Brief overview
- Symptoms: Eosinophilic esophagitis causes, among other things, difficulty swallowing and pain behind the breastbone. Children, on the other hand, usually complain of heartburn, nausea, or abdominal pain.
- Treatment: inhibition of stomach acid production, defense-suppressing drugs (immunosuppressants), or an elimination diet.
- Causes: Eosinophilic esophagitis is a.e. a form of food allergy, causing esophageal mucosa to become inflamed.
- Risk factors: People with allergic diseases and the tendency to them (atopy) are particularly frequently affected by eosinophilic esophagitis.
- Examination: esophagoscopy; to reliably detect eosinophilic esophagitis, the physician takes tissue samples from the esophageal mucosa using an endoscope.
What is eosinophilic esophagitis?
Eosinophilic esophagitis is chronic, inflammatory disease of the esophagus. Medical professionals consider it a form of food allergy. The term eosinophilic esophagitis specifically describes an inflammation of the esophagus with allergy-typical immune cells:
Eosinophilic esophagitis has become one of the most common forms of esophagitis. It affects both adults and children. According to current knowledge, boys and men are two to three times more likely to develop it than people of female gender.
What is the life expectancy for eosinophilic esophagitis?
Life expectancy in eosinophilic esophagitis is not limited with consistent treatment. However, treatment usually lasts throughout life, as the inflammation usually flares up again quickly if left untreated.
This is always the case, for example, when eosinophilic esophagitis is addressed with a special diet and causative foods are avoided. If the food is then eaten again, there is a relapse of the disease (recurrence). The reason: the immune system continues to react sensitively to certain food components. Upon renewed contact, the esophageal mucosa becomes inflamed again and causes the typical symptoms.
Without treatment of eosinophilic esophagitis, the inflammation usually becomes chronic. Over time, the esophageal tissue remodels and the esophagus becomes less mobile. In addition, this results in high-grade narrowing (strictures) in places. Those affected find it increasingly difficult to swallow and notice that food gets stuck.
What are the symptoms of eosinophilic esophagitis?
Eosinophilic esophagitis usually causes different symptoms in adults and children. Adults and teens often have difficulty swallowing and a burning to pain behind the breastbone. Food may get stuck in the esophagus (bolus obstruction). Affected individuals experience a sometimes painful feeling of a lump and have an urge to retch.
Sometimes sufferers also experience an unpleasant sensation or even pain in the esophagus immediately after eating certain foods. This is called food-induced immediate response of the esophagus (FIRE).
The symptoms of eosinophilic esophagitis often begin insidiously and are often underestimated by those affected. Rather, they adjust their eating habits as the disease slowly progresses. Often, sufferers do not even notice that they have changed their eating habits over the years.
The following eating habits are commonly found in chronic eosinophilic esophagitis: patients
- eat rather slowly,
- chew thoroughly,
- cut food very small,
- often use large amounts of sauce,
- drink with each bite to “wash down” the food,
- avoid eating in public because they want to avoid an embarrassing situation due to difficulty swallowing.
Eosinophilic esophagitis in infants and children is usually manifested by heartburn, nausea and vomiting, and abdominal pain. Affected children are fussy, refuse to drink or eat, and may develop more slowly than their healthy peers (growth retardation). Children who do not eat enough are often also tired and sleepy.
How does eosinophilic esophagitis develop?
The exact cause of eosinophilic esophagitis is still unclear. Today, experts assume that eosinophilic esophagitis is a form of food allergy. In this case, the immune system reacts particularly sensitively and violently to certain foods (e.g. cow’s milk or wheat).
Through contact with the food components in question, an allergic reaction develops in the mucous membrane of the esophagus and it becomes inflamed. In the process, it is colonized by allergy-typical immune cells, especially eosinophilic granulocytes. It is also possible that allergenic substances in the air (aeroallergens such as pollen) can cause eosinophilic esophagitis.
Risk factor for the development of eosinophilic esophagitis seems to be when the immune system had little exposure to environmental dirt and germs in childhood. This theory is also called the hygiene hypothesis.
According to this theory, children who grow up in particularly clean households develop allergies more often than children who had intensive contact with their environment. Scientists suspect: The immune system learns to tolerate these substances through frequent contact with potential allergens at an early age.
How does the doctor diagnose eosinophilic esophagitis?
If one has complaints of the gastrointestinal tract, family doctors are suitable first contacts. If necessary, they refer the affected person to a specialist, the gastroenterologist. He examines the esophagus with the aid of a camera (esophagoscopy) and can thus detect eosinophilic esophagitis.
Medical history and physical examination
First, the physician questions the patient in detail (anamnesis). He inquires about the symptoms, how long they have existed and whether they occur only in certain situations. He also asks about any known previous illnesses: Eosinophilic esophagitis is particularly common in asthmatics and (other) allergy sufferers.
Esophagoscopy (esophagoscopy)
If the doctor suspects (eosinophilic) esophagitis, the next step is to plan an endoscopy of the esophagus. Doctors refer to this as esophagoscopy or esophago-gastro-duodenoscopy (ÖGD), since they usually assess the stomach (gaster) and duodenum as well.
For the endoscopy, the doctor inserts a flexible tube with a camera into the esophagus through the mouth. In a patient with eosinophilic esophagitis, it may be narrowed in some places. The mucosa appears swollen and reddish, usually has longitudinal furrows, often annular tissue damage, and bleeds easily.
During this examination, the physician also takes small tissue samples, which a laboratory later examines under the microscope. Here, the investigators see the typical eosinophilic granulocytes.
Blood values
There is no laboratory value that clearly indicates eosinophilic esophagitis. Up to every second patient also has increased eosinophil granulocytes in the blood (eosinophilia). Some patients also have elevated levels of the endogenous antibody immunoglobulin E (IgE). IgE generally plays a role in allergic reactions and elevated levels may indicate allergic disease.
How is eosinophilic esophagitis treated?
There are three treatment approaches in the treatment of eosinophilic esophagitis. The common treatment options are defense-suppressing drugs (“cortisone”), gastric acid inhibitors, or a special diet.
Treatment with glucocorticoids
One possible treatment for eosinophilic esophagitis is glucocorticoids (“cortisone”), which act locally on the mucosa (topical therapy). Most often, doctors prescribe a melting tablet with the active ingredient budesonide. The glucocorticoids inhibit immune responses in the tissues, causing the inflammation to subside.
Patients take the medication for about six weeks, after which doctors mirror the esophagus again. If the inflammation has not completely subsided, they usually prescribe the drug for another six weeks.
Treatment with gastric acid inhibitors (proton pump inhibitors)
Gastric acid inhibitors can also help against eosinophilic esophagitis. Doctors prescribe the tablets in high doses for about eight weeks and then look at the esophagus again. Studies to date show that about one in two to three patients no longer have symptoms under them. In these patients, the stomach acid probably promoted the strong immune reaction.
Elimination diet – diet plan for eosinophilic esophagitis
The knowledge about it is based on previous experience and scientific findings. It is therefore also referred to as an “empirical” elimination diet.
The change in diet requires a great deal of effort on the part of the patients, since they have to avoid large parts of their typical diet. The special dietary requirements also often result in higher costs. What sufferers can still eat includes fruits, vegetables, meat, poultry, rice, beans and grains other than wheat.
After six to twelve weeks of elimination diet, one performs a repeat esophageal mirror examination. If the eosinophilic esophagitis has improved during this time, the patient may try the avoided foods again, one by one. During this process, the physician examines the esophageal mucosa at regular intervals.
An example: the affected person is again test egg for one to two months. Then a control examination follows and the physician checks whether the esophagus has become inflamed again. In this way, it is possible to filter out which foods caused the inflammation and the affected person should then avoid them for life.
If the elimination diet makes symptom-free, eosinophilic esophagitis is thus treatable for life.
Besides the 6-food elimination diet, there are other diets for eosinophilic esophagitis. They can also help, but are hardly useful for various reasons:
Elemental diet: affected persons eat only liquid food, mixed with water and a special nutrient powder (formula food). The elemental diet is very effective, but for most people it is not sustainable. Sometimes the unpleasant taste is disturbing, and children may need a feeding tube.
Allergy test-based diet: First, an allergy test (e.g. prick test) is used to determine which foods a patient reacts to. The patient then specifically avoids these. However, this only helps about one in three patients with eosinophilic esophagitis. Doctors therefore do not recommend this diet.
Long-term treatment of eosinophilic esophagitis
Glucocorticoids or gastric acid inhibitors for six to twelve weeks improve eosinophilic esophagitis in many patients. This first phase of therapy is also called induction therapy. However, if patients were to stop taking medication after this, the esophagus would quickly become inflamed again.
They choose the drug from the successful first phase of therapy and usually reduce the dose. After one to two years, they then check the esophagus again using esophageal endoscopy.
It is the same with a successful diet. If the patients start to eat normally again, the recurrence of esophagitis is certain. It is therefore necessary that they permanently abstain from the causative foods.
If the first treatment failed to relieve eosinophilic esophagitis, doctors recommend one of the other possible therapies.
Treatment of strictures
Often, the esophagus is immobile due to the long-standing inflammation and shows narrowing (strictures). In this case, balloon dilatation can help. In this procedure, doctors push a balloon up to the narrowed section of the esophagus and inflate it. This widens the affected area and food can pass through more easily again.
Alternatively, doctors “bougie” the narrowed area with, for example, cone-shaped plastic caps (“bougies”). During a reflection, they repeatedly press these bougies through the constriction, using larger bougies each time.
