Eosinophilic Esophagitis

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Eosinophilic esophagitis is a chronic, immunologically mediated inflammation of the esophagus, which is more commonly seen in men, with the peak incidence occurring between the ages of 30 and 50. Studies indicate that urban dwellers and individuals residing in Western countries and cold climates are more frequently affected.

The term “eosinophilic” refers to the accumulation of eosinophilic granulocytes in the oesophageal wall, which are not normally found there. In this condition, these cells are detected in tissue samples from the oesophagus. The function of the esophagus, which is to transport food from the mouth to the stomach, is disrupted, and in a small percentage of cases, eosinophilic esophagitis can lead to narrowing of the esophagus.

Patients with eosinophilic esophagitis are more commonly associated with allergic conditions such as hay fever, asthma, and atopic dermatitis compared to the general population. However, it has not been proven that allergic predisposition increases the risk of this condition. Eosinophilic esophagitis is distinct from the common acid reflux disease, although the two can coexist.

What are the main symptoms of eosinophilic esophagitis?

The disease presents with characteristic symptoms, particularly in adults, including:

  • Difficulty swallowing
  • Regurgitation
  • Acid reflux
  • Food impaction
  • Chest pain

What are the risk factors for the condition?

The exact causes and mechanisms of the disease are not yet fully understood. There is evidence of genetic factors and environmental factors playing a role. Risk factors include premature birth, delivery by cesarean section, antibiotic treatment at an early age, and food allergies. The lack of exposure to beneficial microbes in the environment, a fundamental postulate in the hygiene hypothesis for the rise of allergic diseases, is one of the explanations for the development of eosinophilic esophagitis.

In general, men are more affected by swallowing difficulties than women. 75 percent of patients are male, while only 25 percent are female. There is also a higher risk of swallowing difficulties in individuals with a history of allergic diseases. Around 70% of patients already have some form of allergy at the time of eosinophilic esophagitis diagnosis.

Food allergies are commonly found in children, while respiratory allergies, such as allergic rhino conjunctivitis and asthma, predominate in adults. There is also a hereditary component to esophageal allergy, with a higher likelihood of transmission through the maternal line.

Despite efforts to elucidate the pathogenesis of eosinophilic esophagitis and the increase in clinical trials, the practical management of eosinophilic esophagitis remains a challenge due to various contradictions associated with therapeutic approaches and the need for long-term treatment.

What are the causes of swallowing difficulties?

For a long time, it was unclear whether eosinophilic esophagitis (Eosinophilic esophagitis) was an autoimmune or allergic disorder. In summary, Eosinophilic esophagitis is a multifactorial chronic allergic disease characterized by predominance of type 2 immune inflammation. The release of inflammatory mediators from activated eosinophils in the esophageal wall leads to swelling, fibrotic changes, and ring-like strictures observed during endoscopic examination. These changes are responsible for the swallowing difficulties.

Is there a specific allergy underlying this condition?

It is believed that food allergies are at the core of, but the relationship between food allergy and Eosinophilic esophagitis is complex. Allergy tests, such as skin prick tests and serum tests, are important. Based on positive results from these tests, concepts of elimination diets with two, four, or six foods have emerged.

These diets typically exclude major allergenic foods such as milk and dairy products, eggs, soy, wheat, nuts/peanuts, fish, and shellfish. In many cases, symptoms improve within a few weeks after removing the allergenic food from the diet.

Eosinophilic esophagitis is a distinct disease that exhibits various clusters based on immune mechanisms and predominant tissue inflammation, which may not always be of the IgE-mediated allergy type.

Have the mechanisms underlying esophagitis been unraveled?

The mechanisms involved in immune-related swallowing difficulties are not yet fully understood. Immunoglobulins of the IgE class do not appear to be central to all cases of eosinophilic esophagitis. High levels of IgE antibodies, along with elevated blood eosinophils and multiple associated atopic conditions such as asthma, allergic rhinitis/rhino conjunctivitis, and atopic dermatitis, form a subgroup or cluster within eosinophilic esophagitis. T-lymphocytes play a role in this subgroup, and it is referred to as type 2 immune inflammation, which is more responsive to treatment.

In other patients, specific IgE antibodies are not detected in the serum or skin tests, there is no blood eosinophilia, and there are even no tissue aggregates of eosinophils in the oesophageal wall, despite the presence of typical symptoms and familial burden (other family members with identical symptoms).

Yes. In some cases, there are mild swallowing difficulties, while in others, the symptoms are very severe. The severity is determined by the degree of inflammation and changes in the esophageal wall, specifically the development of fibrosis and ring-like narrowing of the esophageal lumen.

What is the diagnostic pathway for eosinophilic esophagitis?

The diagnosis of esophageal allergy is established through a thorough medical history and endoscopic examination of the esophagus with tissue sampling (biopsies) from multiple sites. The presence of a certain number of eosinophils in the histological material confirms the diagnosis.

Is it possible to achieve improvement through dietary regulation?

If it is possible to identify the specific food allergens that contribute to swallowing difficulties, one can eliminate them from the diet. Such an approach, involving the exclusion of certain products, serves both diagnostic and therapeutic purposes. Complete remission is achievable. There are diets that exclude two, four, or six foods, focusing on the most common allergy triggers: dairy products, wheat, eggs, nuts, soy, and seafood.