< Allergy and Immunology

Eosinophilic Esophagitis  (EOE)

What is eosinophilic esophagitis?

Eosinophilic (ee-uh-sin-uh-fil-ik) esophagitis (EoE) is a recognized chronic allergic/immune condition. A person with EoE will have inflammation of the esophagus. The esophagus is the tube that sends food from the mouth to the stomach.

In EoE, large numbers of white blood cells called eosinophils are found in the tissue of the esophagus. Normally there are no eosinophils in the esophagus. The symptoms of EoE vary with age. In infants and toddlers, you may notice that they refuse their food or are not growing properly. School-age children often have recurring abdominal pain, trouble swallowing or vomiting. Teenagers and adults most often have difficulty swallowing, particularly dry or dense, solid foods. The esophagus can narrow to the point that food gets stuck. This is called food impaction and it is a medical emergency.

Allergists and gastroenterologists are seeing many more patients with EoE. This is due to an increased incidence of EoE and greater physician awareness. EoE is considered to be a chronic condition and is not outgrown.

Other diseases can also result in eosinophils in the esophagus. One example is acid reflux. Proton-pump inhibitors (PPIs) are medications that help reduce stomach acid production.  These drugs are commonly used to treat heartburn, GERD (gastroesophageal reflux disease) and other conditions caused by too much stomach acid. Proton-pump inhibitor responsive esophageal eosinophilia or PPI-REE is a condition that has the same symptoms and esophageal biopsy findings as EoE.  However, after a trial of PPIs, symptoms resolve and repeat esophageal biopsies are normal.

How do we treat it?

Empiric Elimination Diets
Eliminating major food allergens from the diet before any food allergy testing is also an accepted treatment of EoE. The foods excluded usually include dairy, egg, wheat, soy, peanut, tree nuts and fish/shellfish. These diets have been shown to be very helpful in treating EoE, although they can be very difficult to follow, especially without the help of a dietician with experience in dealing with EoE. Foods are typically added back one at a time with follow up endoscopies to make sure that EoE remains in control.

Elemental Diets
In this diet, all sources of protein are removed from the diet. The patient receives their nutrition from an amino acid formula as well as simple sugars and oils. All other food is removed from the diet. A feeding tube may be needed since many people do not like the taste of this formula. This approach is generally reserved for children with multiple food allergies who have not responded to other forms of treatment.  

Medical Therapy
No medications are currently approved by the U.S. Food and Drug Administration (FDA) to treat EoE. However, medications have been shown to reduce the number of eosinophils in the esophagus and improve symptoms. Corticosteroids, which control inflammation, are the most helpful medications for treating EoE. Swallowing small doses of corticosteroids is the most common treatment. Different forms of swallowed corticosteroids are available. At first, higher doses may be needed to control the inflammation but the higher doses are linked with a greater risk of side effects. As a result, once esophageal inflammation is adequately controlled the dose of swallowed corticosteroid is tapered to the smallest dose necessary to maintain control.

Proton pump inhibitors, which control the amount of acid produced, have also been used to help diagnose and treat EoE. Some patients respond well to proton pump inhibitors and have a large decrease in the number of eosinophils and inflammation when a follow up endoscopy and biopsy is done. However, proton pump inhibitors can also improve EoE symptoms without making the inflammation any better. Researchers are now looking into using them to manage EoE. Careful monitoring by a physician knowledgeable in treating EoE is very important.

Instructions for use of Flovent (fluticasone propionate) to treat Eosinophilic Esophagitis

  • Place the inhaler device directly into the mouth (do not use a spacer)
  • Hold your breath, pump the inhaler and then swallow
  • Repeat until all of the recommended puffs are taken
  • You may swish a small amount of water (no more than a teaspoon) afterwards to rinse out your mouth, but then spit out the liquid.
  • You should avoid eating or drinking for 30 minutes after fluticasone is taken to prevent the medication from being washed into the stomach. 

Instructions for use of Pulmicort (budesonide) to treat Eosinophilic Esophagitis

  • Each respule should be mixed to achieve a “slurry” consistency
  • Mixing options:
    • Splenda (4 packets/1 respule)
    • Applesauce (1 teaspoon/1 respule)
    • Honey (1 teaspoon/1 respule)
    • Neocate Nutra (½ scoop using the measuring cup that comes with the Nutra – mix with 2 respules)

After mixing, the slurry should be swallowed.

  • You may swish a small amount of water (no more than a teaspoon) afterwards to rinse out your mouth, but then spit out the liquid.
  • You should avoid eating or drinking for 30 minutes after the Pulmicort (budesonide) is taken to prevent the medication from being washed into the stomach.