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  • Dr. Vikki Petersen D.C, C.C.N
    Dr. Vikki Petersen D.C, C.C.N

    Eosinophilic Esophagitis: Do You Know Anyone Who Suffers?

      Journal of Gluten Sensitivity Spring 2014 Issue

    What is eosinophilic esophagitis (EoE)? Let's break it down:

    • The esophagus is the long tube that connects your mouth to your stomach. What goes through your esophagus? Food and drink.
    • Eosinophils are a type of white blood cell that increases in the case of allergy.

    EoE is a condition where eosinophils have infiltrated the lining of the esophagus causing inflammation and discomfort. It affects both children and adults, more males than females, and can manifest in failure to thrive and feed in infants, as well as heartburn and difficulty swallowing solid food in older patients. EoE results in a stiffening of the esophagus with strictures, making it quite difficult and uncomfortable to swallow.

    It seems fairly clear that if white blood cells associated with food allergy increase in an area of the body that food passes through, the obvious conclusion to form is that the individual is eating something they are having a negative reaction to—right?

    Yet standard treatment for this condition, which is rising in incidence, is drugs (specifically proton pump inhibitors) and mechanical dilation of the restricted esophagus when these other medications fail to work. I do find it interesting that we are seeing more and more of this condition over the last 20 years, during which time the American diet has continued to worsen.

    Diagnosis is made from an endoscopy that evaluates swallowing and includes a biopsy of the esophagus that reveals a high eosinophil count.

    Causes of EoE include acid reflux, which affects the lining of the esophagus, often causing ulcers, while less common causes are viruses (herpes simplex) and fungal medications that become stuck in the esophagus, creating the inflammation seen with the condition.

    Due to the acid reflux component and the tendency in our country to treat with drugs first, proton pump inhibitors that lessen acid production and therefore lessen the symptoms of acid reflux, are recommended as the first order of treatment—even in children. The protocol is 4 to 8 weeks of the drug, after which time the symptoms are re-evaluated to see if they have improved or remain the same. If they remain, a diagnosis of EoE is made.

    I'm not saying that short-term use of proton pump inhibitors has no value. If someone has a bacterial infection of the stomach (H. pylori) that can result in ulcers, or an active ulcer, this drug is effective. It can also provide symptomatic relief for someone who is miserable with the symptoms of EoE. But it's not the root cause ‘answer' for the condition and it particularly upsets me when very young children come in who are already on the drug.

    Why?
    The problem with the protocol that uses proton pump inhibitors is two-fold:

    • It's typically not addressing the root cause, which is a food reaction.
    • It's likely making the real root cause worse. This is interesting. If the problem is actually a food reaction or allergy, a proton pump inhibitor that lessens acid production actually compromises the ability of the body to digest food. This compromised digestion makes it MORE likely that an allergy or food reaction will develop.

    Fortunately, a new study sheds light on how effective dietary treatment can be. On February 14, 2014, the journal Gastroenterology published an article entitled "Efficacy of Dietary Interventions in Inducing Histologic Remission in Patients with Eosinophilic Esophagitis: a Systematic Review and Meta-analysis.

    The researchers evaluated 581 references and data from 1317 patients, both children and adults who received different dietary treatments. The treatments included amino acid-based elemental formulas (basically a liquid diet that is completely allergen free), elimination diets based on allergy testing and 6-food elimination diets that include the removal of wheat, milk, soy, eggs, peanuts, tree nuts, fish, and shellfish.

    What the researchers looked for was the ability to reduce infiltration of the eosinophils in follow-up biopsies. This would mean that the body's immune system was no longer mounting an inflammatory response.

    Their findings were as follows:

    • Elemental diets (liquid and allergy-free) were effective in 91% of cases.
    • The Six food elimination diet was effective in 72% of the cases.
    • Foods removed based on the result of allergy tests were effective in 46% of the cases.

    Both adults and children seemed to respond equally.

    What can we learn from this study?
    Eliminating common allergens, including gluten, a known inflammatory agent, is a great place to start when trying to improve this condition. A full 91% and 72% improved when common allergic foods were removed. Those are some pretty impressive percentages.

    I have found an interesting trend in our country. If doctors have the option of giving a prescription or asking a patient to make a dietary change, they will opt for the prescription. It's certainly easier to swallow a pill rather than make a dietary and lifestyle change. I'll grant you that. But is it right?
    When you appreciate that the pill is a mere band-aid and a highly temporary one at that, what really is a doctor doing for someone in NOT insisting that they change their diet? The truth of the matter is that taking the ‘easy' way out is not only cowardly, it is irresponsible.

    After the drug stops working, then what? Realize that throughout the period of time that the patient was on the drug, they were continuing to eat whatever was actually creating the problem and therefore their esophagus became more and more inflamed. While the human body's ability to heal is quite miraculous, once sufficient hardening and strictures have occurred in the esophagus, a full return to normalcy might not be possible. It is important that we intervene with the correct therapy quickly.

    Another facet to the ‘drug over food' decision on the part of most doctors is that they themselves don't change their own diets. I have often spoken with doctors who are themselves unhealthy yet they refuse to change their diets and are therefore convinced that they won't get their patients to make lifestyle changes either. Thus, they don't tend to recommend it because they are already convinced it won't occur.

    Is it fair to the patient to take the easy way out while they continue to worsen? I don't think so.
    Personally, I can tell you that here at HealthNOW Medical Center we have seen many cases of EoE and each one of them was associated with a food reaction, often gluten and dairy. And, because we practice what we preach, we have no trouble with our patients following our dietary and lifestyle change recommendations.

    If you know any youngster, adolescent or adult suffering with this condition, show them (or their parent) this article. A simple dietary change could be all that is needed to improve this serious condition.

    If your health is not at the level you desire, consider contacting us for a free health analysis—call 408-733-0400. Our destination clinic treats patients from across the country and internationally so you do not need to live local to us to receive care. We are here to help!

    Reference:

    • Gastroenterology. 2014 Feb 14. pii: S0016-5085(14)00217-0. doi: 10.1053/j.gastro.2014.02.006. [Epub ahead of print]


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    NOPE. I've eliminated gluten as a result of a celiac disease diagnosis and my acid reflux is getting worse. I also have Barrett´s Esophagus which I didn't find mentioned in this article. I always thought my BE was a result of gluten but now I'm not at all sure.

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  • About Me

    Dr. Vikki Petersen, a Chiropractor and Certified Clinical Nutritionist is co-founder and co-director, of the renowned HealthNow Medical Center in Sunnyvale, California. Acclaimed author of a new book, "The Gluten Effect" - celebrated by leading experts as an epic leap forward in gluten sensitivity diagnosis and treatment. Dr. Vikki is acknowledged as a pioneer in advances to identify and treat gluten sensitivity. The HealthNOW Medical Center uses a multi-disciplined approach to addressing complex health problems. It combines the best of internal medicine, clinical nutrition, chiropractic and physical therapy to identify the root cause of a patient's health condition and provide patient-specific wellness solutions. Her Web site is:
    www.healthnowmedical.com

  • Related Articles

    Diana Gitig Ph.D.
    Celiac.com 12/16/2011 - To date, symptoms of gastroesophageal reflux disease (GERD) - heartburn and acid regurgitation - have been among the only GI symptoms absent from the list of common manifestations of celiac disease. They are usually definitive indicators of gastric acid reflux. But a report from Julio César Bai's group in Buenos Aires notes that at the time of diagnosis, patients with celiac disease were more likely to complain of GERD symptoms than healthy controls. Moreover, maintaining a gluten free diet alleviated these symptoms. Their results are reported in Clinical Gastroenterology and Hepatology.GERD is a chronic condition usually resulting from the reflux of acidic stomach contents up into the esophagus. It is commonly treated with proton pump inhibitors, but some cases are refractory to this treatment. There has been conflicting data as to whether GERD symptoms are more common in people with celiac, and whether a gluten free diet might help. Dr. Bai's group designed a two pronged study to answer these questions: They undertook a cross sectional analysis of 133 people upon their diagnosis with celiac over the course of 2005, and a longitudinal assessment of 53 of them as they maintained a gluten free diet over the next four years.
    At the time of their diagnosis, the proportion of celiac with reflux was six-fold higher than that in the the 70 healthy controls included in the study. Interestingly, more severe reflux symptoms were associated with the classical, rather than the silent, presentation of celiac disease. However, it should be noted that this was somewhat of a selected population; these data were obtained from patients coming to a malabsorption clinic, where the classic presentation of celiac is more prevalent than the silent type. Moreover, for whatever reason, these healthy volunteers had less GERD symptoms than is usually reported. After three months on a gluten free diet symptoms were comparable to those seen in healthy controls. Interestingly, though, this was the case for patients who reported only partially complying to a gluten free diet as well as those who adhered to it strictly.
    Because these symptoms are alleviated upon assumption of a gluten free diet, the authors hypothesize that they might be caused by a nontraditional mechanism in celiac patients rather than by actual reflux. One suggestion they posit is reduced upper gastrointestinal motility, and another is a permeability defect in the stratified esophageal epithelium. In an editorial accompanying the paper, delayed gastric emptying and disturbed neuroendocrine control of upper GI function are floated potentially contributing to GERD symptoms in untreated celiac. Further research would have to be done to bear out these and other ideas.
    Nachman F, Vázquez H, González A, Andrenacci P, Compagni L, Reyes H, Sugai E, Moreno ML, Smecuol E, Hwang HJ, Sánchez IP, Mauriño E, Bai JC. Gastroesophageal reflux symptoms in patients with celiac disease and the effects of a gluten-free diet. Clin Gastroenterol Hepatol. 2011 Mar;9(3):214-9. Epub 2010 Jun 30.
    Source:

    Leffler DA, Kelly CP. Celiac disease and gastroesophageal reflux disease: yet another presentation for a clinical chameleon. Clin Gastroenterol Hepatol. 2011 Mar;9(3):192-3. Epub 2010 Dec 8.

    Jefferson Adams
    Celiac.com 01/04/2012 - A number of cases have led researchers to suspect a connection between eosinophilic esophagitis and celiac disease in children.
    A research team sought to confirm this association in children, and determine whether it extends into adulthood. To do this, they reviewed data from a group of celiac disease patients to learn the number of patients who also had a diagnoses of eosinophilic esophagitis. 
    The team included Jennifer S. Thompson, MD, Benjamin Lebwohl, MD, MS, Norelle Rizkalla Reilly, MD, Nicholas J. Talley, MD, PhD, Govind Bhagat, MD, and Peter HR. Green, MD.
    For their study, they reviewed histopathology reports of esophageal biopsies to identify all cases of increased esophageal eosinophilia.
    The team defined cases of eosinophilic esophagitis as those where biopsies showed Z15 eosinophils per high power field and, which also included associated symptoms.
    Using published US population-derived incidence data as a reference, they formulated age- and sex-adjusted standardized incidence ratios with corresponding 95% confidence intervals (CI).
    In all, the team found 4 children and 10 adults with eosinophilic esophagitis, which makes eosinophilic esophagitis more common in people with celiac disease than in the general population.
    Standardized incidence ratio was 35.6 (95% CI, 9.3-79.0) for children, and 13.1 (95% CI, 6.2-22.5) for adults. Overall, age-adjusted and sex-adjusted standardized incidence ratio was 16.0 (95% CI, 8.7-25.5).
    This study found higher rates of eosinophilic esophagitis in patients with celiac disease than in the general population. The researchers advise doctors to consider the possibility of eosinophilic esophagitis for celiac disease patients who suffer ongoing esophageal problems.

    Source:

    J Clin Gastroenterol. 2012 Jan;46(1):e6-e11.

    Jefferson Adams
    Celiac.com 05/21/2015 - Some studies have indicated higher rates of reflux in patients with celiac disease, but there hasn't really been any clear data on the risk for celiac disease in patients presenting with reflux.
    A team of researchers recently set out to determine rates of celiac disease in patients with GORD, and to better understand the nature of reflux symptoms in newly diagnosed celiac disease patients.
    The research team included P.D. Mooney, K.E. Evans, M. Kurien, A.D. Hopper, and D.S. Sanders. They are affiliated with the Regional GI and Liver Unit, Royal Hallamshire Hospital, Sheffield, South Yorks, UK.
    The team divided the patients into groups as follows:
    Group A included 3368 patients who had undergone routine duodenal biopsy, and prospectively recruited between 2004 and 2014. Researchers compared these results with those of a screening control group.
    Group B included 32 patients with newly diagnosed celiac disease who had undergone esophageal manometry and 24-h pH studies, prospectively recruited.
    The results showed the following:
    Of the 3368 patients in Group A who received routine duodenal biopsy, 850 (25.2%) presented with GORD.
    Rates of celiac disease among GORD patients was just 1.3% (0.7-2.4%), about the same as in the general population (P=0.53).
    Routine duodenal biopsy at endoscopy showed that reflux was negatively associated with celiac disease, with an adjusted odds ratio of 0.12 (0.07-0.23), P<0.0001.
    In group B, about one third of patients complained of reflux. Manometry showed that just under 10% had a hypotensive lower esophageal sphincter, and 40.6% had esophageal motor abnormalities, with 25% showing significant hypocontraction. Also, pH study did show that one in three did in fact suffer reflux episodes.
    The main takeaway from this study is that GORD patients have undiagnosed celiac disease at about the same rate as the general population, and so routine duodenal biopsy cannot be recommended for patients with GORD.
    Interestingly, pH/manometry studies showed a fairly high percentage of newly diagnosed celiac patients with reflux and/or esophageal dysmotility; which might explain the high prevalence of reflux symptoms in celiac disease.

    Source:
    Eur J Gastroenterol Hepatol. 2015 Jun;27(6):692-7. doi: 10.1097/MEG.0000000000000359.

    Jefferson Adams
    Celiac.com 04/20/2016 - People with celiac disease very often have reflux symptoms. A team of researchers recently set out to evaluate mucosal integrity and motility of the lower esophagus as possible contributors to reflux symptoms in patients with celiac disease.
    The research team included María Inés Pinto-Sánchez, Fabio D. Nachman, Claudia Fuxman, Guido Iantorno, Hui Jer Hwang, Andrés Ditaranto, Florencia Costa, Gabriela Longarini, Xuan Yu Wang, Xianxi Huang, Horacio Vázquez, María L. Moreno, Sonia Niveloni, Premysl Bercik, Edgardo Smecuol, Roberto Mazure, Claudio Bilder, Eduardo C. Mauriño, Elena F. Verdu, and Julio C. Bai.
    They are variously affiliated with the Farncombe Family Digestive Health Research Institute at McMaster University, in Hamilton, Ontario, Canada, the Department of Medicine, "Dr. Carlos Bonorino Udaondo" Gastroenterology Hospital in Buenos Aires, Argentina, Favaloro University Hospital in Buenos Aires, Argentina, Consejo de Investigación en Salud, MSAL, Gobierno de la Ciudad Autónoma de Buenos Aires, Argentina, and with the Gastroenterology Chair, Universidad del Salvador in Buenos Aires, Argentina.
    For their study, they enrolled newly diagnosed celiac disease patients with and without reflux symptoms, non-celiac patients with classical reflux disease (GERD), and control subjects, who had no reflux symptoms.
    Using both light microscopy and electron microscopy, they assessed endoscopic biopsies from the distal esophagus for dilated intercellular space (DIS). They used qRT-PC to determine tight junction (TJ) mRNA proteins expression for zonula occludens-1 (ZO-1) and claudin-2 and claudin-3 (CLDN-2; CLDN-3).
    Overall, patients with active celiac disease showed higher DIS scores than controls, and similar to GERD patients. They found altered DIS even in celiac disease patients without reflux symptoms, who had normalized after one year of a gluten-free diet.
    Celiac disease patients with and without reflux symptoms had lower expression of ZO-1 than controls. Celiac disease and GERD patients showed similar expression of CLDN-2 and CLDN-3.
    This study shows that patients with active celiac disease have altered esophageal mucosal integrity, independent of any reflux symptoms.
    Loss of TJ integrity in the esophageal mucosa may result from altered expression of ZO-1, which may contribute to the development of reflux symptoms.
    Source:
    Canadian Journal of Gastroenterology and Hepatology. Volume 2016 (2016), Article ID 1980686, 9 pages

    Jefferson Adams
    Celiac.com 06/14/2017 - Some data have suggested a connection between celiac disease and eosinophilic oesophagitis (EoE)/oesophageal eosinophilia (EE). Any potential relationship has implications for treatment. Should the two conditions be treated together, or separately?
    To better understand any possible connection, and the implications for treatment, a team of researchers recently set out to characterize children with celiac disease+EE in-depth and assess the contribution of each condition to the clinical presentation and treatment response.
    The research team included Anne Ari, Sara Morgenstern, Gabriel Chodick, Manar Matar, Ari Silbermintz, Amit Assa, Yael Mozer-Glassberg, Firas Rinawi, Vered Nachmias-Friedler, Raanan Shamir, and Noam Zevit. They are variously affiliated with the Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Medical Center of Israel, Petach Tikvah, Israel, the Pediatrics Center at Schneider Children’s Medical Center of Israel, Petach Tikvah, Israel, the department of Pathology at Rabin Medical Center in Petach Tikvah, Israel, and the Sackler Faculty of Medicine at Tel Aviv University in Tel Aviv, Israel.
    The research team conducted a retrospective review of medical records of children with both celiac disease+EE, or isolated EoE diagnosed between 2000 and 2014. They then compared these records with those of patients with isolated celiac disease or epigastric pain. To calculate the frequency of EE, they used endoscopy results of patients with suspected celiac disease or epigastric pain between 2011 and 2014. They used a telephone questionnaire to gather missing data.
    At a single large, tertiary pediatric center, the team assessed 17 patients with celiac disease+EE, 46 with EoE, 302 with isolated celiac disease, and 247 with epigastric pain. The patients with celiac disease+EE shared characteristics of both individual conditions. While age at diagnosis, family history of autoimmunity/celiac disease and anaemia were similar to most celiac patients, other characteristics such as male gender, personal/family history of atopy, peripheral eosinophilia and oesophageal white papules more closely resembled those of patients with EoE.
    Most patients with celiac disease+EE tended to present with celiac-associated symptoms, and 63% went on to develop typical EoE symptoms. In celiac disease+EE patients, only 21% saw their EE resolve after a gluten-free diet; another 21% saw their EE normalize after proton pump inhibitor treatment. The rest required EoE-specific treatment.
    Patients with celiac disease found to have EE share characteristics similar to both isolated celiac disease and EoE.
    This study indicates that celiac patients with concurrent EE are actually suffering from two separate conditions, rather than celiac-associated eosinophilia. Therefore, in such patients, doctors should consider treating each condition separately.
    Source:
    Archives of Disease in Childhood Published Online First: 12 April 2017. doi: 10.1136/archdischild-2016-311944

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    He's still going to have to eat gluten even for an endoscopic biopsy. 2 weeks minimum. Plus guidelines say no dx on an endoscopic biopsy alone - you have to have the positive blood to go with it. Even that 2 weeks will deposit more antibodies under his skin if he's got dh.  Let me put it this way. The gut damage is the gut damage & if he's celiac & it sounds like he is but we don't have labs to prove it, then there is a treatment for it. Only 1 treatment for it. A very strict gluten
    Knitty Kitty, Here is the link to the Old research. I think you will find it interesting. ..I know you used Niacin to treat your itching with your DH. https://core.ac.uk/download/pdf/82674034.pdf see Case IV but read them all when you get the chance. they review 12 case studies. I hope this is helpful but it is not medical advise. Posterboy,
    Alaskaguy, Like Knitty Kitty I am one of the researchers on this forum.  she has provide you good links. So I wanted to chime in and share some research I found recently that might help you....entitled "Two Cases of Dermatitis Herpetiformis Successfully Treated with Tetracycline and Niacinamide." This is recent research too which can be hard to come by to find something directly that might help you. https://www.ncbi.nlm.nih.gov/pubmed/30390734 Also see this thread about
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