June is Dysphagia Awareness Month.
Eosinophilic esophagitis (EoE) is a disease that causes chronic inflammation of the esophagus. This inflammation leads to symptoms such as difficulty swallowing, chest pain, and food stasis (when food gets stuck in the esophagus). Although there is no cure for EoE, there are effective treatments to control symptoms and keep the condition under control. Without treatment, EoE typically worsens.
EoE is becoming increasingly common and can affect people of all ages. We spoke with Evan S. Dellon, MD, MPH, gastroenterologist, professor of medicine, and associate professor of epidemiology at the University of North Carolina Chapel Hill to learn more about EoE symptoms, help, and treatment options.
What EoE symptoms should prompt you to see a doctor?
In adults and adolescents, difficulty swallowing or food sticking are the most common symptoms. It’s important to note that it’s actually unusual for food to go down slowly or get stuck. Many people who are ultimately diagnosed with EoE do not initially pay attention to this symptom. They may simply avoid certain foods or chew more carefully until a major problem arises. Don’t wait for that to happen. Any problems with swallowing or swallowing food should be investigated. Some other gastrointestinal symptoms such as chest discomfort or heartburn are also associated with EoE.
Other illnesses can cause food to slowly spoil or stick. If these symptoms occur along with asthma, eczema, or food allergies, it is more likely a sign of EoE.
Children with EoE have completely different symptoms. It may include abdominal pain, vomiting, poor growth, failure to adjust to a different consistency, or avoidance of foods. Many gastrointestinal diseases in children can cause these symptoms. But they could also be signs of EoE, especially if a child also has eczema, asthma or food allergies.
If you have EoE, why is diagnosis so important?
We believe that EoE generally begins as an allergic inflammation. If left untreated, this inflammation can lead to scar tissue over time. The esophagus can then become narrow and stiff, leading to further symptoms and complications such as food debris buildup. Obstruction of the esophagus can lead to perforation or rupture of the esophagus, which is a very serious problem. It’s not common, but these are the complications we worry about. Severely affected children may be malnourished.
There are also impacts on quality of life. Anything that affects your diet will impact social events, family gatherings, work events and travel and can cause significant anxiety. The symptoms, the impairment of quality of life and the possible complications are good reasons to be examined.
How do you get an EoE diagnosis?
The diagnostic process consists of an endoscopy to examine the esophagus. We do not have blood tests or other ways to diagnose EoE.
Endoscopy is a sedated procedure. A lighted camera goes into the mouth and down into the esophagus and stomach. We look for typical signs of EOE. The esophagus may appear swollen. It may be covered with white spots, indicating inflammation. There may be scar tissue such as rings or strictures. We send a biopsy to a pathologist who examines the allergy cells, i.e. the eosinophils. If there are enough eosinophils present and we can eliminate other causes, we can officially diagnose EoE.
Why is ongoing care important when you have EoE?
EoE is a chronic disease that needs to be treated over a long period of time. When people are diagnosed but not treated, many end up developing more serious complications. It is important to have a team on site and to carry out treatment consistently.
There are different degrees of severity of the disease. The team tailors the approach to each person’s situation. For example, someone who has been to the emergency room with an impaction will be monitored much more closely than someone with mild symptoms. Continuing care is different for each person, but it is very important to have it in place to prevent flare-ups and problems from getting worse.
What types of healthcare providers should be part of your care team if you have EoE?
Some people are primarily cared for by gastrointestinal doctors. Some people turn primarily to allergists. Some people may pursue both in a more multidisciplinary way. Children may also need nutritional therapists and other multidisciplinary providers. We often work with dietitians or nutritionists.
How do you manage EoE?
There are two main treatment categories: diet and medication.
We believe that for most patients, EoE is a food-induced illness. Unlike a typical food allergy, which causes an immediate reaction, this is a condition in which eating certain foods over a long period of time triggers inflammation. Current allergy tests aren’t really accurate for EoE, so it’s a bit difficult. But we know the most common food triggers: dairy, wheat, eggs, soy, nuts and seafood. Elimination diets can be used to identify food triggers and remove them from the diet. It’s a good option, but it really depends on the individual patient.
Anti-acid medications like omeprazole (Prilosec) or lanzoprazole (Prevacid) are often the first medications we try. About 30-40% of people may react to these simple medications.
Then there is a topical steroid. We now have an approved medication, budesonide oral suspension (Eohilia), which is specifically designed to adhere to the esophagus. It can be effective in 50-60% of people, if not more.
Another one we use is dupilumab (Dupixent), a systemic drug. It is a weekly injection that blocks some of the allergy factors that cause EoE. It is usually reserved for people who do not respond to other treatments. It could also be used for people being treated for asthma and eczema and EoE, as dupilumab is approved for everyone.
Why is managing EoE a lifelong process?
The vast majority of people can manage EoE, but it is chronic. If people don’t get treatment, they tend to have problems later. Not everyone will have complications, but we have no reliable way to know who is at risk of complications and who is not. That’s why we want to offer everyone individual treatment and regular follow-up care.
New treatment methods are also being developed. The field is moving quickly. Now when I see someone in the clinic, I can offer different options than I did a few years ago. There are also a number of patient advocacy groups that help with education and patient support.
If you experience these symptoms, don’t ignore them. It’s becoming more and more common. Get examined.
This educational resource was created with support from Sanofi and Regeneron.
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