New Treatments for Eosinophilic Esophagitis
The esophagus is the muscular tube that propels food from the mouth into the stomach through a rhythmic, coordinated peristaltic action. The interior lumen of the tube is covered by a thin mucus membrane. This normal function can be impaired when the structure is chronically inflamed by various allergic triggers. A subset of white blood cells, called eosinophils, accumulate in the mucus membrane of the esophagus in response to the exposure of allergens that an individual is sensitized to. These eosinophils will release a number of chemical mediators of inflammation into the tissues causing structural and functional damage. When this occurs, the individual has a condition called eosinophilic esophagitis (EoE).
Eosinophilic esophagitis is a relatively newly recognized condition. It has been increasingly diagnosed in adults and children over the past couple of decades. The frequency of eosinophilic esophagitis has been estimated to be approximately 1 in 2,000 individuals.
Food allergens are the most common cause of eosinophilic esophagitis. Though any food can be an allergen in theory, the most commonly implicated foods in patients with eosinophilic esophagitis are milk, wheat, soy, eggs, peanuts, tree nuts, and fish/shellfish. Individuals with eosinophilic esophagitis often have other allergic diseases such as allergic rhinitis (i.e., hay fever), asthma and/or eczema (i.e., atopic dermatitis).
Genetic factors play a role in the causation of eosinophilic esophagitis as the condition is known to run in families. Some individuals with this condition have been found to have an unusually high expression of a particular gene named eotaxin-3.
SYMPTOMS:
The symptoms of eosinophilic esophagitis ay vary by the age of the patient as well as the severity of the inflammation. The main symptoms are listed below:
- Difficulty swallowing (i.e., dysphagia)
- Food getting stuck in the throat (impaction)
- Nausea/vomiting
- Abdominal pain
- Poor appetite/weight loss
DIAGNOSIS:
The diagnosis is often delayed because of a lack of awareness of this condition. A high index of suspicion is needed for the detection of eosinophilic esophagitis in both children and adults presenting with above symptoms.
In order to confirm the diagnosis of eosinophilic esophagitis, it is necessary to do an upper endoscopy, where a thin flexible tube with a light source is passed into the esophagus through the mouth in order to visualize the esophagus. The appearance of whitish patches (i.e., plaques), furrows, and in late stages, circular rings resulting from scarring, are highly suggestive of eosinophilic esophagitis. Multiple biopsies are needed of the inner esophagus during this procedure. The diagnosis is conclusively established by the demonstration of the excessive accumulation of eosinophils in the biopsy specimens obtained from the esophagus.
Environmental allergies to substances such as pollens, animals, dust mites, and molds possibly play a role in eosinophilic esophagitis. For some patients, it may seem like their eosinophilic esophagitis is worse during pollen seasons. Allergy testing for these common environmental allergens is often part of an eosinophilic esophagitis evaluation.
TREATMENT:
The treatment of eosinophilic esophagitis involves a variety of approaches:
1. Dietary Modifications:
- 6 food (i.e., diary, egg, wheat, soy, nuts, seafood) elimination diet
- Elimination of foods based on allergy skin prick and/or patch testing
- Elemental (i.e., amino acid) diet
If the symptoms improve while on dietary restriction, foods can be gradually be reintroduced, one food at a time, while closely monitoring for the relapse of symptoms.
2. Drug Therapy:
- Proton pump inhibitors (e.g., Prilosec, Nexium) improve symptoms in a subset of patients either by reducing the excessive acid production or more likely by a direct anti-inflammatory action over the esophagus.
- Topical inhaled corticosteroid medications such as fluticasone (i.e., Flovent) and budesonide (i.e., Pulmicort). These are approved only as inhaled anti-inflammatory agents for asthma, but are used off-label as ingestible medications for eosinophilic esophagitis. These medications coat the mucus membrane, reduce the eosinophilic inflammation, and lead to symptom improvement.
- Additional endoscopies and biopsies are usually necessary to monitor the effectiveness of treatment.
3. Biological Medications:
In 2022, dupilumab (i.e., Dupixent) was approved by the U.S. Food and Drug Administration (FDA) to treat adults and children 12 years and older with eosinophilic esophagitis. This is the first FDA-approved treatment for eosinophilic esophagitis.
Dupixent is administered by injection under the skin once a week. This medication reduces the number of eosinophils in the esophagus and can lead to significant relief from symptoms.
SUPPORT:
Families often benefit from participating in support groups and organizations. The American Partnership for Eosinophilic Disorders (APFED) and Campaign Urging Research for Eosinophilic Disease (CURED) are two lay organizations that provide valuable reliable resources for individuals with eosinophilic esophagitis.
The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating eosinophilic esophagitis in both adults and children in patients in the Washington, DC, Northern Virginia, and Maryland metropolitan area for many years. Black & Kletz Allergy has 3 offices in the Washington, DC metro area with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. If you suffer from difficulty swallowing, food getting stuck in your throat, or any other symptom related to eosinophilic esophagitis, please call us to make an appointment at one of our conveniently located offices. Alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergists at Black & Kletz Allergy are confident that we will be able to help you get to the bottom of your problem as well as treat this gastrointestinal disorder. We have been serving the Washington, DC metro area for more than 50 years in the field of allergy, asthma, and immunology and we hope to improve your quality of life by reducing or preventing your unwanted and bothersome allergy symptoms.