Eosinophilic Esophagitis 101
Eosinophilic esophagitis (e-o-sin-o-FILL-ik uh-sof-uh-JIE-tis), also known as EoE, is a chronic condition that affects the function of the esophagus, the tube that connects the mouth to the stomach. You may be surprised to know that it is common in all age groups with the highest affected ages of 5-14 years, and 20-45 year (7), and men are 3-4 times more likely than women to have this condition. We’ve compiled everything you need to know about this condition – from what it is, to what to look out for, and what the treatment options are. Keep reading to find out!
What is EoE?
EOE stands for Eosinophilic Esophagitis, which means inflammation of the esophagus with eosinophils. The esophagus is the food pipe that connects our mouth to the stomach. When we chew food and are ready to swallow, the food enters through the back of the throat into the esophagus. The esophagus then moves it down into the stomach where the digestion process begins. Eosinophils refers to a specific type of white blood cell. Normally the esophagus does not have eosinophils. So the finding of eosinophils in the esophagus is not a normal finding, and are toxic to the lining of the esophagus.
Eosinophils cause inflammation in the esophagus, and this can occur not only in the superficial (top) layer of the esophagus, but in the deeper layers as well. It is not entirely clear why people are prone to deeper levels of inflammation. Not everyone develops deep level inflammation in the esophagus. There is more research needed to understand this.
Eosinophilic esophagitis is a swallowing disorder of the esophagus because the inflammation starts to cause problems in how the esophagus normally works. In a normal person, the esophagus propels food into the stomach in rhythmic waves called peristalsis. In EoE, these waves of peristalsis can be affected by inflammation. Inflammation in the esophagus can cause disturbance in how the peristalsis occurs. For e.g., rings and strictures, which are scars that narrow the diameter of the esophagus, can be a cause for food to get lodged. This means food stuck in the esophagus and cannot move into the stomach.
What to look out for
Difficulty swallowing is a common complaint for adolescents and adults with EoE. Some people may notice no difficulty swallowing if they have made subtle adjustments to the trouble of swallowing over the years. For e.g., people may need liquids to help move food into the stomach. Or they take their time chewing food to a paste before they attempt a swallow. Often people with EoE are the last one at the table. They may choose to avoid pills, tablets, or certain textures of foods (hard breads, steak, etc) because it is painful to swallow. Some individuals have had episodes where food gets lodged in the chest. This can be very stressful and may cause anxiety during mealtimes. People may avoid eating in public due to the fear of choking. Eating disorders may develop because of the fear of having a problem like food impaction (when food becomes stuck in the esophagus).
In many instances, food impaction can require emergency care to remove or dislodge the item from the esophagus. If there is a history of food impaction, it is important that such people seek medical care either during the episode or afterwards. This is so the cause for the food impaction has been found. More than 75% of people with food impactions will have an identifiable cause. Some people with EOE may also complain of reflux, and it is important to address this, as reflux (also known as GERD) can imitate EoE, or it can worsen EoE symptoms. It is believed that GERD and EoE are linked and might be affecting each other. But exact details are not known.
Treatment Options for EoE
Currently, there is no cure for the condition. Treatments should be taken regularly. It is important that the person with EoE consider long term treatment as on/off use does not manage this condition entirely. It is also important to know response to treatment is not reflected in changes with symptoms. Some folks can feel great on treatment, but the esophagus continues to show inflammation. This discrepancy makes managing this condition challenging. At this time, it is important to have a gastroscope (camera test by gastroenterologist) evaluation to confirm that the treatment you are on is helping. There are limited ways to evaluate the esophagus without a scope. Such non-invasive ways are being studied in clinical trials. The treatment options currently available are:
- Proton pump inhibitors (PPIs). These medications are used to manage reflux and ulcer disease. However, it also works in EoE. When first starting on it, its best to take it twice a day (30min before meals ideally) but after confirming this medication is working, it can be reduced to once a day. However, a repeat scope is required to confirm it is working at that lower dose as well.
- Topical corticosteroids (TCS). This is available in various formulations such as tablets, slurry, and puffers. For each type, specific instructions are provided so the medication is maximized for use. For e.g., with tablets and slurry, its best to take the medication and then rinse the mouth after to reduce risk of yeast infections in the mouth/throat. For puffers, its helpful to learn how to capture the ‘puff’ of medication in your mouth and swallow it, rather than inhaling it. Oral hygiene is recommended after puffers as well. Pharmacy can often help with the education component. Cost will often dictate which medication will be the best option for you.
- Diet. There are 6 common food groups are commonly implicated in inflammation in EoE. The groups are soya, nuts, cow’s milk, wheat/gluten, fish and eggs. It is best to do a diet change with the assistance of a dietician who can help ensure the food groups removed do not impact nutrition and general well-being. The food groups can be eliminated one or two at a time to avoid making drastic changes in food options. After elimination for 2-3 months, it is important to have a repeat scope to confirm if there is improvement in healing. Elemental diet is another option but is used in select instances because it is a liquid meal replacement composed of essential nutrients in a predigested form.
- Combination treatment. In some instances, it is helpful to combine both PPIs, diet and/or TCS together to improve the effect on your esophagus. However, this should be done in consultation with a doctor like a gastroenterologist.
Funding for this initiative was provided by Sanofi-Aventis Canada Inc.