Trouble Swallowing? It May Be Eosinophilic Esophagitis

Trouble Swallowing? It May Be Eosinophilic Esophagitis
Eosinophilic esophagitis (EoE) EoE can occur at any age, but it is three times more common in males, especially in white males in their 20s to 40s.(fizkes/Shutterstock)
Melissa Diane Smith
10/18/2022
Updated:
3/21/2023

A few years ago, a client wrote to tell me that her teenage son had just been diagnosed with eosinophilic esophagitis and was wondering if there were any nutritional treatments for it.

Last autumn, a childhood friend emailed me telling me he had been diagnosed with the same condition.

And then few weeks ago, I learned that an out-of-town male relative had also been diagnosed with it.

What is eosinophilic esophagitis? Is it just a coincidence that three people in my sphere have been diagnosed with it in just a few years, or is its prevalence increasing?

What Is Eosinophilic Esophagitis?

In the early 1990s, doctors began describing a new condition called eosinophilic esophagitis (known as EoE) affecting the esophagus, the muscular tube that leads from the mouth to the stomach that is often called “the food pipe.” EoE is a chronic immune system disease in which eosinophils, a type of white blood cell, build up in the esophagus, causing inflammation and injury to the esophagus as a reaction primarily to foods but sometimes to airborne allergens or acid reflux.

EoE is now considered a major cause of digestive illness.

Researchers once thought EoE was a part, or type, of gastroesophageal reflux disease (GERD), but they eventually determined that EoE and GERD are separate conditions.

In a 2020 review article on EoE, United Kingdom researchers explained that people who have EoE may use the terms “indigestion” or “heartburn” but not realize their symptoms differ in nature from discomfort felt by people with acid reflux. The symptoms in EoE occur during or immediately after swallowing while eating a meal, while the symptoms of GERD occur 30 minutes to two hours after eating a meal.

Difficulty swallowing is the most common symptom, and EoE sufferers try to adapt to it. They often are the last to finish a meal, use large amounts of liquid to wash food down, and sometimes suffer through episodes of food obstruction and regurgitating swallowed saliva, fluids, or solids until the food has shifted and passed.

Food obstruction is the most frequent emergency presentation of EoE, occurring in 20 percent of sufferers. EoE is identified in up to 50 percent of food obstruction cases and is the most common cause of food obstruction seen in emergency departments.

Signs and Symptoms

According to the Mayo Clinic, there are multiple symptoms of eosinophilic esophagitis.
Adult Symptoms:
  • Food impaction (when food gets stuck in the esophagus after swallowing)
  • Dysphagia (difficulty swallowing)
  • Pain in the center of the chest that doesn’t respond to antacids
  • Regurgitation (when undigested food comes back up)
Child Symptoms:
  • Dysphagia (difficulty swallowing)
  • Pain in the abdomen
  • Food impaction (when food gets stuck in the esophagus after swallowing)
  • Feeding difficulty in infants
  • Eating difficulty in children
  • Vomiting
  • Poor growth, weight loss, and malnutrition

How Common Is EoE, and Why Is It Increasing?

EoE is estimated to affect 1 in 2,000 adults in the United States, according to a 2013 analysis. However, the authors wrote that this number may underestimate the true prevalence of the condition, because both the knowledge of the new hospitalization diagnosis code and the recognition of EoE are still increasing.
EoE can occur at any age, but it is three times more common in males, especially in white males in their 20s to 40s. This health problem also afflicts people who are predisposed to immune reactions, including food allergy, asthma, and eczema, and there’s an association with autoimmune diseases, including celiac disease, Crohn’s disease, ulcerative colitis, and rheumatoid arthritis. Research has demonstrated seasonal variation in EoE diagnosis, with an increase in EoE cases in the spring and summer months, suggesting that exposure to seasonal airborne allergens or foods more available during those seasons may play a role in its development.
Evidence also suggests that the numbers of new EoE cases have been rising. A review published in 2019 of nearly 30 studies in Europe and North America found that there has been a progressive increase in the number of new EoE cases, especially since the early 2000s.

Greater awareness of the disease and more widespread use of endoscopy—a flexible tube with a light and camera attached to it, typically used to help diagnose EoE—may play a role in the rise in cases. But research points to a true increase in the incidence of the disease.

The exact reasons for the rise in cases are unknown. Possible explanations about why EoE is increasing include changes to food production, such as genetic modification of crops, pesticide use, and antibiotic or hormone use in livestock, as well as the increased use of acid-suppressing medications, which might change microbes in the esophagus to later increase the risk of food reactions and inflammation.

Nutritional Treatment for the Condition

It’s important to diagnose and treat esophagitis. If it isn’t properly diagnosed and treated, EoE may lead to the narrowing of the esophagus over time, and people who have EoE have an increased risk of multiple autoimmune diseases. Treatment options for the condition include swallowed steroids, proton pump inhibitors, periodic esophageal dilations, and food elimination diets.
The most natural and definitive therapy for EoE, which avoids virtually lifelong drug treatments and associated risks and adverse events from drugs and dilations, is for patients to identify their individual food triggers and eliminate them from the diet. Reactions to foods are well-known to trigger EoE but not through the release of immunoglobulin E (IgE) antibodies involved in true food allergy, but through some other undetermined immune mechanism, possibly through the release of IgG4 antibodies, according to a 2014 randomized, double-blind, placebo-controlled study. As of right now, there’s no accurate test to identify food triggers connected with EoE.
Therefore, medical experts recommend an elimination diet to help identify food triggers, improve the condition, and directly address the underlying allergic mechanism that’s leading to esophageal inflammation and damage. Practitioners typically choose one of two types of elimination diets to recommend: the step-down 6-food elimination diet or the step-up 2-4-6 elimination diet.

The Step-Down 6-Food Elimination Diet

The step-down 6-food elimination diet eliminates the six foods most commonly associated with the immune reaction that leads to EoE. The six foods are wheat, milk, soy, eggs, nuts, and seafood/shellfish. EoE symptoms are checked along with biopsy (removing samples of tissue during endoscopy) after six weeks, then each food is slowly reintroduced every two weeks while symptoms are monitored and recorded.
This elimination diet is quite restrictive but typically more effective. In a clinical trial conducted in 2012, 78 percent of patients had a greater than 50 percent reduction in their peak eosinophil density tests, and symptom scores of difficulty swallowing decreased in 94 percent of patients on this diet.

The Step-Up 2-4-6 Elimination Diet

Another elimination diet variation, the step-up 2-4-6, is growing in popularity.
  • It starts with a 2-food group elimination diet, which eliminates all milk products and all gluten grains (not only wheat, but also rye, barley, oats, triticale, farro, einkorn, spelt, and kamut).
  • If patients don’t achieve symptom improvement on the 2-food group elimination diet, they can “step up” to a 4-food group elimination diet, eliminating milk and gluten grains, plus egg and soy/legumes.
  • If that doesn’t resolve their symptoms, they can “step up” again to a 6-food-group elimination diet, which includes eliminating milk, gluten grains, egg, and soy/legumes, plus nuts and fish/seafood.
A clinical trial published in The Journal of Allergy and Clinical Immunology in 2018 found that the step-up 2-4-6 elimination diet achieved EoE remission in 43 percent of children and adults. “A step-up approach results in early identification of a majority of responders to an empiric diet with few food triggers, avoiding unnecessary dietary restrictions, saving endoscopies, and shortening the diagnostic process,” the researchers concluded.

How to Try an Elimination Diet for EoE

Successfully following an elimination diet involves a few important steps and adapting the diet in practical terms to your lifestyle. Also, keep in mind that foods that trigger EoE are highly individual. For those reasons, it’s important to work with a nutritionist or practitioner who specializes in elimination diets for EoE so he or she can help tailor the most appropriate food elimination diet for you and guide you through the process.

When done successfully, completing a trial period of an elimination diet and then challenging yourself with each of the common EoE-triggering foods should not only resolve or alleviate discomfort in your esophagus, but also help you learn which foods are triggering the immune reaction and inflammation in your esophagus, so you can develop your own personalized therapeutic diet to prevent EoE and promote long-term esophageal health.

Melissa Diane Smith is a holistic nutrition counselor and journalist who has been writing about health topics for more than 25 years. She is the author of several nutrition books, including “Syndrome X,” “Going Against the Grain,” “Gluten Free Throughout the Year,” and “Going Against GMOs.”
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