How is eosinophilic or allergic esophagitis diagnosed?
It is first suspected by the classic history and the appearance of the esophagus on endoscopy of multiple rings or constrictions that result in the esophagus looking like that of a cat's esophagus. This is called felinization of the esophagus or ringed esophagus. Other visual signs may be whitish spots, long furrows or a lining that looks like crepe paper and is very easily torn.
The definitive diagnosis is made by the finding of an abnormal number of eosinophils in esophageal biopsy tissue. The number of eosinophils considered abnormal is debated between >15-25 eosinophils per high power field (400x) with most authorities agreeing >20 as being diagnostic. The esophagus normally contains no eosinophils. It has been long accepted that chronic acid reflux commonly can be associated with 5-10 eosinophils per high power field in the lower esophagus but this finding higher in the esophagus should raise likelihood that eosinophilic esophagitis is present.
Why is it important to diagnose eosinophilic esophagitis and distinguish it from acid reflux esophagitis?
Acid reflux esophagitis usually responds to acid blocker medications like histamine 2 blockers ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid) and proton pump inhibitors like omeprazole (Prilosec) or esomeprazole (Nexium) whereas eosinophilic esophagitis often does not get better with these medications. Acid reflux injury to the esophagus can result in narrowing or constriction of the lower esophagus causing a food sticking sensation. This can be treated by a stretching of the constriction known as esophageal dilation that is usually safe and highly effective. Eosinophilic esophagitis also may result in constrictions of the esophagus but the stricture or rings are usually multiple, located higher in the esophagus and carry a high risk of tearing or puncturing the esophagus if dilation is attempted before treatment with steroids. There does not seem to be an association of cancer of the esophagus with eosinophilic esophagitis like there is with acid reflux. However, eosinophilic esophagitis can be chronic and difficult to treat.
How is eosinophilic esophagitis treated?
Identification and elimination of problem allergy foods is the mainstay of treatment. Foods that show positive allergy testing are eliminated. In some people a strict elimination diet is recommended. Rarely, a diet of only basic amino acid proteins in a liquid (elemental diet) is required. Temporary relief can be achieved with steroids. Systemic (oral prednisone) works but has the potential side effects of steroids on the rest of the body. Topical steroids applied directly to the surface that have little or no absorption into the blood stream are preferable. The nasal steroid, fluticasone propionate, has been used successfully. It is sprayed in the mouth and swallowed twice daily. The mouth should be rinsed out followed by spitting out rather swallowing the water. No eating or drinking for 30 minutes is recommended. A few studies have reported response to mast cell stabilizer disodium cromoglycate (Cromolyn), leukotriene inhibitor montelukast (Singulair), immunomodulators such as aziothioprine (Imuran), or monoclonal antibody against IL-5 mepolizumab.
Eosinophilic esophagitis: What role do foods play and what is the diet treatment?
Food allergy plays a major role in the cause and treatment of eosinophilic esophagitis, hence the alternative term used allergic esophagitis. Most patients will be found to have one or more food allergies when adequate testing is done. Skin prick allergy testing or blood tests (RAST, IgE food antibodies) can be negative but patch skin testing or intradermal testing may be positive. Sometimes, elimination diet with re-challenge is the only way to implicate a problem food. In most patients a personal and/or family history of allergic disorders (atopy) such as allergic rhinitis (hayfever), asthma, eczema, atopic dermatitis, or food allergies is noted.
What are the most problem common foods associated with eosinophilic esophagitis?
In descending order, the most common foods reported in the largest series were, milk, egg, soy, corn, wheat, beef, chicken, potato, oats, peanuts, turkey, barley, pork, rice, green beans, apples, and pineapple. Elimination of foods that test positive on allergy testing is the cornerstone of treatment of eosinophilic esophagitis. However, sometimes allergy testing is negative or inconclusive. It it then that an elimination diet is necessary and a pre-elimination diet food symptom diet diary is very helpful.
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