The Role of Allergies in Eosinophilic Esophagitis

Amy Chow, RD

Written by: Amy Chow, RD

Updated: June 4th, 2024

Eosinophilic esophagitis (EoE) is an allergic condition that involves inflammation of the esophagus.  It is a relatively new condition that has first been identified in 1993 and the condition most commonly affects the age groups of 5-14 years, and 20-45 years.  Other risk factors for EoE include and not limited to the biological gender (male has a 3:1 ratio compared to female), genetics (first degree relatives with EoE) and history of other allergic diseases (asthma, eczema, seasonal allergies, food allergies). 

Read on to learn more about the relationship between EoE and food allergies, the common allergens associated with this condition, and strategies for managing EoE and food allergies.

Understanding Eosinophilic Esophagitis

When someone with EoE is exposed to certain foods or environmental triggers, eosinophils (a type of white blood cell) and other immune cells move into the esophagus causing inflammation. Over time, this process called type 2 inflammation, leads to ongoing inflammation and tissue damage to the esophagus. Delayed diagnosis has an increased risk of developing structural changes in the esophagus and further damage leading to scarring, narrowing, and the formation of strictures (tight, narrow areas).

Symptoms of EoE can include difficulty swallowing, upper stomach pain, indigestion, chest pain, and food getting stuck in the throat. In children, symptoms can present as nausea, vomiting, food intolerance, stomach pain, feeding difficulties and weight loss. There is currently no cure for EoE.  The goal of managing EoE is to control the symptoms, reduce the inflammation in the esophagus and hence preventing further complications.

Treatment options may include medication, diet changes, and/or dilation.  Dilation involves stretching the esophagus manually to increase the diameter of esophagus, it does not decrease the inflammation, so it’s used in combination with diet and/or medication therapy.  We will only focus on the dietary treatment in this article.

The Connection Between EoE and Food Allergies

There is a strong connection between food allergies and EoE. Unfortunately, there is no reliable testing, neither through skin nor blood test, to identify the specific food triggers. It is hard to pinpoint the specific food triggers based on symptoms alone as the allergic reactions for EoE are delayed and can develop over days. 

Elimination diet is the only way to identify the specific food triggers. The six foods that have been mostly associated with this condition are: cow’s milk, wheat/gluten, soy, eggs, nuts, and fish/seafood.  It is also important to note that not all patients will respond with dietary treatment alone – this may be due to other environmental allergens and/or other food allergens.

food allergies and EoE

Managing EoE through Diet

Elimination diet is an effective tool to identify which food(s) triggers the allergic responses and which foods do not.  Different elimination diets have been researched as EoE treatment.  The most restrictive option, called the elemental diet, is the most effective but also the hardest to follow. The least restrictive option, which removes just one or two foods, is the easiest to follow but is the least effective.

The elimination diet is followed for at least 6 weeks. After that, an endoscopy is done to check for symptoms and inflammation improvements. The eliminated foods are then reintroduced one at a time for at least 6 weeks each.  Repeated endoscopy is done after reintroducing each food to see if it caused symptoms or inflammation. The goal is to find out which foods trigger the EoE reactions and avoid them lifelong to manage the condition.

Elemental diet

The most effective dietary treatment is the hardest to implement.  Elemental diet involves eliminating all solid foods and replacing your diet entirely with an amino acid-based formula – a liquid meal replacement composed of essential nutrients in a predigested form.  This diet has the highest effective rate (90%) for EoE remission but as you can imagine, it is not a very feasible diet and sticking to this diet long term is nearly impossible. This approach is reserved for children with multiple EoE food triggers who have not responded to other treatment options.

Step Up Approach

The step-up approach is a less restrictive way to reduce unnecessary food eliminations and the frequency of endoscopies needed compared to the traditional six-food elimination diet.  The step-up approach typically starts at the two-food elimination diet (TFED), which involves only eliminating the 2 most common food triggers from the diet – cow’s milk and wheat.  A milk-free diet is sometimes adopted first as a single food elimination diet as cow’s milk is the top food trigger for EoE.

If there are no improvements with the TFED, you will then proceed with the four-food elimination diet (FFED), eliminating cow’s milk, wheat/gluten, egg, and legumes (soy, lentils, chickpeas, peas, beans, and peanuts).  Again, if there’s no improvements with the FFED, you will then proceed with the six-food elimination diet (SFED), eliminating the 6 most common allergens as mentioned above for EoE. 

Repeated endoscopies are needed after each food reintroduction to determine which are the specific food triggers – a minimum of 8 endoscopies are required with the SFED (one at diagnosis, one after elimination and one after each food reintroduction).  Therefore, the SFED is reserved for patients who do not respond to the less restrictive elimination diets.

Support of a Multidisciplinary Team

Managing EoE and food allergies requires a tailored approach – you don’t have to navigate EoE alone!  When you first find out you have EoE, it can be very overwhelming.  Support and guidance from a multidisciplinary team is needed. Doctors and specialists can help you navigate and understand the EoE diagnosis and discuss your treatment options. A dietitian who is knowledgeable about EoE and food allergies can help design and implement effective elimination diets, ensure nutritional balance, monitor progress and more importantly, guide you through the reintroduction process and optimize your eating and nutrition.

Conclusion

Eosinophilic Esophagitis (EoE) is a complex allergic condition that primarily affects the esophagus, leading to inflammation and potential structural damage over time.  You will need the support from a multidisciplinary team, which may include doctors, dietitians, allergists, and/or gastroenterologists. While there is no cure for EoE, various treatment options are available, including medication, dietary changes, and dilation.

Dietary management plays a crucial role in managing EoE. The elimination diets may be daunting to follow but are essential for identifying your specific food triggers, controlling symptoms, and preventing further damage to the esophagus. It is important to consult your healthcare providers to discuss what would be the best treatment for your specific situation.

References:

  1. American Academy of Allergy, Asthma & Immunology. (2021). Eosinophilic Esophagitis: Symptoms, Diagnosis & Treatment | AAAAI. Aaaai.org. https://www.aaaai.org/Conditions-Treatments/related-conditions/eosinophilic-esophagitis
  2. Dutta, P., Shah-Riar, P., Bushra, S. S., Haque, S. N., Rafa, Z. I., Hawa, F., Chakrabarty, S., Dev Nath, S., Afrin, H., Shama, N., Khair, F., Maisha, S., Kapuria, P., & Dam, B. (2023). Recent Trends in the Management of Eosinophilic Esophagitis: A Systematic Review. Cureus, 15(8), e43221. https://doi.org/10.7759/cureus.43221
  3. Feo-Ortega, S., & Lucendo, A. J. (2022). Evidence-based treatments for eosinophilic esophagitis: insights for the clinician. Therapeutic advances in gastroenterology, 15, 17562848211068665. https://doi.org/10.1177/17562848211068665
  4. Gupta, M., & Grinman, M. (2024). Diagnosis and management of eosinophilic esophagitis. Canadian Medical Association Journal, 196(4), E121–E128. https://doi.org/10.1503/cmaj.230378
  5. Roussel, J. M., & Pandit, S. (2020). Eosinophilic Esophagitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459297/
  6. Visaggi, P., Mariani, L., Pardi, V., Rosi, E. M., Pugno, C., Bellini, M., Zingone, F., Ghisa, M., Marabotto, E., Giannini, E. G., Savarino, V., Marchi, S., Savarino, E. V., & de Bortoli, N. (2021). Dietary Management of Eosinophilic Esophagitis: Tailoring the Approach. Nutrients, 13(5), 1630. https://doi.org/10.3390/nu13051630

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