unsafe” food, they may experience a flare up in symptoms within a few days if they continue to consume that item or ingredient.
Frequently Asked Questions
Is EoE is hereditary?
EoE may be more common in families. Family members should be tested if they have symptoms.
Do children outgrow EoE?
There is limited data on long-term outcomes of EoE.
Who should be tested for EoE?
Patients with symptoms listed at the top of this page that do not respond to medical treatment may be tested for EoE. This is especially true for those who have significant difficulty swallowing solid foods.
Are certain people more likely to get EoE?
Although anyone can get EoE, boys tend to develop it more often then girls—approximately three to one.
What is an eosinophil?
An eosinophil is one of several types of white blood cells normally found in blood and certain tissues. Eosinophils help engulf and kill bacteria and microorganisms such as parasites. They also participate in the control of allergic reactions and diseases. Eosinophils normally function to protect the body.
What is an eosinophil-associated disorder?
An eosinophil-associated disorder is a disease state in which there are too many eosinophils in a particular organ or organs, often in the gastrointestinal tract. Too many eosinophils are often associated with abnormal symptoms. The long-term effects of too many eosinophils in a given area of the body are not known.
How common is eosinophilic esophagitis (EoE)?
It is estimated that approximately 55 patients per 100,000 people in the United States have EoE. This may vary by region.
Do adults get EoE?
Adults do get EoE. It can develop in childhood and persist into adulthood. Some people first experience EoE as an adult or only receive a diagnosis once in adulthood. Overall increased awareness of the disorder has improved disease recognition and the need for endoscopic biopsies.
Is it harmful if someone only has a few eosinophils in their esophagus?
The presence of eosinophils suggests that there is inflammation in the esophagus. Inflammation should always be treated and should not be ignored. However, how many eosinophils is “too many” and how long is “too long” is yet to be determined.
Can inflammation of the esophagus be cancerous?
Limited adult data suggests that inflammation does not lead to cancer, but it is too early to know for sure. Any inflammatory process that persists from childhood to the adult years must be of concern.
What is a stricture?
EoE can cause changes in the tissue lining the esophagus that may result in a stricture, or narrowing of the esophagus. This is thought to occur as a result of inflammation in some children and adults with EoE. Food may not be able to pass from the mouth to the stomach when a stricture forms.
How are strictures treated?
Esophageal strictures may improve with EoE treatment and are also treated by dilation or stretching the esophagus. To do this, a long cylindrical rubber tube into the mouth and esophagus or by placing an inflatable balloon through the endoscope into the esophagus. These procedures can cause pain and tears in the esophagus. Patients and their families should discuss these procedures and understand the risks.
How many biopsies should be taken to diagnose EoE?
EoE is a patchy disorder, so usually four to six samples are taken at difference levels of the esophagus to increase the likelihood of finding the disease if it is present.
Can EoE be diagnosed with a blood test?
Unfortunately, an endoscopy with biopsy is the only way to positively diagnose EoE. Blood tests and stool tests may be necessary to help exclude other disorders, but no blood test is available to diagnose a primary eosinophilic disorder.
Will patients have to go through additional endoscopies and biopsies after the initial diagnosis?
Patients will likely need several endoscopies over time to monitor the child’s response to treatment.
Do patients with EoE need allergy shots?
Allergy shots to environmental allergens and their effect on EoE has not yet been studied.