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June 12, 2006
The image of a child with a feeding tube is a tough one to swallow. But that’s one treatment method for this little-known, severe allergic condition, which wages a war in the esophagus. Eosinophilic esophagitis (EE) is a rapidly emerging chronic illness in both pediatric and adult gastroenterology. Often misdiagnosed in the past as gastroesophageal reflux disease (GERD), recent research and new diagnostic techniques have proven EE to be an entity all its own. Most commonly caused by a food allergy, EE is a serious condition that can cause chronic feeding problems. Treatment to control the disease has become a widely discussed and often controversial topic, especially among registered dietitians (RDs), physicians, allergists, and gastroenterologists. Etiology of EE EE affects people of all ages, regardless of gender
or ethnic background, but most patients are in early childhood or aged
20 to 40. Eighty percent of cases are males.3 • dysphagia; • food impaction; • nausea and vomiting; • failure to thrive (poor growth and/or weight loss); • abdominal or chest pain; • poor appetite; • malnutrition; and • difficulty sleeping. Nausea and vomiting are the most common symptoms for children, while dysphagia accompanied by solid food impaction is most prevalent in adults.4 Vomiting, dysphagia, and abdominal pain are also symptoms of GERD, making it easy to misdiagnose EE as reflux disease. Distinguishing the two illnesses is important because patients with EE do not respond to GERD treatments. The symptoms of EE appear intermittently while GERD symptoms are persistent. The results of a pH probe will return normal for patients with EE and abnormal for those with GERD. An acid blockage will be unresponsive in someone with EE whereas it will be responsive in someone with GERD.3 GERD also causes eosinophils in the esophagus, but typically far less than for patients with EE. According to Steven Yannicelli, PhD, RD, the esophageal biopsy of a person with EE will find a “significant infiltration” of eosinophils. Diagnosis An upper endoscopy looks at the esophagus, stomach, and duodenum through an endoscope (a small tube inserted through the mouth) and takes multiple small tissue samples. Even if the esophagus appears normal, the biopsies may show an abnormal accumulation of eosinophils. The pathologist will also examine the biopsy for tissue injury, swelling, and thickening of esophageal layers. Once the diagnosis is confirmed, the next step is a visit to an allergist. Skin prick testing to different foods is the most common type of allergy test, though it doesn’t measure immunoglobulin E-mediated reactions, which can be tested through skin patch testing. Although there may be no obvious, immediate reaction, causative foods can trigger an accumulation of eosinophils over a period of days to weeks that will cause inflammation and injury. Treatment Most children and adult patients have a significantly favorable response to dietary treatment. However, controversy arises when naysayers proclaim that the dietary plans are too restrictive, especially for small children. Elimination Diets “As part of their nutrition assessment, we get a diet history and preferences. Based on what they tell us, we will try to work out the most balanced diet possible with the foods that remain in the diet,” says Shuker. Elemental Diets During an elemental diet, all sources of protein are removed and an amino acid formula lacking any whole or partial proteins is consumed. Elemental formulas are made of amino acids, fats, sugars, vitamins, and minerals. Adults generally rely on an elemental diet for partial nutrition and may still eat other foods; children are more likely to rely on an elemental diet as their sole source of nutrition. This may seem a simple solution, but the quantity of formula required is often difficult for many patients to consume. In such a circumstance, patients may require enteral support to maintain proper nutrition. The amount of formula consumed is unique to each patient, based on his or her estimated need for weight gain and growth. Food Reintroduction Medication Therapy Faubio et al treated 21 children with oral steroids for one month, and almost all experienced near total symptom relief within one week.5 Nutrition vs. Medication Medication, meanwhile, provides quick and effective results without the demands of a restrictive diet. Nevertheless, these medications aren’t suggested for long-term use and the eosinophils will return when medication is stopped. Healthcare providers who support nutrition therapy argue that the pharmaceutical approach should not be the first course of treatment. If nutrition therapy can almost always diminish symptoms completely, why risk the side effects of medication therapy? “Steroids, especially the systemic ones, have been very effective at reducing both clinical systems and the number of eosinophils. The problem is that once you stop, those come back. The symptoms come back and EE does return. So the issue is that, yes, they are effective, but they aren’t recommended for long-term use. If you stay on a diet, it works. It balances against the negative effects of drugs, and there are a number of those,” says Yannicelli. The side effects of steroid therapy to treat EE include decreased growth, protein breakdown, joint necrosis, osteoporosis, behavioral changes, glucose intolerance, increased risk of cataracts, and headaches. “These are all time-dependent and dose-dependent side effects, but they’re well documented. There’s not really an argument—they’re there,” says Shuker. “There’s currently no specific drug to treat this disease,” says Yannicelli. “Although the drugs are effective, the evidence doesn’t support daily use. Everything that’s coming out now really says that diet and [elemental] formulas are the best way forward. With drugs, there aren’t long-term studies to show if it makes a difference in clinical outcome.” Those who favor using pharmaceuticals to treat EE argue that children cannot be trusted to follow such a restrictive diet, especially older children who aren’t under constant parental supervision. Children may become bored with the diet, worry about fitting in with peers, and may not have the discipline to follow such a prohibitive diet. Also, nutrition management may be expensive, whereas a pharmaceutical approach will almost always be covered by insurance. Elemental diets require compliance, and if the patient’s family cannot afford the formula, the physician is unlikely to recommend an elemental diet. “I’m not going to say that in any way, shape, or form an elimination or elemental diet is easy by any means. It is very challenging and does require a team approach,” says Nicole Perna, RD, southwest territory manager for Neocate. According to Shuker, although elemental diets may be a hindrance to a child’s lifestyle, they will resolve the issue in almost all cases and remove most of the eosinophils from the esophagus and keep them from returning. However, there are circumstances in which dietary therapy is unsuccessful. Most RDs are not opposed to using pharmaceutical therapy—just not as a first option. “Steroids are very effective. They work, but when you stop steroids, the cells come back,” says Shuker. “Sometimes people will want to take a break from dietary therapy. It doesn’t happen often, but it happens, and they would just rather treat with steroids.” Choosing the Best Option Although Liacouras ultimately supports nutrition therapy, he argues that patients who are very ill, are losing weight, and can’t function on a normal level should consider pharmaceuticals to alleviate their symptoms. Nutrition therapy does work, but the lifestyle associated with making such drastic dietary changes doesn’t work for everyone. According to Liacouras, “Some people would just rather not be on tube feeding or an elemental formula.” It’s not that changing dietary habits wouldn’t work for these patients, they just choose to not travel that route. Some patients, for various reasons, would simply rather continue their regular eating patterns with the help of medication. While not a long-term option, the aid of pharmaceuticals is an option required for some and chosen by others. Perna suggests the best route to successfully combating EE is to present the treatment options in an unbiased manner to the patients and their families so they can decide “not based on what sounds easier but what is actually a better choice for their lifestyle. “We need to let the family decide what’s best for them and what they would like to do, whether it be a diet or not. We need to take extra care and present all the options that we think are appropriate, and it’s up to us [as dietitians] to decide what’s appropriate, and then to present those appropriate treatments.” If nutritional management is the chosen treatment program, it’s important that a team approach is taken and that doctors are working in conjunction with RDs. “RDs are vital to the success of the process because dietitians are your nutrition experts. They’re going to know how to make sure the kids know which foods may have an ingredient in it that may affect the eosinophils,” says Perna. Perna suggests removing the eliminated foods from the household to remove temptation. Hopefully, in turn, the patients will make healthy decisions outside the home as well. “It definitely takes all the clinicians, the parents, and the child [for successful treatment],” Yannicelli says. “Compliance is one of the biggest problems of staying on a diet like this.” “The good news is that there are so many more products available these days that are free of certain allergens,” Shuker says. “The kids who play sports can have energy bars that are wheat-free, soy-free, and egg-free. So, all it really comes down to is education and working with each family individually to see what’s what. It will still be hard, but there are people and products to help.” Yannicelli says that most clinicians who support pharmaceutical treatments don’t do so because they are against nutritional therapy. They do so because nutrition management takes a complicated and labor-intensive team approach, and many physicians simply don’t have the time. “You have to individualize [the nutritional management] for any patient with a chronic disorder who’s on a diet. That just goes with the game,” says Yannicelli. “But if you take a team approach and you have a great dietitian, the diet for a patient with EE is very doable ... and you have to weigh that with the long-term effects of drugs.” To reach ultimate success, education, communication, and advocacy are paramount. “It’s really just a matter of educating the families. The big thing in food allergies, or any field really, is focusing on what the child can have,” says Shuker. “Communication is key. It’s crucial to developing an effective plan and staying on the same page.” “The message has to be ‘how are we going to do this?’ rather than ‘this is going to be hard to do … let’s do something else.’” says Yannicelli. “We have found that, in almost every case, dietary manipulation will remedy the problem. Sometimes we need to use steroids, and we will if we need to use them,” adds Shuker. Nevertheless, nutrition therapy is the recommended first course of action—and the most successful. Says Shuker about nutrition therapy: “It’s not just that we’re dietitians, it’s that it works.” — Valerie Yeager is an editorial assistant at For The Record. References 2. American Partnership for Eosinophilic Disorders. Available at: http://www.apfed.org. Accessed March 28, 2006. 3. Blanchard C, Wang N, Stringer KF, et al. Eotaxin-3 and a uniquely conserved gene-expression profile in eosinophilic esophagitis. J Clin Invest. 2006;116:536-547. 4. Arora AS, Yamazaki K. Eosinophilic esophagitis: Asthma of the esophagus? Clinical and Gastroenterology and Hepatology. 2004;2:523-530. 5. Food Allergies May Cause Chronic Vomiting. Newswise. Children’s Hospital of Philadelphia. November 4, 2003.
• American Partnership for Eosinophilic Disorders, www.apfed.org • Children’s Hospital of Philadelphia, www.chop.edu • Cincinnati Children’s Hospital Medical Center, www.cincinnatichildrens.org • The National Eosinophilic Enteritis Disease
Foundation, http://c4isr.com/NEED
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