Sublingual immunotherapy(SLIT) provides relief of allergies and allergic asthma without injections. Sublingual means "under the tongue". This is a new form of desentizing for patients without the incovience of weelky shots. It is safe and effective and can be used in children as young as 4 years of age. Treatment can be effective in 12 weeks.
Eosinophilic esophagitis is a recently recognized condition characterized by inflammation of the esophagus. The esophagus is the tube connecting the mouth and the stomach. In eosinophilic esophagitis large numbers of white blood cells called eosinophils are found in the tissues of the esophagus. Normally no eosinophils are found in the esophagus. Eosinophilic esophagitis can occur at any age. It is most commonly found in Caucasian males. The symptoms of eosinophilic esophagitis vary with age.
Allergists and gastroenterologists are now seeing more patients with eosinophilic esophagitis. Dr. Holbreich has evaluated many patients with eosinophilic esophagitis. Eosinophilic esophagitis is considered to be a chronic condition.
Diagnosing Eosinophilic Esophagitis
Currently the only way to diagnose eosinophilic esophagitis is with an endoscopy and biopsy of the esophagus. Your gastroenterologist has made the diagnosis of eosiophilic esophagitis. There are currently recognized criteria for the diagnosis of eosinophilic esophagitis that are followed by gastroenterologists, pathologists and allergists. These include a history consistent with eosinophilic esophagitis, visual inspection of the esophagus during endoscopy and careful evaluation of tissues taken from the esophagus during the endoscopy and evaluated under a microscope by a pathologist.
Eosinophilic Esophagitis and Allergies
The majority of patients with eosinophilic esophagitis are atopic. An atopic individual has a family history of allergies or asthma and symptoms of one or more allergic disorders. These include asthma, allergic nasal disease, atopic dermatitis and food allergies. Allergies both environmental and food related are important causes of eosinophilic esophagitis. Once the diagnosis of eosinophilic esophagitis has been made by your gastroenterologist it is important to have an expert allergy evaluation to understand the role allergies may be playing. Dr. Holbreich is able through the history, physical examination and testing for environmental and food allergies to provide you and your gastroenterologist with a comprehensive evaluation and recommendations for treatment of the allergic aspect of eosinophilic esophagitis.
Eosinophilic Esophagitis: Environmental allergies
Although not considered a major factor in eosinophilic esophagitis, environmental allergies such as dust mites, animals, pollens and molds can play a role in causing eosinophilic esophagitis. Some patients appear to have an increase in the activity of their eosinophilic esophagitis during pollen seasons. Allergy injection therapy for environmental allergies is occasionally recommended as part of the overall treatment program.
Eosinophilic Esophagitis: Food allergies
Research has determined that in a significant number of patients, food allergies are the cause of eosinophilic esophagitis. Food allergy has been established as a major cause of eosinophilic esophagitis in children. Food allergies can be an important factor in adults with eosinophilic esophagitis.
Dr. Holbreich is an expert in the diagnosis and treatment of eosinophilic esophagitis associated with food allergies. The relationship between food allergy and eosinophilic esophagitis is complex. Most food allergies in children and adults are easily diagnosed by a history of an allergic reaction immediately after ingestion of the food. In eosinophilic esophagitis however it is more difficult to establish the role of foods. Therefore Dr. Holbreich and his staff may do a series of different allergy tests to identify the foods contributing to the eosinophilic esophagitis.
Eosinophilic Esophagitis: Prick skin testing
Individuals who are allergic react to a particular substance in the environment such as pollen or animals or in the diet such as dairy or egg. These substances are proteins and are called allergens.
The prick technique introduces a small amount of allergen into this skin by making a small puncture through a drop of allergen. Allergens used in allergy testing can be made commercially and standardized according to the US Food and Drug Administration. Dr. Holbreich, through his own research, has determined that commercial food allergens are often inadequate for the evaluation of food allergy in eosinophilic esophagitis. Therefore all foods for allergy testing are prepared in his office using fresh foods. A large number of foods have been associated with eosinophilic esophagitis therefore we may tests for up to 30 individual foods Results are available in 15 minutes after the prick is done. Allergy skin testing provides Dr. Holbreich with specific information about environmental and food allergy.
Eosinophilic Esophagitis: Blood tests
Dr. Holbreich will occasionally use blood tests to determine the presence of allergies. This test often referred to as a RAST can be helpful in certain conditions associated with food allergies. Currently the results of blood tests are not considered as helpful as skin prick testing in eosinophilic esophagitis and Dr. Holbreich does not recommended them for the comprehensive evaluation of food allergy that is required in eosinophilic esophagitis.
Eosinophilic Esophagitis: Food patch tests
Physicians treating patients with eosinophilic esophagitis have determined that eliminating foods found on prick skin testing alone did not always control eosinophilic esophagitis. Food patch testing is in another type of allergy test that can be used in the evaluation of eosinophilic esophagitis. This test, unlike the prick test which establishes an immediate reaction to the allergen, is used to determine whether the patient has“delayed” reactions to foods. The patch test is done by placing a small amount of a freshly prepared food in a small aluminum chamber. This is called a Finn chamber. The Finn chamber is then placed on the back with tape. The food in the chamber stays in contact with this skin for 48 hours is removed. Dr. Holbreich reads the results at 72 hours. An area of skin in contact with the food that has become inflamed indicates a delayed reaction to that food. Removing that food from the diet may be important in the management of eosinophilic esophagitis.
Eosinophilic Esophagitis: Treatment
Testing Directed Diets
Information about specific food allergies obtained from prick skin testing and patch testing can be used to eliminate specific foods from your or your child’s diet. In some individuals this is the only treatment that is required to control the eosinophilic esophagitis.
Nonspecific Elimination Diets
Studies have been done eliminating the major food allergens from the diet prior to any testing for food allergies. The foods excluded usually include dairy, egg, wheat, soy, peanut and tree nuts, fish and occasionally other foods such as corn. These diets have been shown to significantly decrease eosinophil counts in some patients. It is a difficult diet to follow. If the diet is successful, foods need to be added back individually with follow-up endoscopy to assess which are the foods causing the eosinophilic esophagitis. This may is a difficult diet for families to maintain for long periods of time.
In this diet all sources of protein are removed from the diet. The patient receives complete nutrition from an amino acid based dietary replacement as well as simple sugars and oils. This diet eliminates all other food. In toddlers and young children a feeding tube may be required to assure adequate nutrition. This approach is reserved for individuals with multiple food allergies and failure to respond to other forms of therapy. It is rarely recommended.
No medications are currently approved for the treatment of eosinophilic esophagitis. Medications however have been shown to be very effective in reducing the number of eosinophils in the esophagus and improving symptoms. Steroids, which control inflammation, are currently the most effective medications for the treatment of eosinophilic esophagitis. Swallowing corticosteroids is the most common treatment method. Different forms of swallowed corticosteroids are available. High doses are initially required to suppress the inflammation. The use of systemic corticosteroids (oral liquid or pills) is also effective but is associated with a greater risk of side effects.
Proton pump inhibitors which suppress acid production have also been used in the treatment of eosinophilic esophagitis. Their place in the management of eosinophilic esophagitis is currently being investigated.
New forms of therapy are under investigation and may provide significant relief. Dr. Holbreich can provide you with information about ongoing studies.
Working with Your Doctors
Eosinophilic esophagitis is a complex disorder. Patients must rely on their gastroenterologist for recommendations about following the progress of the illness through endoscopy. Patients must also work closely with their gastroenterologist and allergist to establish appropriate medical therapy along with dietary avoidance. Dr. Holbreich will supervise dietary avoidance, assure adequate nutrition and manage the associated allergic problems such as asthma and allergic rhinitis. This disease requires cooperation among physicians and families. Dietitians can also provide important to nutritional information.
Dr.Holbreich has over 20 years of experience in the treatment and management of allergic disorders. He has a particular interest in eosinophilic esophagitis. He has presented his research on eosinophilic esophagitis at national meetings, participates in national committees setting standards for the role of the allergist in eosinophilic esophagitis and has helped with the management of numerous patients, both children and adults, with eosinophilic esophagitis.
For appointments please contact 317 574-0230
Additional information is available at www.mholbreich.yourmd.com