An alternative diagnosis to GERD centers on food allergies
■ Milk, soy, eggs, wheat, nuts and fish are the likely triggers for an allergy that causes inflammation of the esophagus.
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For patients experiencing symptoms of gastroesophageal reflux disease, or GERD, but who seem beyond the reach of usual treatments, another diagnosis is possible -- eosinophilic esophagitis, or EE.
EE is becoming more frequently recognized as the source of symptoms such as regurgitation, vomiting, chest pain, heartburn and dysphagia.
The condition is believed to be an allergic reaction to food, although pollen is another possibility. The allergens prompt inflammation in the wall of the esophagus resulting in difficulty swallowing. The hallmark of the disease is the presence of large numbers of eosinophils in the esophagus.
Physicians need to think of EE as a possible diagnosis if patients say they have difficulty swallowing, have had food caught in their esophagus or are experiencing little, if any, relief for heartburn despite taking proton pump inhibitors or other medications, said Chris A. Liacouras, MD, professor of pediatrics at the University of Pennsylvania School of Medicine and the Children's Hospital of Philadelphia. The foods most likely to cause problems include milk, soy, eggs, wheat, nuts and fish, he said.
If EE is suspected, a referral to a gastroenterologist and an allergist is the next step, said Dr. Liacouras. Diagnosis is confirmed via biopsy.
While GERD is a relatively common disease, most often characterized by frequent heartburn, EE is much less common. Estimates suggest one to four cases of the disease for every 10,000 children and adults, said Glenn Furuta, MD, director of the Gastrointestinal Eosinophil Diseases Program at the University of Colorado School of Medicine in Denver.
And that number appears to be increasing, said Marc Rothenberg, MD, PhD, director of the Cincinnati Center for Eosinophilic Disorders at Cincinnati Children's Hospital Medical Center. "The first patient with EE recognized at our hospital was in 1999. Now we are seeing three to five new cases per week and 30 follow-up visits per week."
Dr. Liacouras believes this increase is due to greater recognition of the disease as well as its being caused by an allergy. Allergies have been proliferating in recent years.
The recognition of EE also has evolved with the development of endoscopy in the 1960s and 1970s since the procedure is required for diagnosis, said Dr. Furuta. The disease was recognized among children sooner than it was among adults because "pediatric gastroenterologists routinely obtain esophageal biopsies, whereas adult gastroenterologists have not followed this same practice."
Although EE doesn't seem to be life-threatening, it can impact quality of life and thus steroids are often used to decrease the inflammation. "However, since the disease is chronic, repeated doses of steroids are necessary," noted Dr. Furuta.
The elimination of the suspect foods is another treatment path. "Diet to me is the main therapy, but it isn't easy," said Dr. Liacouras. Biologics are also in the pipeline, he added, and treatment could eventually mean an injection every month or so.
The American Partnership for Eosinophilic Disorders is a good resource for physicians as well as patients, said Dr. Furuta.