Eosinophilic Oesophagitis (EoE)

The oesophagus is the ‘food pipe’ or muscular tube that connects the mouth to the stomach. Over the last few decades, doctors have found that some children with poor weight gain and problems swallowing have a condition called Eosinophilic Oesophagitis (EoE). This is where the oesophagus becomes inflamed with a particular type of white blood cell called an eosinophil.

EoE is still relatively uncommon, affecting fewer than 1 in 1000 children. However, it is becoming more frequently diagnosed, and this may be partly due to the increase in allergies over the same period of time. At least 50% of children with EoE have allergies, including food allergies, allergic rhinitis (hay fever) and asthma.

Symptoms

This condition is more common in boys (75%) and older children and adults will complain of problems swallowing food, particularly with a sensation of food ‘getting stuck on the way down’. Younger children may not be able to describe this, and so often present with weight loss, pain on eating and swallowing (causing them to eat slowly as a result), and food refusal in very young children. EoE can be difficult to distinguish from reflux, and treating symptoms with an anti-reflux medication may be a helpful test in this age group (although we now know that some patients with EoE will respond to anti-reflux medicines).

back to top

Diagnosis

Your child’s doctor may suspect the diagnosis, but the only way to confirm the diagnosis is for your child to undergo an endoscopy. The diagnosis is a clinical one combined with the endoscopic findings.  This is where the oesophagus is examined using a special camera called an endoscope. Usually, your child will be sedated with medicines or an anaesthetic during this procedure. A tissue sample (biopsy) will be taken at the same time and examined to look for the presence of eosinophils. Endoscopy and biopsy are normally performed by a gastroenterologist (stomach/bowel medical specialist).

Diagnosis and treatment are vital as the condition can cause scarring and narrowing of the oesophagus, and may predispose to malignancy in later life.

Allergy testing is unhelpful to diagnose EoE, but may be performed as it may give a clue as to what foods might act as triggers for the EoE. When food is involved, cows’ milk (dairy), wheat, meats, soy and egg seem to be the most common triggers.

back to top

Treatment

There are a number of different strategies to treat EoE. Children with EoE are usually looked after by specialists, such as gastroenterologists or allergists, who will decide which option is best for your child.

Treatment options include:

• Dietary elimination: of specific foods or common food triggers; the resulting diet can be complicated and a dietician will generally advise as to what foods can be eaten, in order to ensure your child’s diet is adequate for their growth and development
• Special milk feeds: EoE appears to respond to special milk feeds known as Elemental feeds. Your child will usually need to avoid all other foods during this time. Once the inflammation is under control, the diet can be slowly normalised, avoiding certain trigger foods. This process is complicated and lengthy, and a dietician will generally be involved to assist with this process
• Medication: this usually involves steroid medicines. One effective way of giving the medicine without using oral steroid tablets (which are associated with increased side effects) is to give the steroid as a swallowed liquid (usually mixed with an artificial sweetener) or aerosol. The swallowed steroid reduces inflammation in the oesophagus, and so prevents the scarring that can result from untreated disease
• Other medicines are under trial at the current time

At the current time, our understanding of EoE remains limited but new research is teaching us more about the disease all the time. There are controversies as to the role of allergy and dietary manipulation, and how many people are actually helped by diet. Furthermore, sometimes symptoms may improve with diet manipulation, but the underlying inflammation can still persist. Some people only appear to suffer symptoms during the pollen (hay fever) season, so nasal allergy may be more important in this group than food allergy. As more research is performed, we will learn how to manage this disease and avoid potential complications

back to top

Key Points

• A diagnosis of EoE should always be confirmed first by endoscopy and biopsy
• Dietary management is complicated and should be supervised by a skilled dietician to ensure your child receives enough nutrients
• Eosinophilic oesophagitis is usually related to allergy but requires excluding other conditions
• The diagnosis and treatment is directed by marrying clinical and histological information