Eosinophilic Oesophagitis (EoE)

Frequently Asked Questions (FAQ) 

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Q 1: What is EoE?

Eosinophilic oesophagitis (EoE) happens when white blood cells (called eosinophils) deposit in the lining of the oesophagus, which is the muscular tube that connects the mouth to the stomach. This can be the result of an allergic reaction to food or the environment.

Most cases of EoE are seen in people with other allergies such as allergic rhinitis (hay fever) and asthma. It is estimated to affect around one in 1,000 people (children and adults), and the frequency of EoE appears to be increasing. The reasons are unclear, but it is known that allergies of all types have become more common.

Q 2: What are the symptoms of EoE?

The symptoms of EoE may be different in children compared to adults, as shown below.

CHILDREN

  • Slow eating.
  • Food impaction/food bolus obstruction (FBO) – when food gets stuck on the way down the oesophagus.
  • Choking or gagging on food.
  • Regurgitation of foods.
  • Abdominal (stomach) pain.

ADOLESCENTS AND ADULTS

  • Trouble swallowing.
  • Food impaction/food bolus obstruction (FBO) – when food gets stuck on the way down the oesophagus.
  • Regurgitation of foods.
  • Severe acid reflux (heartburn) that does not respond to medications.
  • Chest pain when eating.
  • Chewing longer and drinking more water with solid food/s.

Mild reflux and vomiting are common in children and adults, and most do not have EoE.

EoE symptoms in infants may resolve in the first few years of life, particularly if only one or two foods are involved. However, when symptoms arise in older children and adults, they usually do not resolve.

If EoE is left untreated, around 30-50% of children and adults with EoE will eventually get food impaction/FBO, which may have to be removed in hospital. This can result in permanent scarring and narrowing of the oesophagus (stricture).

Q 3. Who treats EoE?

Most people with EoE are co-managed by gastroenterologists (stomach/bowel medical specialists), clinical immunology/allergy specialists and specialist dietitians.

Q 4: How is EoE diagnosed?

Diagnosis of EoE should always be confirmed by endoscopy and biopsies, which are normally performed by a gastroenterologist:

  • If EoE is suspected, your doctor will usually confirm this by looking at the oesophagus using an endoscope.
  • Three tissue samples (biopsies) will be taken at the same time and examined to look for eosinophils.

Q 5: Do people with EoE usually have other allergic conditions?

Yes. Around 75% of people with EoE have other allergic conditions such as allergic rhinitis or asthma.

Some people with EoE have found that symptoms appear only during Spring time when they are exposed to pollens.

Q 6: What are the treatment options for EoE?

Treatment options for EoE include:

  • Proton pump inhibitor medication (tablets or liquids) – to reduce acid production and also have an anti-inflammatory action that may reduce or abolish the eosinophilic inflammation in EoE.
  • Swallowed corticosteroids - to help reduce inflammation and the scarring that can result from untreated EoE;
  • Topical asthma corticosteroid puffers (fluticasone).
  • Topical asthma corticosteroid liquid (budesonide) made up as a paste/slurry.
  • Dissolving corticosteroid tablets (budesonide).
  • Dietary modification - to assist both adults and children, undertaken under the direction of a gastroenterologist or clinical immunology/allergy specialist, and supervised by a specialist dietitian. When undertaking dietary modification, certain foods are removed for a period of time and then re-introduced one at a time to see which foods result in symptoms.
  • Dilation - a procedure that may be required if the oesophagus is very narrow, used with endoscopy, to open the narrowed oesophagus. This allows food to pass easier, to provide temporary relief.

It is important to have a rescue plan for worsening symptoms.

Additional treatments for food impaction/FBO include:

  • Oral nitroglycerin
  • Oral salbutamol
  • Carbonated (fizzy) fluid
  • Removal of the food by endoscopy

Adrenaline (epinephrine) and antihistamines do not play a role in the management of EoE. However, some people with EoE may also have a food allergy and be of risk of anaphylaxis, so they should have an ASCIA Action Plan for Anaphylaxis and adrenaline to treat that food allergy

Q 7: What types of dietary modification are used for EoE?

When food is the cause of EoE, cow's milk (dairy products), wheat and egg are the major triggers, with soy, seafood and nuts less commonly being involved. Some researchers have found that people benefit if these foods are removed from the diet.

Dietary modification for EoE should be temporary, initiated by a medical specialist and supervised by a specialist dietitian to ensure optimal nutrition.

Types of dietary modification used include:

  • Common food allergen elimination diets. These usually include the removal of cow’s milk, soy, egg, and wheat. Allergy testing or patient history may result in the removal of additional foods.
  • Step-up diets. Instead of removing many foods at the same time, one to two foods are removed at first, to see if symptoms improve, repeating a biopsy if they do, but removing more foods later on if inflammation persist on biopsy.
  • Amino acid based diets. These are based on amino acid/elemental formula and can be impractical in adults and older children, but are useful and commonly used for babies with EoE.

Allergy testing is not considered to be a reliable indicator of response to dietary modification and is not recommended unless a person has evidence of rapid onset allergic symptoms after food consumption as well as EoE.

Endoscopies and repeat biopsies are essential to monitor response to treatment. Symptoms alone are not a reliable guide to disease control.

Q 8: Are action plans, management plans and dietary guides available for EoE?

Yes. In response to requests from patients, medical specialists and dietitians, ASCIA has developed:

  • ASCIA Action Plan* for EoE – for emergency treatment of food impaction/FBO due to EoE.
  • ASCIA Management Plan* for EoE – to guide ongoing treatment and management of EoE
  • ASCIA Dietary guides for Two Food Elimination Diet (2FED) and Four Food Elimination Diet (4FED)

These resources are available on the ASCIA website www.allergy.org.au/patients/food-other-adverse-reactions

* These plans are medical documents that can only be completed and signed by the patient's clinical immunology/allergy specialist or gastroenterologist and cannot be altered without their permission.

Q 9: Is EoE is a developing area of research?

Yes. There are currently questions about the role of allergy and diet modifcation that need to be answered by more research. In some people symptoms may improve with diet modification, but the underlying inflammation can persist. It is still unclear whether the aim should be to settle symptoms only, or to also control the underlying inflammation.

Whilst there are case reports of benefit from pollen immunotherapy in patients who report symptoms occurring or worsening during pollen seasons, there is no high quality evidence of benefit and this treatment is not recommended specifically to treat EoE.

Q 10: Where can patient support be obtained?

Australian Support Network for Eosinophilic Oesophagitis and related disorders www.ausee.org

Allergy & Anaphylaxis Australia www.allergyfacts.org.au

Allergy New Zealand www.allergy.org.nz 

© ASCIA 2021

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand.

ASCIA resources are based on published literature and expert review, however, they are not intended to replace medical advice. The content of ASCIA resources is not influenced by any commercial organisations.

For more information go to www.allergy.org.au

To donate to immunology/allergy research go to www.allergyimmunology.org.au

Updated July 2021

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