Diagnosing Eosinophilic Esophagitis (EoE): Tests, Early Diagnosis, and Your Doctors

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Microscope biopsy lab
A doctor removes small pieces of tissue from the esophagus during an endoscopy, and then a pathologist analyzes the samples as part of the biopsy.Adobe Stock
Eosinophilic esophagitis (EoE), a chronic disease that causes inflammation and damage to the esophagus, is often difficult to diagnose.

Testing procedures are complex, and many aspects of the diagnostic criteria aren’t standardized.

Additionally, EoE symptoms can look a lot like those of gastroesophageal reflux disease (GERD).

While EoE is frequently missed or labeled as something else, getting an early and accurate diagnosis is important.

The sooner you treat EoE, the better your outcome.

Diagnostic Tests for Eosinophilic Esophagitis (EoE)

EoE is an autoimmune disease in which white blood cells, called eosinophils, build up in the esophagus, causing symptoms such as?difficulty swallowing (dysphagia)?or food getting stuck (food impaction).

At first, your doctor might perform a physical exam to assess your overall health, symptoms, and family history.

But EoE can’t be diagnosed on the basis of symptoms alone.

If the disease is suspected, your provider will probably recommend tests to detect inflammation and increased amounts of eosinophils (special types of white blood cells) in the esophagus.

Various tests are performed to rule out other conditions or determine EoE triggers.

Endoscopy

An endoscopy is a procedure where a flexible tube with a light and camera on the end is passed down your esophagus. The instrument lets your doctor see if your esophagus is inflamed.

An EoE esophagus might also look red, swollen, or narrowed. It could contain white, bumpy patches or have an accordion-like appearance.

But, this procedure has its limitations. Some people with EoE have an esophagus that appears normal.

RELATED: What Is an Endoscopy?

Biopsy

A biopsy is performed during an endoscopy procedure. Your doctor removes small pieces of tissue from your esophagus (and sometimes your stomach and small intestine) to look for eosinophils. Then, a pathologist analyzes the tissue samples in a lab under a microscope.

If a biopsy shows that there are 15 or more eosinophils, EoE is a possibility.

Biopsies are often repeated throughout the diagnostic process to discover the triggers that are causing your EoE reactions.

RELATED: What Is a Biopsy?

Allergy Tests

Immune responses to foods are a main cause of EoE in many patients. Sometimes, doctors recommend allergy testing to get more information about what’s triggering your EoE symptoms, but these tests aren’t always reliable.

While typical food allergies are easy to detect, it’s often difficult to spot the allergens that contribute to EoE.

Traditional allergy testing fails to expose food sensitivities that cause EoE because reactions can be delayed or develop over days. Additionally, EoE flare-ups are generally caused by immune mechanisms that are different from those of traditional food allergies.

Sometimes, environmental allergens, such as pollen, dust mites, or mold play a role in EoE. Allergy testing for these common culprits may be given as part of your evaluation.

If your doctor does recommend allergy testing, you might have a blood test, a prick skin test, or a food patch test.

RELATED: Allergy Symptoms and Diagnosis

Elimination Diet

Doctors may recommend that you try an elimination diet to pinpoint which foods are causing your symptoms. This strategy involves eliminating certain foods or drinks from your diet for several weeks and then adding them back one at a time to see what’s triggering your EoE reactions.

Removing the suspected allergens followed by symptom improvement and less inflammation in the esophagus is needed to show that foods are, indeed, causing your EoE episodes.

It’s possible that one or more foods are triggering your symptoms.

If you add foods back to your diet and your symptoms return, your doctor may perform follow-up biopsies to see if eosinophils have come back. This can help uncover which foods are causing a reaction.

Once the problematic foods are removed, symptoms usually improve in a few weeks.

But foods that trigger EoE can change over time, which further complicates the diagnostic process.

Related: What Is an Elimination or Exclusion Diet?? ?

Tests to Rule Out Other Conditions

Other diseases can cause eosinophils to build up in the esophagus as well. Some of these include:

Sometimes, tests may be needed to rule out these conditions, but it’s often difficult to make a definitive diagnosis.

GERD usually presents with fewer eosinophils in the esophagus compared with EoE, but experts haven’t yet clarified exactly how many eosinophils define severe reflux vs. EoE.

Sometimes, doctors will suggest a GERD treatment before EoE can be diagnosed.

What Happens After an EoE Diagnosis?

After you get an EoE diagnosis, you and your doctor will decide on the best treatment plan.

Because EoE is such a complex disease, you might need to see more than one doctor. Your medical team may include the following experts:

  • Primary care physician?This is your main doctor, who can refer you to other specialists.
  • Allergist/immunologist?These experts can help you determine if your reactions are due to certain foods or environmental triggers.
  • Gastroenterologist?A gastroenterologist specializes in diseases of the digestive tract. They can perform tests, such as endoscopies.
  • Registered dietitian (RD)?An RD can help you come up with an appropriate diet plan for improving your symptoms.

The American Partnership for Eosinophilic Disorders (APFED) provides a specialist finder feature that helps you locate medical professionals who treat eosinophilic diseases. You can search for a provider by specialty and location.

The American Academy of Allergy Asthma and Immunology and the American College of Gastroenterology supply similar resources for helping you find a qualified medical professional.

Coping with an EoE diagnosis can be overwhelming. You may want to seek support outside your medical community of doctors. APFED’s online support community lets patients, caregivers, and family members connect with each other and share information.

Takeaway: Why an Accurate Diagnosis Is Important

Though an accurate diagnosis can be complicated to achieve, it’s an important step in your journey with EoE. A correct picture of your triggers can help doctors effectively treat your disease and prevent severe reactions.

Additionally, keeping EoE symptoms under control can reduce your risk of developing certain complications. EoE that’s not properly managed may lead to long-term damage to your esophagus.

Undiagnosed EoE also puts you at risk for feeding issues or psychological disorders.

Talk to your doctor if you think you might have EoE. An accurate diagnosis is a key factor in successfully managing your symptoms and improving your quality of life.

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