Allergy Clinical Services

Eosinophilic Esophagitis

Eosinophilic esophagitis (EE) has only recently been recognized, and it is being found in many allergic children. Its symptoms mimic gastroesophageal reflux disease (GERD). It is an allergic inflammatory reaction of the esophagus, the muscular tube that carries food from the throat to the stomach.

To distinguish between GERD and EE, a biopsy of the esophagus and GERD studies are preformed. In EE, high levels of eosinophils are detected in the esophagus only, and not other parts of the digestive tract. EE is simply an inflammation of the esophagus caused by the presence of high levels of eosinophils.

Eosinophils are a type of white blood cell that are not normally found in the esophagus. High levels of eosinophils often indicate an allergic response.

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Studies have revealed that symptoms from EE do not improve with aggressive acid blockage therapy used for the treatment of GERD. They do improve with an elimination diet or corticosteroid treatment. Skin prick testing and patch testing can help identify which foods might contribute to this disease. The foods most commonly associated with EE are cow's milk, soy, egg and wheat. Airborne allergens may also be a contributing factor. Many children with this disorder have more than one allergy problem.

Resources on eosinophilic esophagitis

Symptoms

The presence of eosinophils in the esophagus causes inflammation in the gastrointestinal tract, which makes digestion very painful. Some of the symptoms associated with EE are:

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Treatment

All treatment plans should be discussed with your individual physician. The treatment team usually consists of your primary doctor and pediatric specialty physicians in Allergy and Gastroenterology who are familiar with this disorder and can perform all needed diagnostic tests. A nutritionist may be needed to help manage dietary concerns.

After skin testing and patch testing is completed, it is recommended that patients eliminate all positive foods from their diet for eight to 12 weeks. At the same time, any other allergic disorders (asthma and allergic rhinitis) must be treated as well. After two to three months of treatment, repeat endoscopy and biopsy are recommended to check for improvement in inflammation.

Possible biopsy results include:

  1. Biopsy is normal (eosinophils less than 10 per high power field). Foods can be reintroduced back into the diet (see below)
  2. Biopsy is improved. This is the most difficult case. If biopsy is almost normal, you can try to continue avoidance for another one to two months and repeat endoscopy. Alternatives include an elemental diet or the removal of additional potential foods from diet.
  3. Biopsy is not improved. We recommend a four-week trial of an elemental diet. If the symptoms and biopsy do not improve after that period of time, foods are not the cause of the disease.

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Elemental diets

An elemental diet (no large food protein molecules that the immune system can react to) consists of a formula such as NEOCATE, NEOCATE-JR, NEOCATE-1+ or ELECARE. Patients are allowed to drink GATORADE or soda (they do not have protein in them).

Food reintroduction

Foods are reintroduced into the diet after a normal biopsy. In general, new foods are reintroduced one new food per week while watching for symptoms to return. One or more biopsies may need to be performed during this process to check for inflammation. When patients improve on an elimination diet, we generally recommend reintroduction after three to four months of avoidance. The patch test positive foods are reintroduced first at home while the family keeps a diary. Skin test positive foods are reintroduced next. These may need to be tested first by performing a food challenge in a hospital setting if severe reactions are possible.

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Reviewed by: Allergy Section
Date: December 2003

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Treatment at CHOP

CHOP's Center for Pediatric Eosinophilic Disorders treats children with eosinophilic esophagitis and other eosinophilic disorders.