Eosinophilic oesophagitis - could your swallowing problems be caused by allergies?
Swallowing problems (also called dysphagia) are a common reason for patients seeking help from a gastroenterologist. While swallowing problems can be caused by several conditions, one condition, eosinophilic oesophagitis, is actually due to a type of allergy, and it is on the rise.
New, persistent, and worsening swallowing problems should never be ignored, as they can be due to a range of underlying conditions, some of which can be serious, including cancer. Causes of swallowing problems can include:
Acid reflux (gastro-oesophageal reflux disease, or GORD/GERD)
Narrowings of the oesophagus (called strictures)
Infections of the oesophagus with candida
Inflammation of the oesophagus (oesophagitis)
Tumours in the oesophagus, including oesophageal cancer
Problems with the movement of the oesophagus (called dysmotility)
As we do not want to miss worrying underlying causes of swallowing, you should always report new or worsening swallowing problems to your doctor, and seek a specialist opinion. Generally we will arrange an urgent endoscopy, a camera test to examine the lining of the oesophagus and stomach.
When we perform an endoscopy to investigate swallowing problems, we will generally take samples (called biopsies) from the lining of the oesophagus. This is to check for a condition called eosinophilic oesophagitis, also called EoE. This is a common and easily missed condition that can cause real problems with swallowing, and can lead to long term problems if not treated properly.
Eosinophilic oesophagitis (EoE) can affect people of all ages, but it is more common in young people, and in men. We think it is a type of allergic or atopic condition, in the same family as conditions like asthma, eczema, and hayfever. It is very common for people with EoE to have at least one of these other conditions.
We think that an allergic reaction to some foods leads to inflammation of the lining of the oesophagus. We can sometimes see the inflammation at the time of endoscopy (changes like narrowing, ridges, furrows, and small white patches), but we diagnose the condition by taking biopsies (tiny samples) from several areas of the oesophagus. Under the microscope, we can see an increase in the number of a type of white blood cell called eosinophil, as well as other changes of inflammation.
Often people with EoE have had symptoms for years, sometimes even decades. Most commonly they have intermittent issues swallowing some foods, particularly things that are larger and less easily swallowed, like chunks of meat or bread. Some people with EoE will have had a food bolus obstruction, where a lump of food has got stuck in their oesophagus for a period of time. If this clears by itself often people don't seek medical attention, but if this happens, even if it clears relatively quickly, it should still be checked out.
Fortunately, we have a range of treatments that can help with eosinophilic oesophagitis. First, we can settle the inflammation with a course of local steriod treatment, called budesonide (Jorveza). This coats the lining of the oesophagus with the steroid, settling the inflammation quickly, a bit like asthma inhalers or nasal sprays. This type of steroid generally does not cause significant steroid side effects, but we would always keep an eye out for these problems.
Once the steroid treatment as worked, and we have checked that the inflammation has settled with a repeat endoscopy, we can consider options for long term control of the inflammation. This can include working with a specialist dietitian to identify potential food triggers for the inflammation. Previously a six-food elimination diet was recommended, however most patients react to just one or two foods, and so a less restrictive diet can work for many patients. Common allergens include dairy and wheat, and we usually try these foods first. Unfortunately, allergy blood tests are rarely helpful in identifying the cause, although they are sometimes recommended if there are other allergic symptoms.
Long-term control of the inflammation is important as this can help prevent complications of eosinophilic oesophagitis, like strictures, inflammation, narrowing of the oesophagus, and food bolus blockages.
If you have issues with swallowing, or have a diagnosis of eosinophilic oesophagitis, and would appreciate a specialist opinion, please do get in touch to schedule an appointment.
