Is Eosinophilic Esophagitis (EoE) Related to the Atopic March?

Atopic march is the medical term used to describe the history and progression of allergic diseases throughout a person’s life. It is also called the allergic march. The atopic march can begin at any time. But it usually begins in early childhood and after a diagnosis of atopic dermatitis.¹

Typical atopic march involves diagnoses of food allergies, allergic rhinitis, and/or asthma. Research suggests that another atopic condition called eosinophilic esophagitis (EoE) also may be part of the atopic march.^1,2

What is eosinophilic esophagitis (EoE)?

EoE is a long-term (chronic) allergic condition of the esophagus. The esophagus is the tube that sends food from the mouth down to the stomach. A person with EoE has a large number of white blood cells called eosinophils in their esophagus tissue.²

These eosinophils trigger inflammation in the esophagus. This causes damage and can lead to narrowing. This narrowing, in turn, can lead to difficulty swallowing, vomiting, or pain.²

What causes EoE?

EoE is an allergic disorder. But it is unclear what specifically causes EoE. Experts think that the buildup of eosinophils in the esophagus is due to an abnormal immune reaction to foods and other allergens. As is the case for other atopic conditions, environmental factors, genetics, or both may be the root cause.³

Is EoE part of the atopic march?

EoE tends to appear along with other common atopic disorders. A 2018 study followed the progression of atopic diseases in people who had eczema, food allergies, asthma, and allergic rhinitis. It found that having these conditions was linked with a higher rate of EoE diagnosis later on. These findings suggest that EoE is most likely a late development of the atopic march.⁴

What are the symptoms of EoE?

The symptoms of EoE vary depending on age. Among adults, symptoms include:^1-4

• Undigested food coming up from your stomach into your mouth (regurgitation)
• Trouble swallowing (dysphagia)
• Pain in your chest that returns even after taking antacids

Symptoms in infants may look similar to those of adults. They also can include:⁴

• Throwing up
• Stomach pain
• Trouble feeding
• Food refusal
• Growth challenges such as malnutrition and weight loss

In extreme cases, the esophagus can become so narrow that food gets stuck. This can lead to food impaction, which is a medical emergency.²

Most people with EoE have a history of other atopic disorders. These disorders may include asthma, eczema, or food allergies. Exposure to an allergen, either food or environmental, can trigger EoE symptoms.²

How is EoE diagnosed?

Diagnosis of EoE includes one or more of the following tests:^2,5

• Upper endoscopy – A doctor inserts a long, thin tube with a light and a small camera into your mouth and down into the esophagus. This helps them get a clear look at your esophagus and search for any swelling, white spots, and inflammation.
• Biopsy – Your doctor takes a small tissue sample from your esophagus and looks at it under a microscope.
• Blood tests – Your doctor may recommend blood tests if they suspect you have EoE. With these tests, they will look for a high number of eosinophils or high immunoglobulin E levels. High levels can mean an allergy. But not everyone with EoE will have high levels.
• Skin prick tests – A small amount of an allergen is introduced onto your skin by making a small puncture. Your doctor then looks to see if there is any reaction.
• Esophageal sponge – You swallow a capsule attached to a string. When it reaches your stomach, the capsule dissolves and releases a sponge that the doctor pulls out. On its way out, the sponge collects samples from esophageal tissues. This helps your doctor determine the level of inflammation and swelling in your esophagus.

Because of the atopic nature of EoE, you may be referred to a doctor that specializes in allergy and immunology. They can provide guidance for treatment. They may consider environmental allergen testing for atopic disorders such as asthma and allergic rhinitis. Allergy testing to food allergens is not helpful for identifying food causes of EoE.^2,5,6

How is EoE treated?

EoE is a chronic allergic condition. At this time, there is no cure for EoE. But there are several treatments that can help manage symptoms. Your treatments will depend on the condition that triggers or worsens your EoE symptoms. Treatments may include:^2,5

• Medicines
• Diet changes
• Reducing exposure to environmental allergens
• Dilating the esophagus if there is narrowing

Medicines

The first and only drug that has been approved by the US Food and Drug Administration (FDA) to treat EoE is Dupixent® (dupilumab). Dupixent is a biologic drug that reduces inflammation in the esophagus. It does so by targeting a protein involved in the body's allergic process. This drug helps improve symptoms of EoE such as pain and difficulty swallowing.²

Other drugs used to treat EoE are:²

• Corticosteroids – Help reduce inflammation
• Proton pump inhibitors (PPIs) – Control the amount of acid in the stomach and esophagus, and help strengthen the tissue barrier in the esophagus

Diet changes

If a food sensitivity or food allergy triggers EoE symptoms, your doctor may advise you to stop eating certain foods. Unfortunately there is no blood test or skin test to identify food triggers for EoE. The only way to determine this is by eliminating and then reintroducing foods one by one, as instructed by your doctor.^2,5

An elimination diet can be helpful in treating EoE symptoms. But it can be hard to follow. If you are on an elimination diet, work with a dietitian to ensure you are getting the right nutrition.^2,5

Reducing exposure to environmental allergens

If something in your environment triggers your EoE symptoms, try to reduce or stop your exposure. Triggers might include pollen, dust mites, or mold.^2,5

Your doctor can help to identify environmental allergens that may be triggering your EoE with allergy testing. Strategies such as keeping your windows closed during pollen seasons or getting a HEPA air purifier will help reduce your exposure to pollen.^2,5

Dilating the esophagus

This approach involves your doctor stretching your esophagus if there is evidence of narrowing. It may be especially helpful if food often gets stuck in your esophagus. Doctors usually carry out this treatment during an endoscopy (looking at your esophagus with a special camera).^2,5

Work with your doctor

People living with EoE must stay on top of their condition with dietary changes, medicine, and other treatments. The good news is that you can live a long life with EoE. There is also no evidence that it causes other illnesses, such as cancer of the esophagus.⁵

Talk with your doctor about what EoE treatment method they recommend. Together, you can decide what will work best for you and your symptoms.²