Eosinophilic esophagitis (EoE) is a chronic condition that affects the function of the esophagus, the tube that connects the mouth to the stomach. EoE is an immune-mediated inflammatory condition of the esophagus, which is believed to be triggered by abnormal type 2 immune response to food and likely aeroallergens (airborne susbstances or inhalants such as pollens, spores, and other particles that cause allergic disorders)^1,2. Type 2 immune system response refers to the type of immune system activation occurring in the body. Type 2 immune response is seen in allergic disorders like asthma. But the development of this disorder is not simply an allergic reaction. It is a complex interaction between genetics and antigen triggers in the environment³.

Research into how one develops EoE is still being studied. EoE’s rising incidence in the past three decades has established it as a common cause of esophageal dysphagia (difficulty swallowing) and food impactions (when food becomes stuck in the esophagus), requiring an emergency visit (see more details in statistics).

In this video by Canadian Health and Family we hear from Dr. David Armstrong to learn more about this little-known condition which is rising in prevalence.

Pediatric Eosinophilic Esophagitis

To learn more about pediatric eosinophilic esophagitis, watch our CDHF Talks on the subject. In this series of videos, gastroenterologist Dr. Vishal Avinashi goes over what Pediatric Eosinophilic Esophagitis (Pediatric EoE) is, the signs and symptoms, diagnosis, and the treatment options. He will also be answering questions specifically about managing EOE in children.

This depends on the age of the individual. For children over 12 years of age, the most common presentation in EoE is difficulty swallowing (dysphagia). Recurrent and chronic (meaning long term) dysphagia is commonly seen in this condition.

Other signs and symptoms can include:

• Sensation of reflux
• Chest pressure
• Painful swallowing (odynophagia) when eating

Individuals may develop sudden food obstruction or impaction, which can feel like choking. Many seek medical attention in the emergency department for this situation, and often removal of the food from the esophagus is needed to relief the sensation. Individuals with EoE may have anxiety around eating due to fear of choking. In some instances, anxiety and hypervigilance can persist even after confirmed healing of the esophagus with treatment.

Some individuals  don’t describe having difficulty with foods. This may be that they have developed  ways to manage the difficulties of swallowing certain textures of foods by adusting how they eat or drink. They may also have food aversions. It is common to see a 4-10 years gap between start of symptoms and time to diagnosis by a doctor⁴. Delayed diagnosis results in delayed treatment and increases the risk of developing esophageal fibrosis (scarring in the esophagus that causes narrowing)⁴. It can be challenging to differentiate EoE from eating disorders, and so it is important to seek a professional like a doctor to help differentiate between these two. EoE can be present in those with either difficulties swallowing, or those that have behaviours that compensate for textures of food. IMPACT is an acronym to describe how patients can modify their behaviours of eating/drinking to overcome challenges with food. ²

• BOX (Reference – Hirano and Furuta 2020):
• Imbibe fluids with meals to lubricate foods
• Modifying foods (cutting up foods into small bites)
• Prolonged mealtime
• Avoidance of hard textured foods
• Chewing excessively
• Turning away pills

Atopic (allergic disorders) conditions are common to see in those with EoE. More than 75% of people with EoE have food allergies, atopic dermatitis, allergic rhinitis, nasal polyps, and/or asthma (5). Therefore, individuals with a personal history of atopy, frequent dysphagia and/or maladaptive eating should talk to their doctor about being evaluated for the diagnosis of EoE.

Diagnosis requires the right clinical history (outlined above) and biopsies from a gastroscopy (also known as scope) showing high eosinophil counts. The findings on biopsies can be related to other conditions like gastroesophageal reflux disease (GERD), which is why it’s important to be seen by a gastroenterologist, who will assist the patient in figuring out if they have EoE, GERD or another swallowing disorder. If an individual has had a history of food impactions but never had a scope, it’s important they seek out referral to gastroenterology because more than 75% of people will have an identifiable cause. ⁶

Treatment

If an individual has an episode of food impaction, they should go to to their local emergency department for assistance. To dislodge the food, it is ok to trial carbonated beverages like cola to provide immediate relief. If it is dislodged, then it’s recommended that individuals be referred to a gastroenterologist for a scope and follow up. So evaluation at the time of food impaction by a doctor is helpful to understand what may be the cause. If it is not dislodged, then an urgent gastroscopy with removal of food is advised to provide relief.

In the non urgent setting, EoE can be managed by the “3 Ds” – Drugs, Diet and Dilation. Drugs or diet can modify the disease process, but dilation provides symptom relief only. Currently not one treatment type is better. Any treatment the person is willing to adhere to long term is the best one to take.

1. Drugs – these include proton pump inhibitors (PPIs), topical steroids (slurry or orodispersable tablets) or biologics. Other medications like antihistamines, and allergy directed treatments have so far not been successful in clinical trials.
2. Diet – includes empiric elimination, or elemental diets. Empiric elimination diet eliminates 2, 4 or 6 common food groups. The eliminations are temporary until the culprit foods that cause inflammation in the esophagus is found. This is best done in consultation with a dietician to avoid nutritional deficiencies. Elemental diet is a liquid-based diet made of amino acid, short chain fatty acids, short chain maltodextrins and vitamins. This is a challenging diet to do and is often reserved for severe cases of EoE. This is done in conjunction with a dietician and gastroenterologist.
3. Dilation – this involves stretching the esophagus with a balloon or a tube (Savary dilator) that is inserted into the esophagus under sedation. It is completed at the time of a gastroscopy. The purpose of dilation is to increase the diameter of esophagus enough to allow patients to manage food. However, it does not alter the amount of inflammation, so it is best used in combination with diet or drugs.

• Eosinophilic esophagitis (EoE) is a chronic condition that emerged as a disease entity in the 1990s. It is common in all age groups with the highest affected ages of 5-14 years, and 20-45 years⁷. Men are 3-4 times more likely than women to have this condition. Incidence and prevalence are both rising across the world, but most publications are from white majority populations. So nonwhite majority populations are under reported in the literature. EoE does not reduce life span, so prevalence is expected to rise for the foreseeable future⁷.
• In Calgary Canada⁸, prevalence increased from 10.7 to 33.7 persons/100,000, and incidence rose from 2.1 to 10.7 cases/100,000 from 2004-2008. This is the last reported data for adult Canadians to date.
• Delayed diagnosis has been documented to be associated with increased risk of developing esophageal fibrosis (narrowing and scarring of esophagus)⁴. Forty-five percent of patients with a 0-2 year delay in time to diagnosis, and 87% of those with more than 20 years delay to diagnosis have esophageal rings or strictures that cause food to stick or get lodged.

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2. Hirano I, Furuta GT. Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis. Gastroenterology. 2020.
3. O’Shea KM, Aceves SS, Dellon ES, Gupta SK, Spergel JM, Furuta GT, et al. Pathophysiology of Eosinophilic Esophagitis. Gastroenterology. 2018;154(2):333–45.
4. Schoepfer AM, Safroneeva E, Bussmann C, Kuchen T, Portmann S, Simon HU, et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology [Internet]. 2013;145(6):1230-1236.e2. Available from: http://dx.doi.org/10.1053/j.gastro.2013.08.015
5. Van Rhijn BD, Bredenoord AJ. Management of eosinophilic esophagitis based on pathophysiological evidence. J Clin Gastroenterol. 2017;51(8):659–68.
6. Birk M, Bauerfeind P, Deprez PH, Häfner M, Hartmann D, Hassan C, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(5):489–96.
7. Arias Á, Lucendo AJ. Epidemiology and risk factors for eosinophilic esophagitis: lessons for clinicians. Expert Review of Gastroenterology and Hepatology. 2020
8. A.A.N. Syed, C.N. Andrews, E. Shaffer, P. Belletruti, M. Stewart, S.J. Urbanski. The rising incidence of eosinophilic oesophagitis is associated with increasing biopsy rates: A population-based study. Aliment Pharmacol Ther. 2012