“Eczema of the Oesophagus”
By Leyla Moudden, Naturopath
Heartburn is a problematic symptom that can result from a wide spectrum of digestive disorders, ranging from involuntary regurgitation into the oesophagus (GERD) to visceral hypersensitivity. Approximately 15% of the global population will experience heartburn that is severe enough to trigger a doctor’s visit, and an even larger percentage of people will experience heartburn without reporting it.
One driver of heartburn is a condition called eosinophilic oesophagus, or ‘EoE’, an “eczema of the oesophagus”. EoE is a non-IgE mediated atopic food intolerance response occurring in the mucosal tissue of the oesophagus. The reaction is caused by an increase of immune cells within the oesophageal tissue, generating inflammation, heartburn, difficulty swallowing, chest pain and regurgitation. The symptoms of EoE are almost identical to GERD, but unlike GERD, there is no acidic involvement, and the inflammatory reaction is due to an intolerance of food.
Mechanisms
Eosinophils are a type of immune cell that help kill invaders such as bacteria or parasites to protect the body from infection. Eosinophils are a significant feature of allergic reaction and are associated with common allergic conditions such as asthma, atopic dermatitis, and autoimmune diseases.
In EoE, an increase in eosinophil concentration accumulates in the oesophageal tissue in response to an environmental or food trigger. Due to the atopic nature of EoE, the severity of the reaction can be influenced by lifestyle factors, genetics, and emotional health causing a fluctuation in symptoms and severity that create severe disruption to the sufferer’s life.
In endoscopy, common findings are inflammation of the oesophageal tissue, a normal pH, and sometimes stricture (narrowing) of the oesophageal tissue caused by a build-up of scar tissue resulting from chronic inflammation.
Food Intolerance
In a healthy stomach, digestive enzymes will degrade dietary proteins and prevent large immunogenic peptides from reaching the small intestine. In the intestinal lumen, tight barrier junctions will prevent intact proteins’ escape into the peripheral circulation to create an immune reaction.[1]
Food intolerances are generally associated with a lack of these protective digestive features, either due to enzyme deficiencies or genetically inherited transportation disorders. Severe intolerances are usually recognised during childhood and are rapidly treated by eliminating the offending food. On the other hand, adults may develop a food intolerance later in life, caused by altered dietary or lifestyle habits, changes in liver function, increased chemical exposure affecting enzyme production, or alterations to the microbiome. Nutrient deficiencies that have been acquired over time due to diet or stress can affect healthy digestive enzyme synthesis, resulting in microinflammation and ‘leaky’ epithelial membranes that line the digestive tract. Intolerances that appear after age 40 can be due to a natural age-related decline in digestive enzymes or hydrochloric acid.
An increase in toxic load can also stimulate the emergence of an intolerance reaction to previously unproblematic foods. Low molecular weight compounds arising from toxic chemicals such as alcohols, esters, aldehydes, moulds and their derivatives can diffuse in the air and enter the body through the lungs and skin, increasing inflammatory biomarkers such as eosinophils. Increased eosinophils are related to mucosal irritation symptoms, common in leaky mucosa syndromes such as EoE, as well as more systemic manifestations such as nausea and headaches.
Symptoms of Eosinophilic Oesophagitis “EoE”.
EoE will first be experienced by the patient as seemingly random episodes of heartburn. Due to the lack of acidic involvement, the patient will not find relief from over the counter or prescription antacid medications such as proton pump inhibitors.
Depending on the client’s peripheral sensitivity, the sensation of EoE heartburn may be described as heartburn, chest burn, chest pain, chest fullness, abdominal pain, difficulty swallowing, and a feeling that food is difficult to swallow. Pain sensitive clients may also be taking pain medication such as NSAIDs.
The client may have begun to self-regulate by avoiding the foods they associate their symptoms with and may be living on a highly restricted diet.
An Atopic Reaction In The Oesophagus
As the cause of the symptoms is not related to acidic reflux of gastric acid, most antacid interventions will not alleviate symptoms, and the patient will be referred to endoscopy by a gastroenterologist who will make a finding of inflammation.
A biopsy will be performed after eliminating other possible causes of the inflammation such as parasites or bacterial infection. In the biopsied tissue, the gastroenterologist will discover an overabundance of eosinophils, and EoE will be diagnosed. In severe cases, a build-up of scar tissue will cause stricture of the oesophagus, and oesophageal dilation therapies may be administered to allow the swallowing of food.
A child with EoE may complain that their food is “stuck in their throat” and become a fussy eater. Food aversion and avoidance is likely to follow, affecting the quality of life and building a negative relationship with food that can cause long term disordered eating. The removal of the offending food frequently resolves the problem. Even when the inflammation is brought under control, learned avoidance behaviours can last for years and into adulthood.[2]
EoE is more difficult in adults to identify as the intolerance reaction to a food can occur as much as 3-5 days after the food is eaten. Due to this delayed onset, clients may attribute their heartburn to whatever they ate last and fail to identify the real trigger of their symptoms.
It is common for clients to self-medicate with antacids, pain killers, stress and sleep medications. Sufferers are likely to have other atopic conditions and suffer from anxiety. They may also withdraw from social activities due to a fear of a flare-up or are following an overly restrictive diet.
Medical treatment is mostly non-effective, except in very severe cases in which the oesophageal sphincter has constricted to such a degree that food cannot pass through. Extreme circumstances of EoE warrant medical attention and possibly surgery and so would fall outside of the remit of nutritional or naturopathic intervention.
Dietary Therapies
Studies looking at dietary interventions for EoE have found that dietary management is an effective intervention for EoE. An elemental diet rapidly relieves the symptoms of EoE, in 90% of sufferers, but is difficult to adhere to for long periods and negatively impacts the patients’ mental, emotional, and social lives.
Another diet, known as the “six food elimination diet” has been shown to improve EoE in about 70% of cases. This diet excludes the top 6 allergens – dairy, soya, eggs, wheat, peanuts, fish and shellfish.[3]
Nutritionally, a program of gut healing and digestive enhancement can reduce the speed and severity of intolerance reactions, leading to greater freedom and less anxiety for the client.
The Role Of Enzymes – Protecting Your Client From Accidental Exposure
70% of EoE cases are resolved by total avoidance of the six top allergens, however absolute lifelong avoidance of these groups is too limiting and almost impossible – particularly for clients that are not nutritionally minded.[4]
A good enzyme complex focusing on the six main triggers can reduce intolerance reactions by helping to degrade offending proteins before they reach the small intestine. Enzyme Science Intolerance ComplexTM can protect against accidental exposure, providing peace of mind, enabling them greater social freedom.
Enzyme Science Intolerance Complex is an intolerance focused vegetarian digestive enzyme blend that facilitates the breakdown of these foods throughout the stomach and small intestine.
A healthy diet includes an appropriate number of calories, protein, fat, carbohydrates, and micronutrients and suffering with food intolerance can affect a client’s ability to eat a healthy and varied diet, particularly in cases of EoE. A specifically formulated intolerance focused digestive enzyme blend like Enzyme Science Intolerance Complex can give your client protection from accidental exposure as part of a wider gut healing protocol.
References
[1] Ruffner, M. and Spergel, J., 2016. Non–IgE-mediated food allergy syndromes. Annals of Allergy, Asthma & Immunology, 117(5), pp.452-454.
[2] Markowitz, J. and Clayton, S., 2018. Eosinophilic Esophagitis in Children and Adults. Gastrointestinal Endoscopy Clinics of North America, 28(1), pp.59-75.
[3] Anyane-Yeboa A, Wang W, Kavitt RT. The Role of Allergy Testing in Eosinophilic Esophagitis. Gastroenterol Hepatol (N Y). 2018;14(8):463-469.
[4] Chang, J., Yeow, R., Waljee, A. and Rubenstein, J., 2018. Systematic review and meta-regressions: management of eosinophilic esophagitis requires histologic assessment. Diseases of the Esophagus, 31(8).