Eosinophilic esophagitis EE), also known as allergic esophagitis, may be misdiagnosed as acid reflux in adults and children. Symptoms include choking spells or swallowing difficulties, chest or upper abdominal pain, heartburn not relieved by acid blocker medications, and bouts of vomiting refusal to eat. It is caused allergy blood cells called eosinophils that are not normally present in the esophagus with the exception of relatively few numbers in the lower esophagus in the setting of acid reflux invading the lining of the esophagus or feeding tube, often as a result of food and/or inhaled pollen allergies.Eosinophils invade the lining of the gut in response to allergic reactions to foods or medications and parasite infections. Once present in the lining they release chemicals in response to foods or other stimuli that can cause swelling, constriction, bleeding, perforation, itching, pain, or scarring of the affected gut.
EE was first described in children but is now being recognized in more adults, especially young men or teenage boys. During an upper endoscopy exam doctors suspect the diagnosis visually by a characteristic appearance of concentric rings that produce a corrugated appearance of the normal smooth tubular esophagus that resembles a cat esophagus termed felinization though some doctors fail to recognize these signs. The lining usually is friable or prone to tear with a “crepe paper” appearance. The diagnosis is confirmed by biopsies that show > or equal to 24 eosinophils per high-powered field.
Constriction or narrowing of the esophagus in EE is common and associated with painful swallowing and bout of food sticking. Trying to “stretch” or dilate this narrowing by a doctor prior to treatment of the underlying inflammation can result in a superficial tear in the esophagus resulting in severe pain or bleeding or worse a full thickness tear or hole requiring surgery.
Foods allergy is commonly associated though not always proved. If you are found to be allergic to food avoidance is recommended as a treatment. Medical treatment is primarily the use of swallowed inhaled nasal steroids. Though swallowed steroid spray usually works, upon discontinuance the condition may return if the allergic foods are not avoided.
A 2006 randomized, double blind, placebo controlled trial of fluticasone propionate spray in children with EE proved a 50% biopsy proven healing compared with only 9% when placebo used. Interestingly, “non-allergic” kids responded best (66% versus 25%). The fact as few as 25% of the allergic did not respond emphasizes the importance of food elimination treatment in the allergic. In another study, a six-food elimination diet was used successfully in children. Be sure to subscribe to the food doc blog so you don’t miss more on the role of food elimination diets in EE and other food related conditions from Dr. Scot Lewey, the Food Allergies Specialist – the Food Doc.
Reference:
A Randomized, Double-Blind, Placebo-Controlled Trial of Fluticasone Propionate for Pediatric Eosinophilic Esophagitis. Konikoff MR et al Gastroenterology 2006;131:1381-1391.
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Dr. Scot Lewey
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