What it is
Eosinophilic oesophagitis is a chronic inflammatory condition of the oesophagus with an allergic basis, in which a particular defensive cell, the eosinophil, accumulates in the oesophageal wall. Over the years that inflammation stiffens and narrows the passage.
It is now the leading cause of dysphagia and food impaction in younger adults, and its frequency has risen markedly over the past two decades.
The symptoms that give it away
- A sensation that food stops in the chest, particularly meat and bread
- Choking episodes that have required emergency care
- Needing to drink a lot of water or chew extensively in order to swallow
- Eating slowly or avoiding certain foods without consciously deciding to
- Heartburn or chest pain that does not improve with acid suppression
- Personal or family history of asthma, rhinitis or food allergy
Why it gets mistaken for reflux
The symptoms overlap and many patients receive antacids for years. The difference is that the problem here is not acid but allergic inflammation, and it is only visible by taking biopsies of the oesophagus even when it looks normal to the naked eye.
How it is diagnosed
There is only one way: a gastroscopy with biopsies of the oesophagus, taken from several levels. The diagnosis is confirmed when fifteen or more eosinophils per high-power field are counted.
One important point: in up to a third of cases the oesophagus can look entirely normal during endoscopy. If biopsies are not taken, the diagnosis is missed.
Treatment
Three approaches work, and the choice depends on your preferences and circumstances rather than on a fixed rule.
- High-dose proton pump inhibitors. Simple and effective in a proportion of patients
- Swallowed topical steroids. Formulations designed to act on the oesophagus with minimal absorption
- Elimination diet. Stepwise withdrawal of the foods involved with controlled reintroduction, usually alongside a dietitian
- Biologic treatment. An option for cases that do not respond to the above
- Endoscopic dilation. When a narrowing is already established
Whichever route is taken, response must be confirmed with a repeat endoscopy and biopsies. Feeling better does not mean the inflammation has gone, and it is that inflammation which causes narrowing in the long run.
Why it particularly interests me
It is an underdiagnosed condition, with years of average delay between the first symptom and the diagnosis, and with treatment that works well once applied. That combination, a lot of avoidable delay and a good response, is where specialist care changes the outlook most.