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Eosinophilic Esophagitis

By Kristle Lee Lynch, MD, Assistant Professor of Medicine, Perelman School of Medicine at The University of Pennsylvania

Eosinophilic esophagitis is an inflammatory disorder in which the wall of the esophagus becomes filled with large numbers of eosinophils, a type of white blood cell.

  • This disorder may be caused by food allergies.

  • Children may refuse to eat and have chest pain, and adults may have food lodged in their esophagus and difficulty swallowing.

  • The diagnosis is based on the results of an endoscopy and biopsy, sometimes along with x-rays and blood tests.

  • Treatment includes corticosteroids, changes in diet, and sometimes dilation of the esophagus.

The esophagus is the hollow tube that leads from the throat (pharynx) to the stomach.

Eosinophilic esophagitis can begin at any time between infancy and young adulthood. It occasionally occurs in older adults and is more common among males.

This disorder may be caused by an allergic reaction to certain foods in people who have genetic risk factors. The allergic reaction causes inflammation that irritates the esophagus. If not treated, the inflammation eventually leads to chronic narrowing (stricture) of the esophagus.

Symptoms

Infants and children may refuse to eat and have vomiting, chest pain, or both.

People may have symptoms similar to those of gastroesophageal reflux disease (GERD), particularly heartburn (a burning pain behind the breastbone).

People who have a stricture (usually adults who have had esophagitis for a long time) often have difficulty swallowing (dysphagia) and may have food lodged in their esophagus (called esophageal food impaction). People may also have other allergic disorders, such as asthma or eczema.

Diagnosis

  • Endoscopy and biopsy

  • Sometimes barium swallow x-rays

  • Sometimes skin and blood tests

Doctors suspect the diagnosis of eosinophilic esophagitis in people of any age who have symptoms of GERD that do not go away with typical treatment and in adults who have food lodged in their esophagus.

To diagnose the disorder, doctors look in the esophagus with a flexible tube (endoscopy). During the endoscopy, doctors take tissue samples to analyze under a microscope (called a biopsy).

Sometimes, doctors also do a barium swallow. In this test, people are given barium in a liquid before x-rays are taken. The barium outlines the esophagus, making abnormalities easier to see.

Doctors may also do tests for food allergies to identify possible triggers. Skin tests and a radioallergosorbent test (RAST) of the blood may also be done to determine triggers.

Treatment

  • Corticosteroids

  • Changes in diet

  • Sometimes dilation of the esophagus

Corticosteroids (such as fluticasone and budesonide) that are swallowed to coat the esophagus can help reduce inflammation. People may use a fluticasone inhaler and puff the drug into their mouth without inhaling and then swallow it. This way the drug coats the esophagus and does not enter the lungs. Budesonide in liquid form also can be mixed with a sugar substitute or thickener (such as cornstarch) and swallowed. People may rinse out their mouth afterwards to help avoid a fungal infection of the mouth (thrush).

Doctors may instruct people to change their diet. Changes in diet are usually more effective in children than adults. Any food allergies identified through allergy testing are eliminated from the diet, or people can follow a diet that eliminates wheat, dairy, seafood, nuts, eggs, and soy (see elimination diet).

If people have narrowing of the esophagus, doctors inflate a balloon in the esophagus during endoscopy to dilate it. Doctors often do several dilations using progressively larger balloons to prevent the esophagus from tearing.