What is EOE?

Eosinophilic esophagitis also known as EoE, is a relatively newly recognized disease that is characterized by eosinophils (allergy cells) building up in the lining of the esophagus.

The eosinophils cause inflammation in the esophagus, which may cause the following symptoms:

  • Difficulty feeding, including feeding refusal and feeding intolerance
  • Poor weight gain
  • Decreased appetite
  • Chest pain
  • Abdominal pain
  • Reflux-like symptoms
  • Vomiting
  • Trouble swallowing
  • Food impaction (when food gets stuck in the throat)

The reasons why some people have EoE are not fully understood. Research has shown a strong connection between food allergies and EoE.  Environmental allergens may also play a role in this disease but more research is needed. What we do know is that EoE is a chronic disease that can be managed through diet and/or medical treatment. EoE is not life threatening; however, if left untreated it may cause permanent damage to the esophagus.

Many patients with EoE also experience gastroesophageal reflux disease (GERD), a chronic digestive disorder that is caused by the abnormal flow of gastric acid from the stomach into the esophagus. It is not uncommon for a patient to receive treatment for GERD while also undergoing treatment for EoE. Learn more about GERD.

At CHOC, our multidisciplinary gastroenterology and allergy teams work together to diagnose and treat EoE so that our patients can reduce or eliminate their symptoms, prevent future complications and live a happy life. We also understand that with an EoE diagnosis comes many questions about the disease, treatment and long-term health. We have put together the most frequently asked questions we received from our patients and their families. These answers should not replace information or specific instructions provided by patients’ health care providers.

General Information About Eosinophilic Esophagitis

General Information About Eosinophilic Esophagitis

What is the upper gastrointestinal tract?
The upper gastrointestinal includes the parts of the body that break down and digest the food we eat. In a wave-like movement, called peristalsis, muscles push food and liquid along the digestive tract. The involvement of the upper GI tract includes the following:

  • The first major muscle movement is swallowing food or liquid. The start of swallowing is voluntary, but once it begins, the process becomes involuntary and continues under the control of the nerves.
  • The esophagus, which is the muscular tube through which food passes from the throat to the stomach.
  • Where the esophagus and stomach join, there is a ring-like valve that closes the passage between the two organs. As food nears the valve, the surrounding muscles relax and allow food to pass into the stomach. The valve then closes.
  • The food then enters the stomach, which completes three mechanical tasks of storing and mixing the food, then emptying it into the small intestine.
  • The food is digested in the small intestine and dissolved by the juices from the pancreas, liver, and intestine and the contents of the intestine are mixed and pushed forward to allow further digestion.

What is an eosinophil?
An eosinophil is one of several types of white blood cells normally found in blood and certain tissues. Eosinophils help engulf and kill bacteria and microorganisms such as parasites. They also participate in the control of allergic reactions and diseases. Eosinophils normally function to protect the body.

What is an eosinophil-associated disorder?
An eosinophil-associated disorder is a disease state in which there are too many eosinophils in a particular organ or organs, often in the gastrointestinal tract. Too many eosinophils are often associated with abnormal symptoms. The long-term effects of too many eosinophils in a given area of the body are not known.

How common is eosinophilic esophagitis (EoE)?
It is estimated that approximately 55 patients per 100,000 people in the United States have EoE. This may vary by region.

Was my child born with EoE?
Children are probably not born with EoE but develop it over time. They may be born with a predisposition to the disorder.

Do adults get EoE?
Adults do get EoE. It can develop in childhood and persist into adulthood. Some people first experience EoE as an adult or only receive a diagnosis once in adulthood. Overall increased awareness of the disorder has improved disease recognition and the need for endoscopic biopsies.

Is it harmful if someone only has a few eosinophils in their esophagus?
The presence of eosinophils suggests that there is inflammation in the esophagus. Inflammation should always be treated and should not be ignored. However, how many eosinophils is “too many” and how long is “too long” is yet to be determined.

Are certain people more likely to get EoE?
Although anyone can get EoE, boys tend to develop it more often then girls—approximately three to one.

What are the symptoms of EoE in infants?
Infants with EoE usually have symptoms similar to reflux, including spitting up, irritability, vomiting and feeding refusal. Some children may also experience growth problems.

What are the symptoms of EoE in toddlers?
EoE symptoms in toddlers are similar to those in infants, but they may also complain of abdominal pain or have trouble transitioning to solids.

What are the symptoms of EoE in school-aged children?
School-aged children may have reflux-like symptoms and may also vomit intermittently. They may have difficulty swallowing but this may be hard for them to explain.

What are symptoms of EoE in older children and teens?
Symptoms in older children and teens are similar to all of the other age groups, but may also include complaints about difficulty swallowing or food getting stuck in the esophagus.

Who should be tested for EoE?
Patients with symptoms listed at the top of this page that do not respond to medical treatment may be tested for EoE. This is especially true for those who have significant difficulty swallowing solid foods.

Is EoE is hereditary?
EoE may be more common in families. Family members should be tested if they have symptoms.

Do children outgrow EoE?
There is limited data on long-term outcomes of EoE.

Can inflammation of the esophagus be cancerous?
Limited adult data suggests that inflammation does not lead to cancer, but it is too early to know for sure. Any inflammatory process that persists from childhood to the adult years must be of concern.

What happens if someone with an eosinophilic disorder is exposed to an “unsafe” food?
EoE reactions may not happen immediately. Usually, if a child is exposed to an “unsafe” food, he or she may experience a flare up in symptoms within a few days.

Are the symptoms of EoE the same in adults and children?
Symptoms are similar, but adults typically have difficulty swallowing or food getting stuck in the esophagus. Adults are more likely to have strictures that need to be dilated.

What is a stricture?
EoE can cause changes in the tissue lining the esophagus that may result in a stricture, or narrowing of the esophagus. This is thought to occur as a result of inflammation in some children and adults with EoE. Food may not be able to pass from the mouth to the stomach when a stricture forms.

How are strictures treated?
Esophageal strictures are usually treated by dilation or stretching the esophagus. To do this, a long cylindrical rubber tube into the mouth and esophagus or by placing an inflatable balloon through the endoscope into the esophagus. These procedures can cause pain and tears in the esophagus. Patients and their families should discuss these procedures and understand the risks.

Questions About EoE Diagnosis

How is EoE diagnosed?
EoE is diagnosed by evaluating each child’s symptoms, whether the child’s symptoms improve while undergoing EoE treatment and signs of EoE found during an endoscopy. Children with EoE usually show high numbers of eosinophils in the esophageal tissue. Greater than 15 eosinophils per high power field is generally considered suggestive of EoE. The endoscopist may mention seeing trachealization or furrowing (rings) in the esophagus, which is also suggestive of EoE.

EoE can resemble other medical conditions.  Eosinophils may be seen in the esophagus in lower numbers in GERD patients. Both GERD and EoE patients may respond to acid blocker therapy with proton pump inhibitors. Learn more about GERD.

What is an endoscopy?
An endoscopy, also referred to as upper endoscopy, esophagogastroduodenoscopy and EGD, is a test using a special camera to look at the lining of the esophagus, stomach and duodenum. Small tissue samples, called biopsies, are taken to evaluate under a microscope. Sedation is usually required to perform the procedure. Learn more about endoscopy.

What is a biopsy?
In the case of EoE diagnosis, a biopsy is a small tissue sample taken from the lining of the gastrointestinal tract that can be looked at under a microscope to help diagnose EoE and other disorders.

How many biopsies should be taken to diagnose EoE?
EoE is a patchy disorder, so usually four to six samples are taken to increase the likelihood of finding the disease if it is present.

Is there a way to diagnose EoE without invasive tests or through a simple blood test?
Unfortunately, an endoscopy is the only way to positively diagnose EoE. Blood tests and stool tests may be necessary to help exclude other disorders, but no blood test is available to diagnose a primary eosinophilic disorder.

Will patients have to go through additional endoscopies and biopsies after the initial diagnosis?
Patients will likely need several endoscopies over time to monitor the child’s response to treatment.

How do doctors figure out which foods may be causing EoE symptoms?
Our specialists use a combination of the patients medical history and all available tests including skin prick, patch and food challenges to determine the foods causing EoE.

What is skin prick testing?
It is a simple procedure that rapidly detects whether the person has antibodies to an allergen, food or environmental allergen. Using diluted solutions of specific allergens on plastic prongs, one of our allergy and immunology doctors pricks the surface of the child’s skin. A reaction to the skin test does not always mean that your child is allergic to the allergen that caused the reaction. Skin tests provide fast results, typically taking 15 minutes, and are more sensitive than blood tests. Skin prick tests are typically followed up with patch testing.

What is patch testing?
It is a test that is used to detect delayed allergic reactions.  Actual food is used to test how a child’s body reacts to its presence. Foods that yield a reaction may also be causing EoE symptoms, however, this can only be determined after monitoring the child when the food is restricted and then reintroduced. Learn more about patch testing.

Information About EoE Treatment

How is EoE treated?
For children with EoE, the primary goal of treatment is to insure normal growth and development.  Steroids and/or dietary modifications are the most common therapies. Treatment regimens are often difficult to maintain and must be individualized according to each family’s concerns and lifestyles. Learn more about EoE treatment at CHOC.

Is it true that some children with EoE cannot eat food?
Most children can eat some food but every patient with EoE is a little different. Some patients must rely on specially designed formula for their nutrition. These diets are called elemental diets. Learn more about the different types of diets used to eliminate EoE symptoms.

What medications help EoE?
Some patients with EoE take “swallowed steroids” to destroy the eosinophils, fight inflammation and allow healing to take place. The products that are used for EoE treatment were originally studied in asthmatics.They are approved for use in children. In fact, some of the steroids are approved for children as young as 12 months.

Some patients with EoE may also have allergy symptoms that require daily medications. Not every patient with EoE will need allergy medicine.

New therapies called “biologics” have been studied in patients with EoE. It is not known how helpful these man-made antibodies will be in the future.

Where can I get more information on treatments for eosinophilic disorders?
For more web-based resources on eosinophilic esophagitis, please refer to our list of online resources.

Where can I get more information on experimental treatments?
More information on experimental resources is available through the American Partnership for Eosinophilic Diseases and the National Institutes of Health.

Are there side effects from topical steroids such as fluticasone and budesonide?
The human mouth and throat contain many organisms including bacteria and yeast. Sometimes when medications like these are taken, small amounts of residue remain on the surface of the mouth and throat. This change can allow yeast organisms to multiply and cause soreness and trouble swallowing.  This side effect can be eliminated by gargling with water and spitting after each use.

Do patients with EoE need allergy shots?
Allergy shots to environmental allergens and their effect on EoE has not been studied.