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Eosinophilic Esophagitis

In esophagitis (inflammation of the esophagus), immune cells (white blood cells) accumulate in the lining of the esophagus. Eosinophilic esophagitis is a chronic inflammatory esophagitis where eosinophils (a certain kind of white blood cells) can accumulate in large numbers in the lining of the esophagus. The process affects the normal function of the esophagus. The eosinophils are normally activated in allergic immune responses, therefore the theory is that eosinophilic esophagitis is a form of food allergy.

Causes

The triggers of the allergic-like inflammatory response in eosinophilic esophagitis are not known or understood. Food allergens and even airborne allergens are implied as possible triggers.
Newly found awareness about eosinophilic esophagitis in patients with dysphagia has recently increased the reported incidence of this condition.

Symptoms

The most common symptoms of eosinophilic esophagitis are dysphagia (difficulty swallowing) mostly with solid food.
The dysphagia is in part due to the inability of the esophagus to accommodate the food due to the chronic inflammation that stiffens the esophagus. Other symptoms may include heartburn and chest pain, but these are less frequent. In advanced disease, the food can get impacted in the esophagus, requiring endoscopic treatment and removal of the food blockage.

Eosinophilic Esophagitis Diagnosis

Patients with dysphagia will get an upper endoscopy to rule out other conditions such as esophageal cancer, achalasia and strictures. However, patients with eosinophilic esophagitis have specific endoscopic characteristics like narrowing of the esophagus, concentric rings and longitudinal furrows, as shown in this image.

In some cases, the endoscopic evaluation shows normal esophageal mucosa and diagnosis is made by biopsies that show the large amount of eosinophils in the lining of the esophagus, as shown below.

Eosinophilic Esophagitis Treatment

Since the major theory about the cause of eosinophilic esophagitis is allergic reaction to certain foods, identifying and eliminating those foods is the main part of the treatment.

In patients with dysphagia and food impaction, endoscopic dilation of the esophagus has provided relief in most cases.

Medications

Medications such as proton pump inhibitors and fluticasone propionate (Inhaler steroids sprayed at the back of the throat and swallowed) are used to treat eosinophilic esophagitis. Oral steroids such as prednisone also can be used in refractory cases of eosinophilic esophagitis.

By Michel Kafrouni, M.D.

References 

1. Furuta GT, Liacouras CA, Collins MH, Gupta SK, Justinich C, Putnam PE, Bonis P, Hassall E, Straumann A, Rothenberg ME; First International Gastrointestinal Eosinophil Research Symposium (FIGERS) Subcommittees. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007 Oct;133(4):1342-63. Epub 2007 Aug 8.
2. Moawad FJ, Veerappan GR, Wong RK. Eosinophilic esophagitis. Dig Dis Sci. 2009 Sep;54(9):1818-28. Epub 2009 Jun 25