In recent years, eosinophilic esophagitis (EoE) has emerged as a condition encountered more frequently by allergy/immunology and gastroenterology specialists. In patients with EoE, esophageal symptoms occur in association with an eosinophil-rich infiltrate in the esophagus, defined as > 15 eosinophils per high-power field in the appropriate clinical context.
The etiology, appropriate management and natural history of EoE are poorly understood. At Cleveland Clinic, we recently carried out a study to assess the utility of routine allergy/immunology evaluation in adults with EoE.
Endoscopic biopsy of esophagus from a patient with acute relapsing dysphagia shows numerous intraepithelial eosinophils, with surface layering and formation of eosinophilic microabscesses, consistent with eosinophilic esophagitis.
Consensus-Based Recommendations for Management
The high rate of allergic rhinitis, atopic dermatitis and asthma reported in case series of pediatric and adult EoE patients, combined with the established role of eosinophils in atopic disease, imply that, at least in some patients, immunoglobulin E (IgE)-mediated or IgE-associated response to one or more antigens may provoke and perpetuate this inflammatory disorder.
Recent consensus-based recommendations for EoE management state that patients should undergo allergy/immunology evaluation; however, these recommendations are based primarily on pediatric studies. Although immediate hypersensitivity skin testing has been associated with excellent negative predictive value and can reliably detect clinically relevant inhalant and/or food allergens in individuals with IgE-mediated disorders, the value of skin (or in vitro) testing has not been established in adult patients with EoE.
Cleveland Clinic Experience
In a study carried out at Cleveland Clinic involving 26 subjects with EoE (confirmed by history and upper gastrointestinal endoscopy with biopsy and referred for allergy/immunology evaluation), 13 (50 percent) exhibited wheal/flare reaction to > 1 food. Of the 15 subjects with EoE who had concomitant respiratory symptoms, 14 (93 percent) had wheal/flare reaction to one or more inhalants. Twenty-one of these 26 subjects (81 percent) had > 1 allergen identified, 16 (62 percent) had > 5 allergens identified and 4 (15 percent) had > 10 allergens identified (range: 0 to 20 allergens identified). Peanut, egg, soy, cow’s milk and tree nuts (including walnut, almond and Brazil nut) were the most common food allergens identified in our series. Allergy/immunology evaluation frequently leads to detection of allergens via skin (or in vitro) testing that can direct avoidance measures.3 In patients with EoE, avoidance measures carry the potential for improving outcomes by reducing both symptoms and reliance on medication. These findings provide further support for the utility of routine allergy/immunology evaluation for adults with EoE.
- Penfield JD, Lang D, Goldblum JR, Falk GW. The role of allergy evaluation in adults with eosinophilic esophagitis. J Clin Gastroenterology. 2010 Jan;44(1):22-27.
- Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007 Oct;133(4):1342-1363.
- Bernstein IL, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008 Mar;100 (3 Suppl):S1-S148.