Eosinophilic oesophagitis

What is eosinophilic oesophagitis?

Oesophagitis means inflammation of the gullet or oesophagus. In eosinophilic oesophagitis (EO) lots of white cells called eosinophils can be seen in the oesophageal lining. EO is thought to occur due to a combination of genetic makeup and the body's response to the environment.

If you have EO you may be allergic to certain foods, although tests do not always identify the specific foods causing the problem. You are also more likely to have other allergies such as asthma or hay fever.

What are the symptoms of eosinophilic oesophagitis?

The symptoms of EO vary depending on whether you are an adult, a teenager or a child.

Adult symptoms

• Difficulty in swallowing (dysphagia).

• A feeling that food is sticking in the gullet.

• Chest pain.

• Regurgitation.

Child and teenager symptoms

• Being sick (vomiting), in teenagers.

• Chest pain.

• Stomach pain.

• Difficulty eating, in children

• Weight loss.

These symptoms are similar to those of people who have acid reflux (also known as gastro-oesophageal reflux disease).

What causes eosinophilic oesophagitis?

The cause or causes of EO are not fully understood, but it is thought that it is due to a combination of your genes, and how your body's immune system responds to the environment around us. The symptoms can be triggered by eating certain foods and possibly by breathing in certain substances. Once triggered, lots of eosinophils build up in the lining of the oesophagus (the swallowing tube between the throat and stomach) and this causes the symptoms.

Who does eosinophilic oesophagitis affect?

Most people with EO are white men between the ages of 30-50 years. However, the condition can occur in all ages and in both sexes. Men are three times more likely than women to be affected. For unknown reasons, it has become more common in recent years, currently affecting about 7 in 100,000 people every year.

How is eosinophilic oesophagitis diagnosed?

If you are suspected of having EO, you will need to have a gastroscopy (endoscopy). This involves putting a thin flexible telescope called an endoscope through the mouth or nose and down into the gullet (oesophagus). The endoscope has a tiny light and video camera at the end. These help the doctor to take a film or photographs and see inside your oesophagus.

An instrument can also be passed down the endoscope to take a small sample of the lining of the oesophagus (a biopsy). Your symptoms, the appearance of the lining of your oesophagus and the biopsy report will all help the doctor to diagnose EO.

If your child is suspected of having EO, endoscopy can be performed using a smaller tube.

Sometimes, blood tests and/or skin prick tests are used to help identify specific foods that might be causing the condition. These are more commonly used in children than in adults.

What are the treatments for eosinophilic oesophagitis?

Dietary manipulation

You may be advised to alter your diet, either as the main treatment for your EO or in addition to other treatment. Dietary manipulation may involve cutting out certain foods to which you may be allergic.

Sometimes food allergy tests may be able to identify which foods to avoid but these tests do not always provide the answer. If your allergy tests are not helpful, you may be advised to avoid the types of food which are well known to cause allergic reactions. A dietician and/or an allergy specialist may be involved in giving you advice about what changes to your diet you need to make,

What foods trigger eosinophilic oesophagitis?

• Nuts.

• Seafood.

• Milk.

• Egg.

• Wheat.

• Soya products.

Usually you need to avoid these foods for about six weeks and then gradually reintroduce them one by one. Another approach, most commonly used in children, is to try a specially made-up mixture of basic food chemicals called amino acids. This mixture needs to be taken instead of food for about six weeks. Your child may not like the taste of the mixture and it may be difficult to persevere with this treatment. However, it is particularly useful if your child has a severe form of EO which is difficult to control.

Steroids

Steroids such as fluticasone are often recommended, with or without dietary manipulation. They are usually prescribed in the form of an inhaler. It is the same type of inhaler as that used by patients with asthma. However, you will be asked to spray the inhaler into your mouth without breathing in and to swallow the powder without water. You should not eat food or drink liquids for half an hour after spraying the medicine.

Another type of steroid called budesonide is also available in liquid form. The liquid form is not specially made for people with EO but comes in small plastic containers called budesonide respules which are used by asthma patients. This can be mixed with something sweet, such as a sweetener called sucralose, or with honey or chocolate syrup, or apple or oranges juice. This is a particularly useful option for children who have problems with the inhaler method.

Budesonide is now also available in orodispersible tablet form. These are tablets which dissolve in your mouth - they are sometimes called orally disintegrating tablets. These tablets can be used as an option for treating symptoms of eosinophilic oesophagitis in adults only.

Proton Pump Inhibitors (PPIs)

These are medications that are commonly used to treat acid reflux. While EO is not caused by acid reflux, PPIs can be effective in reducing the symptoms. These include medicines such as Omeprazole and Lansoprazole and they come in tablet, dispersible tablet, and liquid forms.

Gastroscopy (endoscopy)

You may need to have a gastroscopy using an endoscope if dietary manipulation or steroids do not work. You may also need endoscopy if you develop a complication of EO such as narrowing of the oesophagus.

Does eosinophilic oesophagitis get better?

EO can be controlled in most cases by dietary manipulation and/or steroid medicine. However, you or your child may find that the condition returns as soon as treatment is stopped. Treatment may therefore need to be continued long-term to keep the condition under control.

Understanding the oesophagus and stomach

When we eat, food passes down the gullet (oesophagus) into the stomach. Cells in the lining of the stomach make acid and other chemicals which help to digest food. Stomach cells also make mucus which protects them from damage from the acid. The cells lining the oesophagus are different and have little protection from acid.

Barrett's oesophagus

There is a circular band of muscle (a sphincter) at the junction between the oesophagus and stomach. This relaxes to allow food down but then normally tightens up and stops food and acid leaking up (refluxing) into the oesophagus. In effect, the sphincter acts like a valve.