Eosinophilic Esophagitis (EoE)

What Is Eosinophilic Esophagitis?

Eosinophilic esophagitis (EoE) is a chronic allergic/immune-mediated condition in which a type of white blood cell called an eosinophil accumulates in the lining of the esophagus (the tube that connects your mouth to your stomach). These cells release substances that cause inflammation, leading to symptoms of esophageal dysfunction.

Signs & Symptoms

The symptoms of EoE can differ significantly by age:

Adults & Adolescents

• Difficulty swallowing (dysphagia) - the most common symptom in adults
• Food impaction - food getting stuck in the esophagus, requiring emergency intervention
• Chest pain - not responsive to antacids
• Regurgitation of food
• Heartburn - that doesn't improve with acid-reducing medications
• Avoidance of certain food textures or types
• Slow eating or excessive chewing
• Drinking large amounts of liquid with meals to help food pass

Children

• Feeding difficulties (infants and toddlers)
• Poor appetite or refusal to eat
• Abdominal pain
• Vomiting or nausea
• Poor growth or failure to thrive
• Regurgitation or reflux symptoms
• Picky eating or food aversions

What Causes EoE?

EoE is an immune-mediated condition often triggered by allergic reactions to foods or, in some patients, environmental allergens such as pollen or animal dander. The exact cause is unknown, but a combination of genetic, environmental, and immune factors likely contributes.

Associated Conditions

Many people with EoE also have other allergic conditions, including:

• Asthma
• Allergic rhinitis (hay fever)
• Atopic dermatitis (eczema)
• Food allergies
• Environmental allergies

Common Food Triggers

While any food can potentially trigger EoE, the most common culprits include:

• Dairy products (milk, cheese, yogurt)
• Wheat and gluten-containing grains
• Soy products
• Eggs
• Nuts and seeds (tree nuts and peanuts)
• Fish and shellfish

How Is EoE Diagnosed?

The diagnosis of EoE requires both clinical symptoms and proof of inflammation in the esophagus through endoscopy and biopsy.

Diagnostic Criteria

• Upper endoscopy with biopsies is required for diagnosis
• Biopsy specimens are examined for eosinophil count; finding ≥15 eosinophils per high-power microscopic field supports the diagnosis
• At least 6 biopsies from different locations in the esophagus are recommended to improve diagnostic accuracy
• Other causes of eosinophilia, such as GERD, must be ruled out first
• Some patients may be given a trial of proton pump inhibitors (PPIs) before endoscopy to rule out acid reflux as the cause

Endoscopic Findings

During endoscopy, doctors may observe characteristic features of EoE, including:

• Rings or corrugations in the esophagus (giving a "ringed" or "corrugated" appearance)
• White spots or plaques (eosinophilic exudates)
• Narrowing of the esophagus (strictures)
• Furrows or vertical lines
• Tissue fragility (the lining tears easily during the procedure)

Allergy Testing

Allergy testing (skin prick tests or blood tests) may be part of the evaluation but often does not definitively identify trigger foods in EoE. These tests are more helpful for identifying environmental allergens or IgE-mediated food allergies.

Treatment Options

Treatment focuses on reducing inflammation, managing symptoms, and preventing complications such as strictures and food impaction. There is no one-size-fits-all approach, and treatment is individualized based on age, symptoms, and patient preference.

1. Diet Therapy

Dietary modification is often the first-line treatment, especially in children. There are several approaches:

Six-Food Elimination Diet (SFED)

• Removes the six most common trigger foods: milk, wheat, egg, soy, nuts/tree nuts, and fish/shellfish
• Used for 6-8 weeks, followed by endoscopy to assess response
• If successful, foods are reintroduced one at a time to identify specific triggers
• Success rate: approximately 70% of patients respond

Four-Food Elimination Diet (FFED)

• Removes milk, wheat, egg, and soy
• Less restrictive than SFED while still effective for many patients
• Success rate: approximately 50-60%

Two-Food Elimination Diet (TFED)

• Removes milk and wheat/gluten
• Least restrictive empiric diet
• May be tried initially or in patients who need a simpler approach

Elemental Diet

• Uses an amino acid-based formula (like Neocate or EleCare) to eliminate all potential food allergens
• Most effective dietary approach (success rate >90%) but also most restrictive
• Typically reserved for severe cases or when other approaches have failed
• Can be difficult to maintain, especially in adults

Allergy Test-Directed Diet

• Eliminates foods based on allergy testing results
• Less effective than empiric elimination diets
• May be combined with other approaches

2. Medications

Proton Pump Inhibitors (PPIs)

• Medications like omeprazole (Prilosec), esomeprazole (Nexium), or lansoprazole (Prevacid)
• Some patients with EoE respond to high-dose PPIs
• Reduces acid production and has anti-inflammatory effects
• Usually tried for 8-12 weeks before reassessment
• May be used alone or in combination with other treatments

Swallowed (Topical) Corticosteroids

• Budesonide - Available as oral viscous suspension or effervescent tablets that dissolve in the mouth
• Fluticasone - Asthma inhaler sprayed into the mouth and swallowed (without the spacer)
• Work by directly reducing inflammation in the esophagus
• More effective than PPIs alone for many patients
• Generally well-tolerated with minimal systemic absorption
• Possible side effects: oral/esophageal candidiasis (thrush)
• Should not eat or drink for 30 minutes after taking to allow medication to coat the esophagus

Biologic Medications

• Dupilumab (Dupixent) - FDA-approved for EoE in patients 12 years and older (as of 2022)
• Injectable medication given every 2 weeks
• Blocks specific immune pathways (IL-4 and IL-13) involved in allergic inflammation
• Shown to reduce eosinophil counts and improve symptoms
• Also approved for asthma, eczema, and chronic rhinosinusitis with nasal polyps
• May be particularly useful for patients with multiple allergic conditions

3. Procedural Therapy

Esophageal Dilation

• Used when the esophagus becomes narrowed (strictures) causing difficulty swallowing
• Performed during endoscopy to gently stretch the esophagus
• Provides symptom relief but does not treat underlying inflammation
• May need to be repeated periodically
• Should be combined with anti-inflammatory treatment (diet or medications)
• Carries a small risk of esophageal perforation

Choosing the Right Treatment

The choice of treatment depends on several factors:

• Patient age and preference
• Severity of symptoms
• Presence of strictures or food impaction history
• Patient's ability to adhere to dietary restrictions
• Insurance coverage for medications
• Presence of other allergic conditions

Long-Term Management & Follow-Up

EoE is a chronic condition requiring ongoing management and monitoring.

Regular Follow-Up Care

• Gastroenterology appointments - typically every 3-6 months initially, then annually once in remission
• Allergy specialist visits - for comprehensive allergy evaluation and management
• Repeat endoscopies - usually performed 8-12 weeks after starting treatment to assess response, then periodically to monitor disease control
• Dietitian follow-up - for patients on elimination diets

Monitoring Treatment Response

Success of treatment is measured by:

• Reduction in symptoms (improved swallowing, less chest pain, better appetite)
• Decrease in eosinophil counts on repeat biopsies
• Improved quality of life
• Prevention of complications like strictures and food impaction

What Is Remission?

• Histologic remission: Fewer than 15 eosinophils per high-power field on biopsy
• Clinical remission: Improvement or resolution of symptoms
• Both histologic and clinical improvement are important goals

Frequently Asked Questions