An allergic gullet can look like heartburn yet shrug off acid blockers
In eosinophilic esophagitis, immune cells that should never be in the gullet flood into it, apparently in response to food. The result mimics acid reflux, with trouble swallowing and food getting stuck, but most patients barely respond to acid suppression. Only a biopsy counting at least 15 eosinophils per microscope field confirms it.
Healthy oesophagi contain essentially no eosinophils, although the cells are normal further down the gut. In this condition they pour into the oesophageal lining, where their chemical signals inflame the tissue and can, over time, cause narrowing. The trigger is thought to be an antigen, often from food, meeting a genetically susceptible immune system: lining cells release alarm signals, helper T cells respond with IL-13, IL-4 and IL-5, and a molecule called eotaxin-3 draws in eosinophils, mast cells and basophils. Why the cells migrate there in the first place is still under study.
It was first described in children and is commoner in males, but it affects every age group, and symptoms shift with age. Young children may feed poorly and gain weight slowly; older children choke or gag on coarse foods; adults mainly struggle to swallow, and because years of unnoticed inflammation may have scarred the tube, they suffer more food impactions and structural problems such as Schatzki rings. Asthma, coeliac disease and mast cell disorders frequently accompany it.
Diagnosis combines symptoms, biopsy and ruling out lookalikes, including reflux, achalasia, infection and Crohn's disease. On camera the wall may show rings, furrows or white patches; multiple rings give the so-called feline oesophagus, named for its resemblance to a cat's. Biopsy is the gold standard, with reported sensitivity of 100% and specificity of 96%, and samples come from both the upper and lower oesophagus whatever the lining looks like. Allergy tests are poor at predicting which foods matter.
Management uses diet, drugs and dilation. Elimination diets remove up to six food groups, often for about six weeks, while an elemental formula of amino acids brings responses in almost 90% of children and 70% of adults. Oral corticosteroids improve roughly 95% of patients, but about 90% relapse once they stop. In May 2022 the FDA approved dupilumab, the first licensed treatment in the United States for the disease. Stretching narrowed sections is deferred until the inflammation is controlled.
Source: Eosinophilic esophagitis
