Eosinophilic Gastrointestinal Disorders

Loretta Jay is president of Parasol, a US consulting organisation that specialises in the management of food allergies

Jack didn’t sleep more than ten minutes at a time during his first eight months of life. He cried constantly until he was two and his screams led his grandmother to refer to him as the ‘baby from hell’. Horrible eczema covered his arms, neck and face; his face oozed pus. Michele Friedman, Jack’s mother, was a practising psychotherapist. A new mother, but seasoned in life, her gut told her that there was something terribly wrong – that his screams were provoked by pain.

Jack’s doctors didn’t support this theory, maintaining that he was simply colicky. Even her suggestion that Jack’s diet could be the cause was rebuffed. It wasn’t until his second anaphylactic reaction, at two years of age, that Jack tested positive for the top eight food allergens, as well as apples and melons. Jack was hurting, and food allergies were responsible.

An increasing number of people are experiencing numerous food allergies: not just nuts and milk or eggs, but many other foods as well. Some of these people have something called eosinophilic gastrointestinal disorders (EGID). Most EGIDs are triggered by food and environmental allergens. When exposed to an offending trigger, symptoms resemble gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). Other symptoms include vomiting in children or food impaction in adults.

Pathologically, white blood cells called eosinophils develop in the gastrointestinal tract indicating a problem. If eosinophils are present in the esophagus the disease is called eosinophilic esophagitis (EE). Eosinophils in the stomach is called eosinophilic gastritis (EG), and if they permeated the large intestine, eosinophilic colitis (EC). Finally, if eosinophils affect the stomach and/or the small intestine it is called eosinophilic gastroenteritis and eosinophilic enteritis.

EGIDs are a new disease, first identified in the 1970s, and formally recognised only 20 years ago. At that time they were thought to be extremely rare, only affecting one in 20,000-100,000. The diagnosis rate has steadily increased, with EE now affecting one in 2,500 children and adults. It remains unclear whether a growing awareness of the disease is affecting the rate of diagnosis, or if there is an actual increase in the number of people with the disorder.

The varied presentation of symptoms can make it challenging to identify and categorise EGIDs. Symptoms affect different people in different ways. Jack has anaphylactic reactions to peanuts, eggs, shellfish and garlic. Other foods, including wheat, dairy, chicken and beef give him stomach aches, headaches, vomiting, sore throat, trouble swallowing and gagging. Like many other people with EGIDs, Jack also experiences asthma, eczema and rhinitis symptoms.

Most children experience heartburn and regurgitation and other reflux symptoms that may not resolve completely with acid blocking medications (ie Lansoprazole, Esomeprazole). Young children who are unable to express how they are feeling may resist eating or refuse food altogether. Nausea, vomiting and stomach aches are also common, as is difficulty swallowing or food getting stuck in the esophagus. Dysphagia (difficulty swallowing) and food impaction are the most common symptoms for adults with EE.

The Center for Pediatric Eosinophilic Disorders at the Children’s Hospital of Philadelphia (CHOP) has the largest number of clinical patients with EE in the world. Dr Chris Liacouras, the co-Director at CHOP’s Eosinophilic clinic, said that physicians are beginning to see the same symptoms for children and adults. Varied symptoms are now being recognised in different age groups and therefore diagnosed more readily across the spectrum.

A diagnosis of an eosinophilic disorder requires a physician’s confirmation of the symptoms, coupled with an analysis of biopsies taken during an endoscopy. Scoping, as the endoscopy is referred to informally, is performed when a gastro- enterologist puts an endoscope (a thin tube with a video camera at the end), through the person’s mouth and into the targeted GI area; the patient is sedated during the procedure. Tissue samples, or biopsies, are taken of the different parts of the GI tract. Although a normal esophagus has no eosinophils, the American Gastroenterological Association’s consensus recommendation concluded that 15 eosinophils per high powered field is the current criterion for an eosinophilic diagnosis. (Gastroenterology, 2007;133:1342-1363.) A few eosinophils may be present with untreated reflux, so patients are typically placed on a reflux medication prior to the scope, to avoid any confusion with GERD.

Eosinophilic food allergies may be IgE-mediated, causing an immediate and sometimes anaphylactic reaction. They may also be cell mediated, resulting in a delayed hypersensitivity. One study (Assa’ad et al, Journal of Allergy and Clinical Immunology, 2007; 119: 3,731-738) found a nearly three-year lag between the onset of symptoms and the first endoscopy. The researchers interpreted this to mean that it wasn’t the severity of the symptoms that led to the scoping, but their duration.

Some people are able to figure out what foods trigger a reaction for them, and modify their diet on their own – without securing a diagnosis. Dr Liacouras explained that if someone is experiencing EGID, it is important to obtain an accurate diagnosis, and not self-manage by restricting one’s diet. For example, he said that about 50% of those with EG have an autoimmune problem, which means that their antibodies are attacking their own body in an attempt to rid it of the toxin. Others may have internal tissue damage due to unknown allergens without any overt symptoms.

If the eosinophilic disorder is identified early, Dr Liacouras believes that the likelihood of long-term problems, such as strictures or morbidity is low. One quarter of those affected have intermittent symptoms, another quarter have long-term or exasperated symptoms, and the rest fall somewhere in between.

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First published in 2008

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