Eosinophilic gastrointestinal disorders are not well understood despite their increased recognition. Finding answers can be difficult.  Several physicians with expertise in these disorders have provided answers to some of the more frequently asked questions. 

My child has no outward signs of a food allergy but has a high level of eosinophils present in his / her endoscopy biopsy as well as positive skin tests to several foods. Does this mean that he / she has food allergy and we should eliminate the foods he tested positive to? 

The presence of eosinophils in gastrointestinal tissue biopsies does not necessarily mean food allergies. First, it depends upon the level of eosinophils -- the higher the more likely. But even if the child has very high levels, this does not mean that the positive foods in skin testing are the cause of the problem. Over 80 percent of individuals with eosinophilic esophagitis and eosinophilic gastroenteritis have positive skin tests to multiple foods. However, the benefit of a specific allergen elimination diet has not yet been proven. We are currently analyzing our own cohort of patients to answer this, but it is too early to tell. Our current approach however is to eliminate foods that children are positive to on skin tests.

After 3 or 4 months we re-endoscope the patients and if the biopsies are still not improved, we then start medical therapy -- especially with steroids -- either through an inhaler or directly swallowed. Finally, some patients benefit from a special "elemental diet" that consists only of amino acids (no proteins). While amino acid diets are hard to comply with, they can have very positive effects on eosinophil-associated gastrointestinal diseases.

What happens if we decide not to start any treatment for the eosinophilic disorder?

The natural history of untreated eosinophilic disorders is not completely clear. However, a number of complications can occur depending upon the specific medical problem. Below are some examples:

Allergic Colitis

This disease most commonly presents in early infancy. Children with this disorder have an allergy to milk protein. The severity can go from losing a very small amount of blood in the stools (not able to be seen with the naked eye) to having gross blood in the stool. If you do not treat the mild disorder, maybe (again, maybe) not much will happen. However, if you do not treat the more severe forms, anemia and failure to thrive is likely to occur. Most children outgrow this problem by 3 years of age.

Eosinophilic Esophagitis

It is our feeling that constant inflammation in the esophagus leads to chronic scarring such as strictures. The esophagus becomes so inflammed that it narrows and does not let food travel through it normally.

Eosinophilic Gastroenteritis

The severe cases have diarrhea with malabsorption. The patient can stop growing, which is very detrimental for a child.

How do we know that the elimination diet is working for my child with an allergic eosinophilic gastrointestinal disorder?

If the patient affected by the allergic eosinophilic gastrointestinal disorder is having symptoms with certain foods and the symptoms disappear after elimination of those foods, that is an indication that the elimination diet is probably working. In practice this is difficult to figure out because (a) some patients have delayed reactions (up to several days later after ingestion) to foods and elimination of these foods for a few days might not be enough time; and (b) it is sometimes difficult to pinpoint exactly which foods are the culprit. The only way to figure this out is to do extensive allergy testing for foods. Some patients might eliminate only some of the foods that they are allergic to and in these cases the elimination diet is seen as a failure (because they did not eliminate all the foods that they are allergic to!). Several studies and our clinical experience have shown that patients improve on elemental diets. An elemental diet is a special diet that contains amino-acids (the building blocks of proteins, that are not recognized as allergens). In some very specific cases, such as allergic colitis of the infant (milk-induced eosinophilic colitis) elimination of milk from the diet is all that is needed.

For eosinophilic esophagitis and gastroenteritis, more extensive evaluation and treatments might be needed. The only way to know for sure that the diet is working is to perform a follow-up esophagogastroendoscopy with biopsies. The biopsies should show improvement. A good indicator of tissue improvement is the clinical improvement. That means, if the patient is doing better, the biopsies should be better.

How is an eosinophilic disorder diagnosed?

Because there are several conditions than can cause elevated eosinophils in the gastrointestinal tract, a complete medical history and physical examination (H&PE) is needed in order to try to make a specific diagnosis. The history and physical exam (H&PE) and the biopsy results will most likely focus on a few possible diagnoses. If a primary eosinophilic disorder of the gastrointestinal tract is considered, possible evaluations in some patients include:

Complete Cell Blood Count with Differential

This analysis is to assess the number of eosinophils in the blood and also to check for anemia and other conditions that might require specific treatment.

Stool Examination

Stool examination includes microscopic evaluations, cultures, and analysis for occult blood, ova and parasites. These tests will address possible blood loss, bacterial infections, and presence of parasites.

Allergy Evaluation

Allergy evaluation assesses for other associated conditions such as asthma, rhinitis, atopic dermatitis (eczema), and food allergies. The determination of food and environmental allergies is done by skin testing and/or measurements of specific immunoglobulin E in the blood (IgE RAST).

Evaluation of Gastroesophageal Reflux

If reflux is a consideration, a pH probe could be indicated to assess its severity.

Tissue Biopsy Evaluation of the Affected Area

The only way to diganose an eosinophilic disorder of the gastrointestinal tract is by a tissue sample. All these disorders are to be proven by a biposy. Other evaluations are often necessary to distinguish a primary disorder from a secondary.

Can eosinophilic esophagitis be seasonal?

Eosinophilic esophagitis does have seasonal variation in some patients, typically with worse symptoms in the spring and summer.

For those patients with only aeroallergen-associated eosinophilic esophagitis (positive skin tests for aeroallergens but not food), is there any rationale for using immunotherapy (allergy shots)?

An allergic profile in which skin tests are limited to only aeroallergens is rarely seen. Most patients with eosinophilic esophagitis have positive skin tests to both food and aeroallergens. Although skin testing is a marker for allergy, the specific foods identified do not correlate very well with the food triggers that are causing the esophageal inflammation. This may be related to the recent finding that the esophagus is a site of local antibody production (An antibody is a type of protein that the body's immune system produces when it detects harmful substances, called antigens). While it is a reasonable to think that aeroallergen immunotherapy (allergy shots) may be helpful for eosinophilic esophagitis, this has not been formally tested in a clinical trial. However, clinical anecdotes, from patients with eosinophilic esophagitis whose esophagitis was monitored after allergy shots for their other allergy problems, have not found notable improvement of eosinophilic esophagitis following immunotherapy.