Eosinophilic oesophagitis (EoE) is a condition that affects the gullet (oesophagus). There is a build up of a particular type of immune cell (eosinophils) in the lining of the gullet causing inflammation or irritation. This affects how the gullet works, causing symptoms such as difficulty swallowing. The condition is diagnosed by using a telescope to look inside the gullet and take small samples (called biopsies) of the lining. It can be a long-standing condition, but it is not cancer and is not life-threatening. It can be successfully managed with diet and/or medications.

Figure 1. Characteristic endoscopic appearance of trachealisation in eosinophilic oesophagits. Source: UHBW NHS Foundation Trust.

We do not fully understand what causes EoE, but it is thought to occur due to a combination of genetic makeup and the body's response to the environment.  We also know that it affects more men than women and is also more likely if you have allergies such as asthma or hay fever.

Difficulty swallowing

The main problem caused by EoE is usually difficulty swallowing. The medical term for this is dysphagia. Some people find that food may get stuck on the way down after chewing and swallowing. Often food then slowly works its way down into the stomach, but sometimes people will bring the food back up.

Regurgitation

Some people find that food or fluid they have swallowed comes back up into the back of their throat. Usually this will be a small amount, which some people automatically swallow again.

Indigestion, heart burn or pain

People with EoE may experience burning or an achy sensation in the middle of the chest behind the breast bone or in the upper part of the abdomen or tummy. Sometimes this can be severe and people report feeling pain in this area. These symptoms are similar to acid indigestion, which is very common. However, in people with EoE, these symptoms will not respond to anti acid medications.

Chest pain

As the gullet is irritated and does not work normally, some people with EoE experience pain in the middle of the chest. This can be from irritation or inflammation, or from spasm of the muscle in the gullet.

Weight loss

As people with EoE have difficulty eating and drinking normally, they may reduce the amount they eat and drink, leading to weight loss.

People who have symptoms that may suggest eosinophilic oesophagitis (EoE) will usually be referred for an upper GI endoscopy. This is used to diagnose EoE and also looks for other causes of the same symptoms.

Upper GI endoscopy

The most common test for EoE symptoms is an upper GI endoscopy (also often referred to as an OGD). This is a common procedure involving the insertion of a thin tube with a camera on the end through the mouth into the oesophagus, stomach and first part of the small bowel called the duodenum. This test is important to look for signs of EoE as well as to look for other problems such as acid damage or oesophageal cancer. It is a very routine procedure, but as with any test there are benefits and risks, even though the risks are very low. More information on this procedure, its benefits and risks are available here.

To diagnose EoE, small samples of the gullet (called biopsies) need to be taken during the endoscopy. The tissue samples are very small, usually 2-3mm in size, and you will not be able to feel them being taken. These samples are sent away to be examined by a tissue expert under a microscope. In patients with EoE, this analysis shows an unusually high number of immune cells called eosinophils that give the condition its name.

Contrast swallow

This test may also be called a barium swallow and is often combined with a meal test to examine the stomach as well as the oesophagus. This is a useful test of how the oesophagus squeezes and to check that the stomach is lying in the normal place. It is not used to diagnose EoE, but may be used to look for other problems such as achalasia or a hiatus hernia. It involves drinking some fluid (called barium) and having x-ray pictures taken of the fluid going down the oesophagus into the stomach. X-rays are a form of ionising radiation. Doctors always minimise the amount of radiation to which patients are exposed. Your doctor will weigh the benefits and risks of having this test in making a decision to request this test for you.

Eosinophilic oesophagitis (EoE) is a condition that will need lifelong management. This can involve preventative measures, such as changes in a person's diet, or medication, which is often used to treat flares of the condition.

Occasionally, other treatments may be required. If EoE is not treated, sometimes scarring can occur, resulting in narrowing of the gullet. If this happens, further telescope procedures and treatments can be needed (see below under the heading 'Endoscopic treatment').

With careful and proactive management, most people who have EoE can maintain a good quality of life.

Dietary management

If you have EoE, you may be allergic to certain foods. You may be referred to a dietician to discuss how to identify which food this may be. This can involve a very careful diet in which several different types of food are all avoided for 4-6 weeks to see if this improves a person's symptoms. Then, different food groups may be re-introduced one at a time to see which food type causes the problem. This process can be difficult to stick to, and should only be done with input from a qualified dietitian. Some people need supplements to ensure that they are getting all the nutrients they need. It can take months to work through the whole diet and identify the food type that causes symptoms. However, if this is done properly, it can give a long-term way of controlling the condition. Unfortunately, it is not always possible to identify a food type that causes symptoms for every patient.

To help people manage their diet, some people find it very useful to use specially designed apps on their smartphone or other handheld device. This can be discussed with your dietitian or doctor. It is important to note that we are not responsible for third party content which may change over time.

Medications

You may be offered medications to try and treat EoE. One first line medication is an acid-lowering tablet called a proton pump inhibitor. This does not treat the underlying problem behind EoE. However, it may ease the inflammation and improve some of the symptoms. For some patients, this is enough to help manage their symptoms. However, for many patients this medication on its own does not improve their symptoms long term.

The main treatment recommended for EoE is steroid medication. This is usually a dissolvable tablet that you place on your tongue. As you swallow this with saliva, the steroid coats your gullet. This medication is normally taken twice a day for 6 weeks to see if your symptoms improve. Longer courses can be given if needed. Currently this medication needs to be started by a specialist in hospital.

Endoscopic treatment

Over time, irritation or inflammation in the gullet can lead to narrowing of the tube. If a person with EoE develops a narrowing in their gullet (called a stricture), this can make it difficult to get food, or sometimes even fluids, to pass into the stomach. This can be treated with an upper GI endoscopy and stretch with an inflatable balloon (called a dilation). This procedure can be very effective in improving a person's swallowing, but it also has risks of causing problems. These include tearing a hole in the gullet. Although the risk of this is low, it can be very serious if it occurs. Endoscopy and balloon dilation can help treat a narrowing, but will not treat the underlying EoE, so without effective treatment the narrowing can come back. This is one of the reasons why it is important to treat EoE, to try and limit the inflammation and prevent the development of narrowing.

Figure 1. Endoscopic balloon dilation of an oesophageal stricture. Source: UHBW NHS Foundation Trust.

Figure 2. Endoscopic balloon dilation of an oesophageal stricture - annotated picture. Source: UHBW NHS Foundation Trust.

Here are some useful links to other sources of information on eosinophilic oesophagitis. However, as these are external websites, we are not responsible for the accuracy of any external content which may change over time. We do not endorse specific commercial products or entities.

Guts UK:

https://gutscharity.org.uk/advice-and-information/conditions/eosinophilic-diseases/

Dr Falk Pharma:

• Eosinophilic oesohpagits explained - click here
• Eosiniophilic oesophagitis - what it is and how it's treated - click here