Eosinophilic Esophagitis as a Chronic Immune System Disease

Anatomy of esophagus

The esophagus or gullet is a muscular canal, about 23 to 25 cm. long, extending from the pharynx to the stomach. It begins in the neck at the lower border of the cricoids cartilage, opposite the sixth cervical vertebra, descends along the front of the vertebral column, through the superior and posterior mediastina, passes through the diaphragm, and, entering the abdomen, ends at the cardiac orifice of the stomach.

Introduction

Eosinophilic esophagitis is a chronic immune system disease. It has been identified only in the past two decades, but now days considered a major cause of digestive system (gastrointestinal) illness. In the presence of eosinophilia (an abnormally increase in a number of white blood cells) the esophagus has been noted in patients who were believed to have had (GERD). It is an inflammatory condition of the esophagus. White blood cells build up in the lining of the tube that connects your mouth to your esophagus. This occurs, due to a reaction to foods, allergens or acid reflux; causes inflammation or injure the esophageal tissue. Damaged esophageal tissue can lead to difficulty swallow.

Clinical Sign & Symptoms

In Adults:

- Dysphagia

- Repeated food Impaction

- Centrally located chest pain (not respond to antacid)

- Not responded to GERD medication

- Heart burn

- Stomach-ache

- Undigestedfood backflow

- Diarrhea(Rarely)

- Nausea

In Children:

- Feeding problem in infants

- Eating problem in children

- Emesis

- Abdominal pain

- Poor growth

- Malnutrition

- Weight loss

- Heart burn

- Food impaction

Age Grouped

The patient age group ranged from 2 months to 89 years.1 It was reported that males are more commonly affected in both children (66%) and adults (76%).

Possible Etiology of Eosinophilic Esophagitis

Allergic responses have been powerfully recommended as a reason of EE. This has been evidenced with results showing that 50% to 80% of patients with EE have simultaneous conditions such as atopic dermatitis, allergic rhinitis, asthma, and eczema. The patients with EE also show allergic antigen sensitization from skin testing or antigen-specific immunoglobulin E (IgE) presentation from plasma testing. Interleukin (IL)-4, IL-5, IL-13, and mast cells are found in the esophagus of patients with EE. Seasonal differences in symptoms have been reported, and case reports have shown seasonal changes in eosinophilic levels in the proximal esophagus. The elevated rate of eczema and other atopic allergies requires that the patient be evaluated by an allergist who is familiar with EE. Inhaled allergens may also play a role in EE, and the patient should thus be evaluated for this as a contributing factor.

Diagnosis

Diagnostic test for Eosinophilic Esophagitis includes: Upper endoscopy. Use a long narrow tube (endoscope) containing a light and tiny camera and put in it through mouth down the esophagus. Inspect the lining of esophagus for irritation and amplification, horizontal rings, vertical furrows, narrowing (strictures), and white patches.

Biopsy

In an endoscopy, perform a biopsy of esophagus by taking a small piece of tissue & take multiple samples from esophagus and then check the tissue under a microscope for eosinophils.Blood tests. If suspect EE, some additional tests to confirm the diagnosis and to begin to seem for the sources of allergens. Blood tests to check for elevated than normal eosinophil counts or total immunoglobulin E levels, suggesting allergy.

Treatment of Eosinophilic Esophagitis

Treatment strategies for EE are include: Dietary control: If patients have food allergies, take allergen-free diets. If patients do not respond to food taking away of specific antigens, amino acid-based formula management is the recent gold standard for evaluating. This treatment has been very important in children, with a success rate of 92% to 98%.Resolution of symptoms occurred within 7 to 10 days, and with histological improvement seen within 4 to 5 weeks. Amino acid-based formulas generally have an unlikable taste, and often the feedings are given via nasogastral tubes. A slow introduction of certain foods can be started when symptoms resolve and histology recover. The six most common allergic foods are:Dairy,

Eggs, Wheat, Soy, Peanuts and Fish or shellfish

Treatment

Esophageal dilation may be required in patients with food impactions cause by fixed strictures as a effect of esophageal narrowing. Esophageal dilation may be done to treat the stricture in cases of dysphagia or esophageal impaction. It is suggested that, if feasible, an endoscopy with biopsy be done earlier to an esophageal dilation, helpful for medical or dietary treatment. Complications from dilation can effect in esophageal tears or lacerations. Presently, there are no records to assess which patients will be at high risk for complications. However, patients who have already developed esophageal rings, strictures, or narrowing are considered to be at high risk for difficulty.

Role of antibiotics

A new study information that antibiotic use in the first year of infancy was related with six times the odds of developing EE. The usage of antibiotics has been linked to allergy development in mice. Amusingly the occurrence of Helicobacter pylori in gastric biopsies is also inversely associated with EE. There is, however, no indication to recommend that patients undergoing antibiotic induced H pylori eradication are at higher risk for EE.

In summary, EE is a polygenic disorder in which a dysregulated environment in the oesophageal mucosa shows to lead to inflammatory cell infiltration and disease development in response to food allergens and aeroallergen). Both genetic and/or environmental cause appear to manipulate the production of mediators such as TSLP and eotaxin-3 by epithelial and other stromal cells. Eosinophils, Th2 lymphocytes, and mast cells are conscript to the mucosa. B lymphocytes may go through local IgE class switching. Increasing evidence show that environmental factors, in particular medications such as antibiotics, particularly early in life, could put in to disease development and may even account for the amplified occurrence of disease observed.

Lifestyle modification home remedies

If heartburn, these way of life modification may help decrease the occurrence or severity of indication:

Maintain a well weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus. If weight is at a healthy level, work to maintain it. If obese, work to slowly drop weight — no more than 0.5 to 1 kg /week. Evade foods and drinks that cause heartburn. General triggers, such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine, may create heartburn worse. Evade foods you know will cause your heartburn.Raise the top of your bed. Regularly experience heartburn at night or while trying to sleep, put gravity to work . If it's not possible to elevate your bed, insert a lodge between your mattress and box spring to elevate your body from the waist up.

Alternative medicine

No other medicine remedy has been proved to treat eosinophilic esophagitis. Still, some complementary and substitute treatment may provide some release from heartburn or reflux signs. Other treatments choiceS may include: Herbal therapy. Herbal therapy sometimes used for heartburn or reflux symptoms include licorice, slippery elm, chamomile, marshmallow and others. Herbal treatment can have serious side effects, and they may hinder with medications. Relaxation treatment. Method to calm stress and anxiety may decrease signs of heartburn or reflux. such as progressive muscle relaxation.Acupuncture. Acupuncture involves introduce thin needles into definite points on your body. Limited data suggests it may help people with regurgitation and heartburn, but mostly studies have not show a benefit.

Conclusion

EE is a chronic disorder. Earlier, it may have been misdiagnosed as GERD. Though GERD can co-exist with EE and both have mostly same symptoms, EE not respond at high dose (2 mg/kg/day) PPI therapy. Allergic responses have been strongly recommended as a reason of EE, and many patients respond to an allergen-free diet. Other non-FDA recommended treatments consist of short-term use of systemic and topical corticosteroids. Montelukast has been used to treat a lesser number of EE patients along inhaled allergens. Reslizumab, anti-IL-5, mepolizumab, and viscous budesonide are presently in clinical test for the treatment of EE. Finally, esophageal dilation may be necessary in patients who develop a food impaction as a result of esophageal narrowing.

Main messages:

- The occurrence of eosinophilic oesophagitis (EE) is rising.

- EE is characterized clinically by signs of dysphagia, food impaction and proton pump inhibitor defiant dyspepsia, and histologically by major eosinophilic infiltration of the oesophageal mucosa.

- A minimum of 2–4 oesophageal biopsies should be taken from the proximal and distal oesophagus to identify EE.

- EE is related with atopy and a T helper type 2 (Th2) reaction. A detailed allergy history required to be taken before testing for food and aeroallergens in EE patients.

- Genome-wide analysis studies (GWAS) have found EE to be associated with a region on chromosome 5q22 in a paediatric cohort. The gene for thymic stromal lymphopoietin (TSLP) is localised to this region.