Eosinophilic Oesophagitis (EoE)
This allergic response results in the excessive production of cells called eosinophils, which are usually only present in the oesophagus in very low numbers, if at all. Over time, the eosinophils infiltrate and make changes to the lining of the oesophagus which can lead to re modelling or thickening (fibrosis) which make it hard to swallow food, or strictures (narrowings) which cause food to get blocked (bolus). EoE affects all age groups but is more commonly found in men aged 30 – 50. In the western world, around 16 people out of every 100,000 are thought to have the condition with the numbers of those being diagnosed growing year on year. It is not known why some people suffer this allergic response, although it is thought there may be a genetic link. Around half of people diagnosed with EoE also have another allergic conditions such as allergic rhinitis, eczema or asthma.
Symptoms and Disease Course
The main symptoms of EoE in adults are dysphagia (difficulty in swallowing food) chest pain, heartburn and food bolus impaction (food sticking in the oesophagus) or a sensation of sticking food. People with EoE typically tend to eat more slowly than others, drink lots of water with their food and avoid ‘harder to swallow’ foods such as bread or red meats. In children, symptoms may include vomiting, nausea, abdominal pain, reluctance to eat and failure to thrive. If left untreated the symptoms can worsen, with increased oesophageal fibrosis and incidence of bolus impaction. Over 50% of admissions to A & E with food bolus impaction is due to EoE. Because of some similarity in symptoms, EoE is often misdiagnosed as GORD (gastro oesophageal reflux disease) although the two conditions are completely different and usually require very different treatment pathways.
EoE is diagnosed using three main criteria:
Symptoms and history (as above), how the oesophagus looks, on examination (endoscopy) and under the microscope (histology) and by excluding other possible diseases such as GORD, Crohn’s and Coeliac Disease. It is vital that during endoscopy enough biopsies (at least three 6 from the proximal, mid and distal parts of the oesophagus), are taken to allow the clinicians to be able to correctly count the number of eosinophils present.
EoE Patient Leaflet can be downloaded from here.
There is no cure for EoE although with adequate treatment the disease can be kept in remission.
There are three main treatment pathways:
Dietary Exclusion – this involves identifying the cause of the allergic response and excluding it from the patient’s diet or environment. Although this can be a very successful approach to resolving EoE, it is extremely hard for the patient to maintain and involves a great deal of external support and follow up investigations.
PPIs (proton pump inhibitors) – these work in a small number of cases of EoE but it is not exactly clear why. There are no placebo controlled studies into the use of PPIs in treating EoE.
Steroids – there is plenty of evidence to show that topical steroids as opposed to systemic steroids can be very successful at treating EoE with few side effects. Up until now topical steroids have been prescribed either using an inhaler or in a liquid or ‘slurry’ form. Recently a drug called Jorveza, which has been specifically designed to deliver the steroid to the site of the oesophageal inflammation, was licensed for use in the UK.
Endoscopic oesophageal dilation is sometimes used when strictures have developed in the oesophagus. However, although dilation relieves the symptom, it does not treat the disease and without other treatment (as above) the strictures can and often do return. In addition, there are some risks to the procedure including bleeding and perforation.