Eosinophilic esophagitis (EoE): chronic inflammation of the esophagus

Eosinophilic esophagitis (EoE): chronic inflammation of the esophagus

In medicine, eosinophilic esophagitis is a chronic allergy-like inflammation of the oesophagus, mainly associated with difficulty swallowing. There is currently no cure for the disease, but therapy for eosinophilic esophagitis can alleviate the symptoms. Below, we explain what you should know about eosinophilic esophagitis.

What is Eosinophilic Esophagitis?

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the oesophagus caused by the immune system . Due to the change in the mucous membrane of the oesophagus; it leads to difficulty swallowing and pain when eating.

Eosinophilic esophagitis is the second most common cause of chronic esophagitis after reflux esophagitis due to heartburn (acid-induced esophagitis). Nevertheless, EoE is a relatively young disease since it was only recognized as an independent clinical picture in 1993/94. Since then, the number of diagnoses has increased steadily.

 

Who is most likely to experience EoE?

For a long time, eosinophilic esophagitis has been considered a rare disease, but in recent years, it has been diagnosed with increasing frequency. It is questionable whether the increase in diagnoses is related to a better medical understanding of the disease or its actual increase.

The incidence of the disease has been increased in both children and adults. Eosinophilic esophagitis can occur at any age and is responsible for seven per cent of oesophagal symptoms.

Men are particularly frequently affected, representing about 70 per cent of EoE sufferers, while women (and children) only make up about 30 per cent. The disease occurs most frequently between the ages of 30 and 50. Most EoE patients also have allergic comorbidities, so 50 to 70 per cent of those affected also suffer from allergic respiratory diseases such as asthma or eczema.

In children suffering from eosinophilic esophagitis, it can often be traced back to food allergies.

Causes of eosinophilic esophagitis

Eosinophilic esophagitis (colloquially: “oesophagal asthma”) is caused by the accumulation of eosinophilic granulocytes, a subset of white blood cells, in the lining of the oesophagus. In the healthy mucous membrane of the oesophagus, dormant, non-specific T cells can initially be found, i.e. precursor cells of the immune system that have not yet specialized in their defence function.

The causes of eosinophilic esophagitis are relatively unexplored. Still, in most cases, an interaction between allergy-causing substances (food allergens or environmental allergens) and a disrupted membrane of the oesophagus is assumed to be the cause. This activates antigen-presenting cells – these are cells that generally recognize invading pathogens or altered body cells and initiate the immune reaction. These activate the dormant T cells, forming T helper cells. The eosinophilic granulocytes are attracted by the T helper cells.

The eosinophilic granulocytes, which generally serve to defend against parasites and are responsible for allergic reactions, now begin to attack not only the allergens but also the lining of the oesophagus. This leads to an allergy-related autoimmune disease in the oesophagus: eosinophilic esophagitis develops.

In short, allergy-causing substances are probably the cause, but in response, a type of autoimmune disease develops that leads to chronic esophagitis.

 

Sequelae of eosinophilic esophagitis

The eosinophilic granulocytes, lead to a permanent inflammatory reaction in the esophagus, leading to a change in the tissue on the mucous membrane:

  • The tree ring aspect is particularly striking in eosinophilic esophagitis. This refers to annular mucosal defects that look like the rings of a tree.
  • Another typical feature is the so-called crepe paper mucosa, which describes the now fragile, easily bleeding oesophagal mucosa (mucous membrane of the oesophagus).

Symptoms of eosinophilic esophagitis

The clinical symptoms of eosinophilic esophagitis can differ for each affected person, depending on their age. Symptoms of EoE include:

  • Difficulty swallowing (dysphagia)
  • Food getting stuck (bolus impaction or bolus obstruction)
  • heartburn
  • Vomit
  • backflow of the contents of the oesophagus into the mouth (regurgitation)
  • Pain behind the breastbone (retrosternal pain)

Below, we present the symptoms of eosinophilic esophagitis in detail.

Dysphagia: trouble swallowing

Dysphagia is a swallowing disorder that is usually associated with pain. As the most common symptom of eosinophilic esophagitis, dysphagia causes problems in sufferers during eating, ranging from mild gagging to complete obstruction of the oesophagus. The symptoms can last from a few minutes to several hours.

Dysphagia can present with a refusal to eat, especially in children.

 

Bolus impaction or obstruction: When food gets stuck

The bolus impaction or obstruction manifests itself in the unpredictable, long-lasting entrapment of food, so more than a third of those affected by EoE have had to have an emergency endoscopic removal of the trapped food.

Heartburn: Acid-Related Problems

Usually, chronic heartburn is a symptom of gastroesophageal reflux disease (GERD). A disruption between the oesophagus and stomach is often the cause. Usually, the sphincter at the entrance to the stomach ensures that there is no backflow of stomach contents with gastric acid into the oesophagus (reflux).

When the sphincter malfunctions or there is an overproduction of stomach acid, stomach acid can enter the oesophagus and cause pain. Eosinophilic esophagitis can also cause heartburn due to structural changes in the oesophagus.

Vomiting and Regurgitation: When food comes back up

Nausea is usually caused by irritation of the duodenum, a section of the small intestine. Overstimulation of the oesophagus is responsible for eosinophilic esophagitis.

Regurgitation refers to the pathological backflow of the contents of the oesophagus into the mouth. This happens mainly due to a so-called achalasia, which refers to the dysfunction of the smooth muscles. As a result, the chyme is not transported further due to the reduced locomotion due to the lack of muscle contraction.

 

Retrosternal Pain: Pain behind the breastbone

Retrosternal pain, which occurs behind the breastbone, affects about 20 to 50 per cent of people with eosinophilic esophagitis. However, they can also happen for other reasons, for example, during gastritis and stomach lining inflammation. In contrast to heartburn, retrosternal pain has a fixed localization.

Altered food intake as a result of EoE

The symptoms described above are usually more pronounced in children or adolescents than adults. Affected children often refuse to eat and complain of pain in the chest and abdomen, vomiting and severe food regurgitation.

Reduced food intake also causes growth and development disorders in children, as well as physical symptoms such as tiredness and listlessness.

Many adults also adapt to their limitations, resulting in hasty food intake and avoiding dry and fibrous food (e.g. dry rice, fibrous meatcorn ). The disorder of the oesophagus, i.e. the oesophagus, can, therefore, not always be determined solely based on the symptoms.

Diagnosis of eosinophilic esophagitis

An endoscopy, i.e. an examination of the oesophagus with an endoscope, must be carried out to diagnose eosinophilic esophagitis. The structural changes in the oesophagal mucosa can be seen in the endoscopy findings: the tree ring aspect mentioned above and the crepe paper mucosa can typically be seen.

A tissue sample must also be taken to confirm the diagnosis. The finding is confirmed if more than 15 eosinophilic granulocytes are found per HPF (i.e., in the visible section at 400x magnification under the microscope).

 

What to do? Therapy of eosinophilic esophagitis

Although eosinophilic esophagitis cannot be cured, proper therapy can restore symptom-free eating habits and significantly improve quality of life.

The three primary treatment options are:

  • Topical corticosteroids
  • Elimination and Elemental Diets
  • esophageal dilatation

In the following, we present the treatment options for eosinophilic esophagitis.

Topical corticosteroids: drugs against EoE

Corticosteroids are very effective medications for treating eosinophilic esophagitis because they help control both the swallowing difficulty and the inflammation. Fluticasone and budesonide (contained in the drug Jorveza®, for example) are two equivalent active ingredients that can be taken using an inhaler, with which the drug is blown into the mouth and swallowed.

The drug must be taken 30 minutes before breakfast and dinner for eight weeks. Budesonide can also be mixed up in a suspension and swallowed.

Elimination and Elemental Diets: What to Eat at EoE?

Those who do not want to take medication can try to treat eosinophilic esophagitis naturally. A change in diet in the form of a special diet can help here. This is often successful, especially with children.

With the elimination diet, the food allergens are individually determined with the help of allergy tests and omitted.

The elemental diet, which can relieve symptoms in children and adults, aims to be as protein-free as possible for six weeks, resulting in a virtually allergen-free diet. Six foods in particular are avoided during this diet, namely cow’s milk, wheat, soy, eggsnuts and seafood. However, care must be taken during this diet to avoid deficiency symptoms.

 

Esophageal dilatation: widening of the esophagus

This therapy option is only used in those affected with severe stenoses, i.e. a severe narrowing of the oesophagus. The oesophagus is carefully expanded, for example, with a balloon. Care must be taken to avoid oesophagal tears (tears in and around the oesophagus) or perforation.

Homeopathic treatment of eosinophilic esophagitis

Alternatively, homoeopathy also offers treatment approaches for uncomplicated and mild forms of eosinophilic esophagitis, which have not been scientifically investigated and proven. Therapy should always be discussed with and accompanied by a doctor.

 

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