What is eosinophilic esophagitis (EoE)? Are food allergies and EoE related? How is EoE diagnosed and managed? We'll answer these questions and more in this parent's guide.
What is eosinophilic esophagitis (EoE)? Are food allergies and EoE related? What are the similarities and differences between traditional food allergies and EoE? How is EoE diagnosed and managed? We'll answer these questions and more in this parent's guide.
What are food allergies?
Food allergies always involve the immune system.
Normally, our immune systems defend and protect us from harmful invaders, like certain viruses and bacteria. But when someone has a food allergy, their immune system over-defends the body against certain types of food proteins, and mistakenly treats these food proteins as harmful invaders.
This causes the body to develop an allergic reaction whenever someone eats the food(s) that their immune system "flagged" as harmful. For example, if someone has a peanut allergy, their immune system thinks peanuts are a threat to the body, and triggers symptoms of an allergic reaction whenever they consume peanuts.
The most common type of food allergy is called an IgE-mediated food allergy.
When someone has an IgE-mediated food allergy, their immune system makes specific allergy antibodies called IgE antibodies to help fight off the proteins of the food(s) they are allergic to. These IgE antibodies trigger symptoms of an allergic reaction seconds to hours after the person eats a food that they are allergic to.
But some food allergies don't involve IgE antibodies, even though they do still involve the immune system. These food allergies are called non-IgE-mediated food allergies. The causes of this type of food allergy aren't widely understood, but all non-IgE-mediated food allergies cause GI symptoms hours to days after someone consumes a food they're allergic to. EoE is one type of non-IgE-mediated food allergy.
What is EoE?
Eosinophilic esophagitis, or EoE, is a condition that causes chronic inflammation in the esophagus. The condition is relatively newly recognized, and is classified as an allergic condition.
When someone has EoE, large amounts of specific white blood cells are present in their esophagus, the tube that connects the mouth and stomach. These white blood cells are called eosinophils.
Eosinophils are associated with the immune system, and they release substances that cause inflammation. They normally protect us from infections like parasites, but they are also associated with allergies.
Usually, someone won't have eosinophils present in their esophagus. But in a person with EoE, eosinophils build up in the esophagus' inner lining in large amounts, and cause inflammation of the esophagus. This makes swallowing food difficult and painful.
In most patients, EoE's main cause is an adverse immune system response to a given food. This means that the eosinophils build up in the esophagus so the body can over-defend against a certain food, and eating that certain food is what triggers the esophagus inflammation and other symptoms. So, EoE is considered a type of food allergy.
EoE is considered a type of food allergy.
It is a non-IgE-mediated food allergy, because IgE antibodies aren't involved, and because the symptoms it causes are all associated with the GI tract.
Learn more about Eosinophilic esophagitis, or EoE from Cincinnati Children's Hospital:
EoE Vs. IgE-Mediated Food Allergies: Symptoms
EoE causes different symptoms than IgE-mediated food allergies (traditional food allergies).
In babies and young children, hives and swelling are two of the most common symptoms of an IgE-mediated food allergy reaction. (Read this linked article for a more complete list of IgE-mediated food allergy symptoms).
But EoE doesn't cause hives or swelling.
EoE may cause the following common symptoms in babies and young children:
- Refusal to eat
- Problems with feeding
- Hindered growth
- Difficulty gaining weight
- Trouble transitioning to solids
- Decreased appetite
- Trouble swallowing
- Food impaction (food stuck in the esophagus)
- Vomiting
- Abdominal pain
- Chest pain
- Irritability
- Reflux-like symptoms
- Difficulty sleeping
These symptoms may appear hours to days after your child consumes a food that they are allergic to. But in some cases, they may even take weeks to appear.
IgE-Mediated Food Allergies Vs. EoE: Severity
IgE-mediated food allergies can sometimes cause anaphylaxis. Anaphylaxis is a severe, potentially life-threatening allergic reaction where the symptoms involve more than one organ system. Anaphylaxis requires an immediate epinephrine (Epi-pen) injection and prompt emergency attention.
Non-IgE-mediated food allergies, including EoE, usually don’t cause severe allergic reactions. So, EoE is very rarely life-threatening in that regard, and EoE symptoms hardly ever require an Epi-pen injection.
However, there is one potential symptom of EoE that can require emergency attention. This is when food gets firmly stuck in the esophagus, known as food impaction. Food impaction occurs when the esophagus is so inflamed that it becomes too narrow for food to move down. Food impactions don't always become medical emergencies. But if food doesn't quickly get unstuck to move into the stomach, or doesn't get vomited up quickly enough, this can cause a medical emergency.
And if EoE isn't properly diagnosed and managed, it could cause lifelong damage to the esophagus.
EoE and Other Allergies
As explained above, EoE is considered a food allergy because it usually involves an immune system response to a food.
Although EoE is a non-IgE-mediated food allergy, someone can also have a more traditional food allergy (an IgE-mediated one) at the same time.
In fact, someone is more likely to have EoE if they have another allergic condition, such as asthma, eczema, or a more traditional food allergy.
Environmental allergies (like dust mite allergy and pollen allergy) may also sometimes play a role in EoE, and trigger inflammation. But their role isn't widely understood yet.
How is EoE Diagnosed?
Traditional food allergy tests, like skin prick tests, blood tests and food challenges, can't accurately diagnose EoE. This is because these tests depend on detecting IgE antibodies, or on identifying a more immediate allergic reaction to a food. (EoE symptoms can take days to emerge after someone eats a food, and don't involve IgE antibodies.)
Making things even more complicated, inflammation in the esophagus could be caused by a condition other than EoE.
Gastroesophageal reflux disease (GERD), an infection, or inflammatory bowel disease could also cause these esophagus problems. In babies and young children, EoE and GERD symptoms are extremely similar.
The only way to accurately diagnose EoE is with a procedure called an upper endoscopy. In this procedure, a doctor passes a tube with a camera and light source down the esophagus, to check for inflammation. The doctor will also take a biopsy (tissue samples) to see if there are high levels of eosinophils. But this is a very invasive procedure, and usually requires sedation.
EoE and an Elimination Diet
An allergist can help make a probable diagnosis of a non-IgE-mediated food allergy without an endoscopy, and help your child manage the symptoms, but they won't be able to pinpoint that symptoms are caused by EoE for sure without endoscopy results.
Your doctor may recommend an elimination diet. This involves eliminating the food(s) you think are triggering EoE symptoms from your child's diet in consultation with a doctor, then waiting a few weeks to see if symptoms improve.
For example, if you and your doctor think that cow’s milk is causing symptoms, you will stop feeding your child milk for several days. Also, if you're breastfeeding, you'll need to stop consuming milk as well.
Then, you'll see if the symptoms improve after you’ve removed the suspected food. After that, you'll reintroduce the food back into your child's diet and see if the symptoms reappear.
(Sometimes, a doctor will recommend removing several common allergy-causing foods from your child's diet at once, then reintroducing foods one by one to pinpoint probable causes).
If your child’s symptoms improve when you remove a food, but then reappear once a food is reintroduced into their diet, they may have EoE, but it's still difficult to know for sure. They may also have a different type of non-IgE-mediated food allergy, or they may have a food intolerance---especially if symptoms don't point to esophagus inflammation.
Managing EoE
If your child has EoE, your child's allergist and gastroenterologist will work together to help them manage the condition. These doctors will likely recommend continuing an elimination diet, where your child avoids the food(s) that trigger EoE. Every child, and every case if EoE, is different, so treatments will be individualized.
Someone who has EoE will also need regular endoscopies to check the amounts of eosinophils in their esophagus, and see if the EoE is improving or getting worse.
No medications are approved by the FDA to treat EoE, but new treatments are currently being studied--- and the AAAAI reports that some medications show promise in helping to control inflammation and in bringing eosinophil levels down.
Can EoE Be Outgrown?
Sometimes, babies or young children are diagnosed with EoE but then outgrow EoE when older, with no explanation. But other children end up with EoE that persists into adulthood, and that they never outgrow. Also, some adults are only diagnosed with EoE as adults. We still need more information on why some people outgrow EoE and others don’t, and on when it’s usually outgrown.
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