The increasing prevalence of a rare inflammatory disorder known as esophageal asthma is cause for concern.
At the age of 50, Lisa Thornton, who resides in the New Forest in Hampshire, recalls experiencing a blockage sensation in her oesophagus during her early 30s while pregnant. She initially attributed it to her pregnancy, but as time passed, the condition worsened.
While enjoying a Sunday meal with her loved ones, a piece of broccoli became stuck in her throat, resulting in prolonged spasms. Despite trying to drink water to dislodge it, the liquid only came back up. She then went to a nearby medical center, where medical professionals attempted to use muscle relaxants to remove the obstruction, but were unsuccessful.
After almost 20 hours, she was admitted to the emergency room. She was given fluids through an IV and the doctors discussed the possibility of a procedure to widen her oesophagus and alleviate the blockage. However, as a final effort, a young doctor administered morphine (which has both muscle relaxant and pain-relieving properties). Upon waking up, she discovered that after 36 hours, the lump had finally passed. It had been a traumatic and puzzling ordeal, with no explanation as to its cause.
However, this was just the start. It would be another ten years and additional events before Thornton was finally diagnosed with a rare condition known as eosinophilic esophagitis (EoE), also referred to as asthma of the esophagus.
Many of us are not aware of the extent to which we depend on our oesophagus every day. While it is typically less than one centimetre wide when at rest, it has the ability to expand to over three times its size in order to accommodate larger pieces of food.
According to consultant gastroenterologist Prof Stephen Attwood, it is not uncommon for individuals to accidentally ingest solid objects that measure approximately two to two and a half centimeters in size. This is possible because the esophagus is able to stretch and create an opening for food to pass through.
However, for individuals like Thornton, the tissue lining the esophagus experiences ongoing inflammation, resulting in rigidity, swelling, and a lack of elasticity. This can also lead to obstructions when consuming food. This condition is brought on by an overactive immune response, which is fueled by specific white blood cells called eosinophils. While these cells are necessary for removing harmful bacteria and parasites in the intestines, miscommunication within the immune system can cause them to induce allergic reactions and eczema.
In the late 1980s, Attwood was the first to discover Eosinophilic Esophagitis (EoE). At the time, it was extremely uncommon, with estimated rates of less than 10 per 100,000 individuals. However, similar to food allergies which are also influenced by eosinophils, EoE has become more prevalent among all age groups, ranging from young children to those over 70 years old. The exact reasons for this increase are not yet fully understood.
According to the British Society of Gastroenterology, the current estimate is that approximately 63 out of every 100,000 people are affected by this condition. Attwood states that this is enough to classify it as a “common disease”.
A study conducted in Sweden in 2022 found that the prevalence of a certain condition could potentially affect more than 1 in 1,000 individuals, which is double the previous estimate. According to Attwood, this aligns with the observed increase in patients seeking assessments for difficulties with swallowing, indicating a higher rate of diagnosis.
What is happening? Hannah Hunter, a dietician specializing in allergies at Guy’s and St Thomas’ NHS foundation trust, has been treating patients with EoE for the last ten years. She mentions several theories that have also been linked to the increase in allergies, asthma, eczema, and hayfever cases. One of the most talked about is the hygiene hypothesis, which suggests that the rise of EoE is due to modern cleanliness leading to fewer childhood infections. This can result in a weaker immune system that is more prone to malfunction.
Continued harm to the delicate cells that coat the esophagus from contemporary eating habits and prevalent substances like pesticides and detergents have also been considered as a potential reasoning.
According to Hunter, the data indicates that there has been a real rise in cases that cannot be solely attributed to increased awareness. There are various hypotheses for this, such as decreased exposure to microorganisms during infancy, inadequate vitamin D levels, and greater consumption of processed foods containing additives, preservatives, sweeteners, and emulsifiers.
Although the prevalence of EoE is increasing, many GPs are not well-informed about it. Studies indicate that it typically takes six years for patients to receive a proper diagnosis. While there is a useful medication called budesonide (sold as Jorveza), it is often overlooked as patients are mistakenly diagnosed with other conditions such as indigestion or GERD.
Without proper treatment over an extended period of time, EoE can progress and cause significant scarring in the esophagus, leading to difficulties with eating and even difficulty swallowing small pills.
Chairperson of the Royal College of General Practitioners, Prof Kamila Hawthorne, explains that identifying this condition is a challenging task for physicians. She states that although GPs have the most extensive curriculum among all medical specialties, their training program is the shortest at only three years. A complete diagnosis of EoE entails a comprehensive evaluation and taking samples from the esophagus in a secondary healthcare setting.
Diagnostics companies are currently developing methods to simplify the detection of EoE for doctors, eliminating the need for a complete endoscopy procedure involving the insertion of a long, narrow tube with a small camera down the patient’s throat. In December, Cyted, a gastrointestinal health company based in Cambridge, announced that it had received a £1m grant from Innovate UK, the UK’s innovation agency, to broaden the application of its EndoSign capsule sponge test (typically used for diagnosing and monitoring Barrett’s esophagus, a precursor to esophageal cancer) for EoE.
Marcel Gehrung, the CEO and co-founder of Cyted, states that this method would enable patients to undergo testing faster and with less discomfort compared to an endoscopy, while maintaining the same level of accuracy.
According to Hunter, further research is necessary to comprehend the impact of various foods on the inflammation that causes EoE. The most frequent triggers are cow’s milk, wheat, and eggs. Despite being distinct from typical food allergies, certain foods can worsen the symptoms of EoE.
The allergy dietician suggests that it would be beneficial to have a deeper understanding of how diet affects inflammation, not just in terms of certain trigger foods. Research has shown that our eating habits can impact our immune system and potentially contribute to EoE. Consuming highly processed foods, sugar, and trans fat may have negative consequences.
Thornton experienced a significant shift in her daily routine as she focused on avoiding certain foods and developed heightened anxiety around eating, especially in social settings, due to her condition, EoE. After being wrongly diagnosed for a considerable amount of time, she was not aware of a new medication available until she met Attwood, through a patient group, two months ago.
Following Attwood’s suggestions, she changed to a different advisor and recently began using Jorveza, which has greatly improved her life.
She believes that the diagnosis process should be faster, considering the significant impact it has on one’s life. She started taking Jorveza before Christmas and has noticed a significant improvement. She even ate a steak last week, something she wouldn’t have done previously.