Eosinophilic Esophagitis : Recognizing Symptoms and Comprehensive Management

1. Introduction

   1. What is Eosinophilic Esophagitis?

      Eosinophilic esophagitis is a chronic immune-mediated disorder characterized by the presence of an abnormally high number of eosinophils.

      Eosinophils are a type of white blood cells that are typically involved in allergic reactions and inflammation. Increased presence of eosinophils in the esophagus leads to inflammation and damage to the tissue. This can lead to a range of symptoms, including difficulty in swallowing, food impaction, chest pain, and other gastrointestinal issues.

      Eosinophilic esophagitis is a type of allergic or immune-mediated disorder and is distinct from conditions like gastroesophageal reflux disease. It requires specialized medical care for diagnosis and management involving a combination of dietary changes, medications, and occasionally endoscopic procedures.

   2. Importance of Recognizing Symptoms

      Identifying the symptoms of eosinophilic esophagitis allows for prompt medical attention and intervention. This can be helpful in effectively managing and preventing the progression of the condition.

      Recognizing symptoms of eosinophilic esophagitis is important for several reasons: 

      • It can be helpful in improving the quality of life of a person as timely intervention can improve overall well-being.
      • This can be helpful in preventing complications, which may exacerbate swallowing difficulties requiring more invasive treatment.
      • Recognizing symptoms can help distinguish eosinophilic esophagitis from other gastrointestinal disorders like gastroesophageal reflux disease or irritable bowel syndrome.
      • Eosinophilic esophagitis may result in malnutrition, especially in children. Symptom recognition helps in implementing dietary changes or alternative feeding strategies to ensure proper nutrition.
      • Early recognition of symptoms prompts healthcare providers to conduct appropriate diagnostic tests.
      • It can be helpful for the individual and their families to access educational materials and support groups that can provide valuable information about the condition and coping strategies.

2. Causes and Risk Factors of Eosinophilic Esophagitis

   What exactly causes eosinophilic esophagitis is not yet known. It appears to occur due to abnormal immune system response related to food allergy or environmental triggers.⁽¹⁾ It is estimated to occur in 1 out of every 2000 people.⁽²⁾ It is believed that eosinophilic esophagitis may be caused due to a combination of genetic and environmental factors.

   The risk factors of eosinophilic esophagitis include:

   • Sex: Eosinophilic esophagitis is known to occur more commonly in males than females.⁽³⁾
   • Medical History: It is known that 50% of people with eosinophilic esophagitis also have asthma.⁽⁴⁾ A history of food allergy also increases the risk of the condition.
   • Family History: Specific types of genes such as eotaxin-3 may lead to the development of eosinophilic esophagitis.⁽¹⁾

3. Symptoms of Eosinophilic Esophagitis

   There are a range of symptoms of eosinophilic esophagitis. These vary in intensity and presentation. The symptoms include: 

   • Dysphagia: Having difficulty in swallowing is known as dysphagia. As the esophagus gets inflamed, swelling occurs. This may make swallowing difficult. 70% of adults with eosinophilic esophagitis have difficulty in swallowing solids.⁽⁵⁾ Individuals with eosinophilic esophagitis need to drink plenty of fluids to help swallow food

   In some people with this condition, the esophagus gets so narrowed that the food cannot pass properly. This may lead to food impaction causing the food to get stuck in the esophagus.⁽⁶⁾ This may sometimes further lead to life-threatening complications.

   A study done in 2020 found that 50% of adults seeking treatment for food impaction were eventually diagnosed with eosinophilic esophagitis.⁽⁷⁾

   • Stunted Growth: Due to difficulty in swallowing, children may not get the appropriate nutrition needed for proper growth. This may cause stunted growth. The symptoms present by children with eosinophilic esophagitis include abdominal pain, vomiting, food refusal, and failure to thrive. Their appetite may decrease. All of these symptoms and problems with swallowing may lead to malnutrition and stunted growth.
   • Other Symptoms: There are a few symptoms that may occur just in children but not in adults, which include abdominal pain. There may be other symptoms of gastroesophageal reflux disease such as heartburn.

   Less common symptoms associated with eosinophilic esophagitis include chronic cough which may be due to irritation and inflammation of the esophagus. The persistent cough may be mistaken as another respiratory condition. Also, eosinophilic esophagitis is linked to asthma-like symptoms.

   Eosinophilic esophagitis can also coexist with allergic conditions such as atopic dermatitis, suggesting a shared immunologic mechanism.

   Recognizing various manifestations is important for thorough evaluation and tailored management approaches for individuals affected by this complex condition.

4. Diagnostic Procedures and Test for Eosinophilic Esophagitis

   Some people may experience a delay in the diagnosis, due to the lack of awareness about the condition. The diagnosis of eosinophilic esophagitis includes: 

   • Endoscopy: It involves inserting a small tube into the esophagus through the mouth to take a tissue sample. The eosinophil count is then analyzed. If the eosinophil count is more than 15, eosinophilic esophagitis is diagnosed.
   • Allergy Testing: This helps in identifying specific allergens that may be triggering eosinophilic esophagitis. Certain foods or environmental allergens may exacerbate the condition.
   • pH Monitoring: ph monitoring helps in differentiating eosinophilic esophagitis from gastroesophageal reflux disease by assessing the level of acid exposure.
   • Esophageal Manometry: This test helps in ruling out the underlying motility disorders that may be contributing to symptoms or mimic eosinophilic esophagitis. The procedure involves inserting a catheter through the nose and into the esophagus to measure the strength and coordination of esophageal contractions
   • Radiologic Imaging: Imaging studies like barium swallow tests or CT and MRI scans may be helpful in obtaining detailed images of the chest and upper abdomen.

   Diagnostic procedures and tests collectively provide a comprehensive evaluation of eosinophilic esophagitis, aiding in accurate diagnosis and guiding the development of a tailored treatment plan for affected individuals.

5. Differential Diagnosis of Eosinophilic Esophagitis

   Some people with eosinophilic esophagitis experience heartburn and acid reflux. These are frequent symptoms of gastroesophageal reflux disease as well. As these symptoms overlap, doctors might initially diagnose the condition as gastroesophageal reflux disease.⁽⁸⁾

   After clinical evaluation, the two conditions can be distinguished. However, there is no significant increase in the eosinophils in gastroesophageal reflux disease.

6. Treatment of Eosinophilic Esophagitis

   Dietary Management

   The treatment of eosinophilic esophagitis includes a combination of medication and diet management.

   The individual is advised to make dietary modifications including an elimination diet. This involves removing suspected foods that might be causing an allergic response. This includes a six-food elimination diet which involves eliminating foods that are commonly known to cause allergies, such as: 

   • Animal milk
   • Soy
   • Nuts
   • Fish and shellfish
   • Wheat
   • Eggs

   There is also a step-down approach in which the individuals are put on a highly restrictive diet and gradually reintroduced to foods. This helps in identifying specific triggers.

   Pharmacological Interventions

   Acid suppressors such as proton pump inhibitors are used as they help reduce stomach acids and are beneficial for individuals with concurrent acid reflux.

   Topical steroids are used to target inflammation of the esophagus. These are often considered the first line of treatment for eosinophilic esophagitis.

   Systemic corticosteroids are used in severe or refractory cases of eosinophilic esophagitis. These medications are taken orally or intravenously and can provide rapid relief of symptoms. These provide rapid relief from symptoms but are reserved for acute situations due to long-term side effects risk.

   Biologic Therapies

   Anti-IL-5 agents are the biologic medications that target eosinophils. These drugs work by inhibiting interleukin-5 which is crucial for eosinophil activation. Interleukin-13 (IL13) is another cytokine that is involved in the inflammatory response seen in eosinophilic esophagitis. Anti-IL-13 aims to modulate this immune pathway. These therapies are currently being studied in clinical trials.

   Endoscopic Interventions

   For individuals with esophageal strictures balloon dilation can be performed during endoscopy. This helps in widening the esophagus which alleviates swallowing difficulties.

   Esophageal plicature is a novel endoscopic technique aimed at reducing the diameter of the esophagus, providing relief from the symptoms.

   Follow-Up and Monitoring

   After initiating treatment, the progress of esophageal tissue is monitored. Follow-up endoscopies and biopsies are done to assess the treatment response.

   It is important for the patient to regularly report the symptoms to the healthcare provider.

   Patient Education and Empowerment

   Educating the patient and their families about the condition is important. Management strategies empower them to actively participate in their treatment.

7. Conclusion

   Recognizing indicators of eosinophilic esophagitis is important for early intervention and effective management. The are various symptoms ranging from dysphagia and food impaction to chest pain and allergic comorbidities.

   Having an understanding of the less common presentations such as chronic cough and asthma-like symptoms, expands the diagnostic spectrum. Additionally, considering associated risk factors, such as allergies and genetic predisposition, contributes to comprehensive assessment.

   Diagnostic procedures including endoscopy, biopsy, allergy testing, and pH monitoring further refine the diagnosis. By diligently recognizing and investigating these indicators, healthcare providers can move towards a timely diagnosis and initiate tailored treatment strategies. All of this enhances the quality of life of a person affected by eosinophilic esophagitis.

Also Read:

• What is Eosinophilic Esophagitis: Causes, Symptoms, Treatment, Prognosis