Eosinophilic esophagitis – Important information about esophageal inflammation

The eosinophilic esophagitis is a chronic disease of the esophagus, which can result from a malfunctioning of our immune system leading to an inflammatory response with eosinophilic granulocytes. The disease was first described 25 years ago and is now one of the most common diseases of the esophagus. The most common symptoms are dysphagia and stuck food leftovers. Last year the European Society for Eosinophilic Esophagitis (EUREOS) published a new guideline focusing on diagnosis and therapy. In this article we summarize the most important points of this guideline with additional background information.

What does eosinophilic esophagitis mean?

Esophagitis refers to an inflammation of the esophagus. With eosinophilic esophagitis defensive cells remain in the mucous membrane for a long period of time. If you look at a tissue sample of the esophagus under the microscope, in patients with eosinophilic esophagitis, a subgroup of white blood cells, eosinophilic granulocytes, is conspicuous. All granulocytes are formed in the bone marrow and then released into the bloodstream. If they can be colored red-orange with the dye eosin (ancient Greek "dawn"), then they are eosinophilic granulocytes. They usually control allergic reactions and fight parasites or viruses.

With some illnesses mediators are released that activate selected cells of the immune system. In some cases, eosinophilic granulocytes are then lured into the mucosal surface of the esophagus. When diagnosing eosinophilic esophagitis, doctors consider the following other diseases (potential for confusion):

• Crohn's disease
• Eosinophilic gastroenteritis
• Movement disorder of the esophageal muscles (achalasia)
• Infections, especially from parasites
• Hypersensitivity to drugs
• Inflammatory diseases of the blood vessels (vasculitis)
• Pemphigoid
• Connective tissue diseases
• Rejection reaction (graft versus host disease)

Who can suffer from eosinophilic esophagitis?

The disease is possible in all age groups. Most commonly it affects people in late adolescence and adults between the age of 30 and 50. Men are two to three times more likely to get sick. Twin studies prove there is a genetic component, but environmental factors seem to have a greater impact on the development of the disease. Rhinitis, asthma, eczema and food allergies are known as possible comorbidities.

What are the symptoms?

With eosinophilic esophagitis, chronic inflammation leads to morphological changes in the esophagus. Lumen is restricted through a thickening in the wall, so that there is less space for the food.

Symptoms in children:

• Developmental disorders
• Vomiting
• Regurgitation of stomach acid
• Gagging
• Food refusal

Symptoms in adults:

• Dysphagia
• Stuck food leftovers
• Vomiting

What is the course of the disease of eosinophilic esophagitis?

It is currently unclear whether eosinophilic esophagitis is a lifelong disease in all cases. In untreated patients, the inflammation of the esophagus and thus the symptoms usually remain. The same applies to patients who start therapy and end it early. Many patients suffer from reduced quality of life and psychosocial restrictions, **which often improve under treatment. With eosinophilic esophagitis and existing Barrett's esophagus, there is **no increased risk of developing a malignant tumor.

How is the diagnosis of eosinophilic esophagitis made?

To make a diagnosis small pieces of tissue from different parts of the esophagus are taken (step biopsy). To do this, the doctor pushes a flexible tube with a light and a video camera into the esophagus (endoscopy). He or she can thereby assess the appearance, narrowing and organ remodeling. Doctors use the same procedure to evaluate the success of the therapy. In the future, biomarkers from the esophageal secretion might be used for therapy monitoring. So far, data from large-scale studies are still missing.

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How is eosinophilic esophagitis treated?

Local glucocorticoids have the greatest chance of success for initial therapy. Another possible initial option is proton pump inhibitors. The two therapies mentioned can partially reverse the changes in the esophagus. Dietary intervention usually remains a reserve therapy when other options are exhausted.

What drugs are used for eosinophilic esophagitis?

Local steroids

The application of fluticasone or budesonide is by far the most effective, scientifically proven therapy option. They are available as a spray or suspension for drinking. They are considered safe drugs with few side effects. The application time varies between six and twelve weeks. Current studies are currently also testing the two-week intake of budesonide tablets, which are only supposed to work in the esophagus.

Systemic steroids

Systemic steroids are ingested as a tablet and act at many different points of attack throughout the body. Therefore, they are used much less often and are explicitly not recommended in the new guidelines of 2017. They have a less favorable side effect profile and offer no advantages over local steroids.

Proton pump inhibitors (PPI)

The use of PPI is indicated if you have reflux symptoms or reflux lesions in the esophagus. Reflux lesions occur when gastric juice enters the esophagus over a long period of time, causing damage to the mucous membrane. PPI leads in 50 percent of patients to a decrease in tissue damage and in more than 60 percent to an improvement of symptoms. So far there are no reliable indications that can predict whether therapy with PPI will work.

Which diet or nutrition helps with eosinophilic esophagitis?

Our nutritionists are specially trained on digestive diseases. Arrange a non-binding initial consultation here.

Avoiding foods that trigger eosinophilic esophagitis for a defined period of time, can lead to permanent freedom from symptoms. There are three dietary treatment options:

1. empirical elimination diet
2. elemental diet
3. allergy-test based elimination diet

With all of these diets, the support of certified nutritional counseling is recommended, as this is the only way to ensure success. Nutritional therapy is usually reimbursed by all statutory health insurance companies.

Empirical elimination diet

If dietary therapy is chosen, then the 6-food elimination diet is mostly the first choice. It reduces the absorption of the most common food allergens:

• Cow's milk protein
• Wheat
• Eggs
• Soy
• Nuts
• Fish / Seafood

The diet needs to be carried out for six weeks. The food can then be gradually reintroduced. Numerous endoscopic interventions are necessary in this period to assess the esophagus. The response rates are quite high at 60–85 percent, but the therapy requires a high expenditure of time and excellent cooperation by the patient. Many patients experience the elimination diet as extremely restrictive. Therefore, nowadays it is only used as a reserve therapy.

Elemental diet

Here the patient only consumes a liquid amino acid-based formula solution. All other foods have to be completely avoided, Such a diet is very drastic and can only be carried out over a very short period of time. It is an absolute reserve therapy, although it has the highest effectiveness compared to all other forms of therapy. The formula solution has a bitter taste, which is why children usually even need a gastric tube.

Allergy-test based elimination diet:

Foods that trigger allergies can be found using three different test methods:

• Prick test
• Patch test
• IgE specific blood test

The allergy-causing foods are completely avoided. Eosinophilic esophagitis improves with this form of therapy in a third of adults and half of children. However, allergy screening is not recommended as the standard procedure, There are two reasons:

• Allergens that do not cause disease are often found in the test
• Allergens causing the disease are often not found in the test

In recent years, 4-food (Cow's milk, wheat, eggs, legumes) and 2-food (Animal milk, cereals containing gluten) diets have been evaluated but they showed worse success rates regarding the inflammatory response in the esophagus.

By the way: Our practice specializes in digestive diseases and especially eosinophilic esophagitis.  We offer **therapy courses for long-term changes in diet** with certified nutritionists. Arrange your free initial consultation under this link.