EoE = Eosinophilic Oesophagitis

Sometimes described as Oesophageal Asthma or Eosinophilic Esophagitis in the US and Canada

This is the more common of the eosinophilic gut disorders occurring in approximately 1 in the 2000 in US and 1 in 3000 in the UK. 

What are the symptoms?

The symptoms of Eosinophilic Oesophagitis EoE can vary from one person to another and depending on age, but they are usually related to difficulty in getting food down the Oesophagus (the tube going from mouth to stomach).   

The medical word for this type of swallowing difficulty is dysphagia, but there are many types of dysphagia and the one that occurs in EoE is a feeling of food travelling more slowly down or sticking (usually) in the chest, often intermittent but sometimes with every swallow. The sensation of food sticking can range from mild, making eating difficult/uncomfortable to severe and very distressing. It can occur without pain or with significant pain. 

In children there can be difficulties with nutrition/poor growth, vomiting/regurgitation (sick going up and down, which can disturb sleep), food refusal (fussy eating), abdominal and or chest pain.

In older children, adolescents and adults occasionally the food can stick severely stopping all other swallowed material for hours, this is called food bolus obstruction or food impaction and may require emergency medical attention. 

Those suffering from long term undiagnosed Eosinophilic Oesophagitis EOE will often have learnt coping strategies such as:

• Slow eating, excessive chewing – last to finish a meal
• Food avoidance i.e. meat, bread - preferring softer/wetter foods
• Drinking lots during a meal

Symptoms of EOE can become so severe that it may prevent sufferers from normal social eating and cause anxiety, particularly when eating out in a restaurant.

WHAT IS THE CAUSE OF EOSINOPHILIC OESOPHAGITIS EOE?

The cause of Eosinophilic Oesophagitis EoE is not yet completely understood but it has been found to be triggered by eating certain foods, most commonly (but not exclusively) milk, wheat, nuts, soya, fish and eggs. It may possibly be triggered by breathing in certain allergens like pollen. 

Eosinophilic Disease is often found in those with a family history of allergic diseases such as rhinitis, asthma and/or eczema. In fact, a personal history of atopy is documented prior to EOE diagnosis in 50-60% of cases. To make things even more complex the substance triggering each condition may differ within the same individual, e.g pollen for Asthma and maybe Milk for EoE.

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How do you get diagnosed?

A referral to an Eosinophilic Oesophagitis EOE expert Gastroenterologist is needed as the only way to make the diagnosis is by an examination with a ​flexible endoscope and to have biopsies taken. 

The normal oesophagus has very few or no eosinophils in biopsy samples but patients with ​EoE have a clearly defined abnormality when the density of eosinophils are ≥15/hpf (equal to or greater than 15 per high ​power microscope field). 

Neither blood tests nor x-rays are of value in the ​diagnosis.

What are the treatment options?

Eosinophilic Oesophagitis EoE is a chronic disorder that can wax and wane. Currently, there is no known cure. There are various symptom management options which need to be discussed with your expert consultant in Eosinophilic Oesophagitis  EoE as each option has its pro and cons with a variable chance of success and may require one or more approaches i,e drug and diet. 

• Dietary Treatments

Sometimes the first dietary approach adopted by patients is often to avoid the ​types of food that stick. These may not actually be the foods that cause the inflammation but may ​just be solid types of food (meat or bread) that just get stuck and as such may be of little help in treating their condition. 

• Elimination diets of foods ​that might trigger the symptoms or inflammation.

Although a natural method, it requires careful ​avoidance of 2 to 6 or more foods and repeated (up to 7 or more) endoscopies to discover the ​true reactivity to each food, so that a long-term plan can be reached. The common foods linked to ​the condition which might be excluded include Dairy, Wheat, Eggs, Soya, Rice some fish and some ​vegetables (legumes).   During this process, careful attention to nutrition with the help of a ​dietitian, expert in EoE, is essential as these diets can have a high success rate, but they can be difficult to adhere to in the long term. 

• Elemental formula diet 

There is a limited place for an elemental diet (amino acid-based formula) such as Neocate or EO28 in Eosinophilic Oesophagitis EoE but only after failure of properly performed medical treatment and/or elimination diet.

This is mainly due to the fact that it can be difficult to drink due to its palatability as such it can require a nasal gastric tube (a tube inserted from nose to stomach) in order to consume the correct amount needed for nutrition. 

Also, the negative impact on the quality of life when abstaining from all kind of normal eating i.e. social mental impact on the sufferer and their family must be considered. 

• Topical steroids (budesonide or fluticasone)

Topical steroids have the ability to reduce ​the symptoms quickly in the majority of patients (up to 85% resolution of signs and symptoms 12 ​weeks after commencing therapy). They treat the underlying inflammation and so may prevent ​or treat the fibrous narrowing’s(oesophageal strictures) that occur in some patients with Eosinophilic Oesophagitis EoE. 

The treatment is given in the morning and last thing before bed via either an asthma style pump which you are swallowing fluticasone rather than inhale or budesonide slurry (thick liquid) which you swallow to coat the affected area.

For adults in some countries, there is also a dissolvable budesonide tablet licenced, that you dissolve on the tongue.

This treatment is given last thing before bed as a specially formulated dissolvable tablet that is held in the mouth and not swallowed the optimal amount of the drug gradually moves to into the oesophagus with normal amounts of saliva.

 

Whichever way the budesonide or fluticosone is administered, pump spray swallowing fluticasone / budesonide slurry or tablet it is very important that it is not washed off with liquid (drink or food) for as long as possible – preferably overnight but a minimum of 1 hour.

  

• Proton pump inhibitors PPI (Omeprazole Lansoprazole)

These drugs often used for acid-related diseases (of which ​EoE is not one) and they can reduce the symptoms and signs of inflammation on biopsy in up to 50% ​of patients.

• Dilatation

An endoscopic procedure performed under sedation usually, in which a ​narrowing (oesophageal stricture) is stretched to make the calibre of the oesophagus wider and allow food to ​pass through more comfortably.  It can be needed if the drugs/management is not effective and it would need to be complemented with a continuation of either a diet or ​drugs as above.

 

Allergy Testing 

Many of the triggers for Eosinophilic diseases are non IgE mediated - (delayed responses) intolerances which commonly do not show on a skin prick test. However, as 50-60% of Eosinophilic Oesophagitis EoE patients have an atopic (allergic) history, holistically, it is essential to manage any identified IgE mediated - (immediate) allergies such as pollens, dust or foods etc. It is also important to note seasonal allergy reactions (hayfever/asthma) have been reported by some patients to coincide with increased EoE symptoms; further research is needed in this area.

What are the long term issues?

If left untreated long term permanent damage can be caused to the oesophagus due to strictures (narrowing)

Eosinophil gut disorders are long term conditions (chronic is the medical term) and therefore patients need a lifelong method to control the symptoms and reduce the potential complications. The lack of generally accepted therapies makes the management of the condition challenging for both doctors and their patients.

Current Medical Guidelines

Download PDF Guidelines for the treatment of Eosinophilic Oesophagitis click below:

Latest International Guideline (2011)

Latest European Consensus (2017) 

Currently, there is no cure for EoE. 

More research is needed!

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Last updated 23/01/20 ©EOS Network 2020 All rights reserved