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Eosinophilic Esophagitis EoE or EE
The esophagus is the portion of the anatomy in the throat that connects the digestive system delivering food from a person’s mouth to the stomach. Sometimes, conditions can develop causing the esophagus to become inflamed resulting in difficulties from discomfort to malnutrition. There are several reasons inflammation can exist including acid reflux, viruses, and bacterial infections.
Usually, these cases can be treated with medication to alleviate the reflux or help the immune system fight off the imposing virus or bacteria causing issue. Yet, when esophagitis is present due to a high-level of esophageal eosinophils, the immune system itself has become the problem. Eosinophils are white blood cells that help the immune system fight off parasites and other illnesses, but when they accumulate in a specific area of the body, like the esophagus, the cells’ toxins can degrade normal healthy tissue causing Eosinophilic Esophagitis. This is a serious illness with no known cure, but for those afflicted, understanding and identifying the signs of EoE to get an early diagnosis can provide substantial improvement in symptoms and reduction in future damage.
Possible Causes of Eosinophilic Esophagitis
Most physicians believe Eosinophilic Esophagitis is related to allergic response. Allergies in general are a product of the body misidentifying a benign substance in the body as a serious invader that causes illness. In its efforts to protect the human system and keep a person healthy, the immune system targets the invader. In a healthy immune system Eosinophils are present in low levels (<3%) in the blood stream as well as the tissues of the digestive system including esophagus, stomach, and intestines to quickly identify and combat any ingested parasites.
When an individual suffers from frequent allergies, particularly food-related allergies, the immune system produces more eosinophils than normal depositing them throughout the digestive track. As the food allergen passes through the esophagus the eosinophils attack releasing disease fighting enzymes and toxins. The presence of these biochemicals in higher levels directly causes esophageal irritation and inflammation.
Patient Types
Eosinophilic Esophagitis is found in children and adults of both genders, though there is a higher number of men afflicted than women. People with a family history of Eosinophilic Esophagitis and / or a family history of severe allergy are more likely to experience the illness.
Symptoms
In adults, the primary symptom is difficulty swallowing, known as dysphagia, which results in the feeling of food being stuck in the esophagus. This may be accompanied by esophageal pain when swallowing (odynophagia), chest pain in and around the breast bone, heartburn, and nausea. In children, the most common symptoms are abdominal pain, potentially with nausea and vomiting, and excessive coughing when eating. Often the first noticeable sign of Eosinophilic Esophagitis in children is the inability to grow or gain weight, classified as failure to thrive. Both adults and children may exhibit decreased appetites.
If untreated, Eosinophilic Esophagitis will continue to damage the esophagus decreasing the space available for adequate passage of food. This constriction is due partially to the Eosinophils and the space they occupy, partially to scarring of the tissue from eosinophilic damage, and partially to irritation and inflammation. As the illness escalates people may begin to avoid eating to eliminate the discomfort. In severe cases, individuals may begin to experience malnutrition or food may become lodged (impacted) in the esophagus. If experiencing severe symptoms, including but not limited to food impaction in the esophagus, one should seek medical attention as soon as possible.
Diagnosis
Unfortunately, there are no non-invasive techniques to fully diagnose Eosinophilic Esophagitis. When presenting with mild symptoms of EoE, physicians will sometimes begin with a noninvasive Barium X-ray. After drinking a barium mixture the lining of the esophagus and stomach will be visible on x-rays allowing preliminary view of the digestive system. This will not provide a definitive diagnosis for Eosinophilic Esophagitis and is usually a method utilized when ruling out other potential issues with hernias, structural changes in the digestive system, or the presence of tumors.
When presenting with any level of dysphagia, odynophagia, or for definitive diagnoses following a non-conclusive Barium X-ray, the only diagnostic tool available is the Endoscopy. In this exam, a specialized micro-camera will be inserted down the esophagus allowing the physician to see the tissue and make visual assessments of any problem areas. These signs may include a complete narrowing of the esophagus, sections of inflamed tissue that appear as rings or furrows, or white spots along the esophageal lining indicating large levels of degranulated eosinophils.
In addition, to the visual exam, the physician performing the endoscopy will remove small pieces of esophageal lining for further laboratory tests. These biopsies are conducted whether there are visual signs of Eosinophilic Esophagitis or not, as not all afflicted patients will exhibit visible damage to the esophagus. Tissue is then tested to assess levels of Eosinophils present.
Treatment options
Once a confirmed diagnosis of Eosinophilic Esohagitis is obtained there are three main treatment options: (1) elimination diets, (2) medications, and (3) esophageal dilatation.
As EoE is believed to be heavily related to allergic response the first place to begin treatment is to identify the most severe allergens and eliminate them from the system. If blood tests reveal a specific food allergy is likely it can help target the elimination plan; however, as food allergies can be very difficult to identify via blood or skin allergic response tests, this may not be the only food allergen causing problems and the elimination diet should preliminarily include other food types. This is done first by eliminating all common food allergens and waiting for an improvement in symptoms. Once improvement is seen, allergens are added back into the diet in low levels, one at a time, to identify those which result in increased illness.
When successful, elimination diets can reverse the effects of the illness eliminating symptoms and allowing the esophagus to fully heal. However, the process of identification through complete elimination and slow reintroduction is time consuming and may not result in the identification of the offending allergen. If relief from symptoms is necessary quickly the elimination diet may be used in conjunction with other treatment options.
There are numerous medications available to treat the inflammation and irritation of Eosinophilic Esophagitis quickly. All medications prescribed are steroid-based and they work by easing the inflammation of the area. Patients may be prescribed oral steroids, inhaled steroids, or a proton pump. Long-term use of steroids is associated with side effects including loss of bone density, growth impairment in children, mood disorders, and rarely diabetes. Because of the severity of the potential side effects and the difference in absorbed steroids between oral and inhaled methods, inhaled steroid treatments are much more commonly prescribed. A proton pump is used to combat the effects, and subsequent damage, of acid reflux.
Though acid reflux is neither a cause nor symptom of Eosinophilic Esophagitis, it can be seen in EoE patients and physicians may describe a proton pump to eliminate the reflux damage to the esophagus. When the esophagus has become damaged substantially and has severe constriction or impaction issues, a esophageal dilatation procedure may be performed. In this procedure a specialist uses endoscopic tools to gently break away constricting bands in the esophagus and stretch the esophageal lining with adjustable balloon attachments. These procedures have a long history of providing relief for esophagitis and its resulting constrictions and it is generally considered a safe and effective treatment.
Complications include tears in the esophageal lining or complete esophageal perforations. Tears in the lining may cause pain and discomfort for the patient while complete perforations could result in chest infections and more serious illness. Due to the severity of potential complications, dilation of the esophagus is reserved for severe cases of dysphagia and impaction.