Allergic or Eosinophilic Esophagitis or Acid Reflux or both?

GERD causes symptoms of heartburn and food sticking but so can an allergic condition of the esophagus known as eosinophilic esophagitis (EE). EE is characterized by the presence of an abnormal number of allergic type cells called eosinophils in the esophagus. In many patients and the number of eosinophils may not be high enough to separate EE from GERD, however a new study found another allergy cell, the mast cell, may help differentiate allergic esophagitis from acid reflux esophagitis. This study also provides further support that some people have both acid reflux and allergy.

Eosinophils are not normally present in the esophagus but are seen in small numbers under the microscope in biopsies of esophagus due to acid reflux. A count of more than 15-20 eosinophils per high power field (HPF or 40x) is the usual range considered diagnostic of EE though some pathologists use 24 or more. In reflux, up to 7 eosinophils per HPF is considered typical.

This study found significantly higher eosinophils (on average 55/HPF) in EE along with the presence of mast cells compared with reflux. However, though 96% of the EE biopsies showed IgE on cells so did 41% of those with GERD. This is consistent with some earlier studies that have suggested some people with reflux, especially those with more than 7 eosinophils per HPF, also have an allergic component. This also may explain the failure of acid blocking medications alone to relieve the symptoms in some people with reflux. The study also highlights the importance of biopsies when the gut appears normal for detecting microscopic signs of allergy, food intolerance or inflammation. This is also supported by recent studies confirming presence of mast cells in the intestine of people previously labeled as irritable bowel syndrome.

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Reference: Activated mucosal mast cells differentiate eosinophilic (allergic) esophagitis from gastroesophageal reflux disease. Kirsch R et al. Journal of Pediatric Gastroenterology and Nutrition 2007;44:20-26.

Food reactions related to pollen allergy: The burning mouth syndrome

Hay fever or allergies are very common. However, an odd and little known but well recognized reaction associated with pollen allergies is the oral allergy syndrome (OAS) or “burning mouth syndrome”. Does your mouth burn, swell or itch after eating certain foods? Is it worse during certain times of the year, especially when your hay fever is worse? If so, you may have this well-recognized but little known condition.

Classically, OAS presents as burning pain and swelling of the mouth after eating specific foods. This is where it gets the more commonly known name, the “burning mouth syndrome”. However, some people may not have the typical burning and swelling mouth but have itching of the back of the throat and difficulty swallowing. In this rather curious disorder, specific foods cause OAS symptoms without you necessarily being allergic to those foods. Instead, you are likely allergic to pollens or dust that cross-react with certain foods. Trees, grasses, weeds, house dust mite or latex allergies are related to certain food sensitivities. For example, those with ragweed allergy commonly react after eating melons or bananas but not other foods.

Though this reaction is well documented in allergy literature it is not commonly recognized or diagnosed by physicians including some allergists! There are lists of the common foods that are associated with certain pollens or latex but to my knowledge a comprehensive list that is easy to read or interpret is not to be found. Also, the names of some of pollens or the common link between a group of pollens and a group of foods can be confusing. However, I have created such a list.

In its classic form OAS should be easy to recognize. After eating a food known to be associated with a pollen to which you are allergic you experience near immediate burning sensation in your mouth or throat with or without swelling. Frequently in medicine, symptoms do not occur in the “classic” or typical manner in a specific person. You may experience throat swelling or tightening, burning when swallowing, a lump in the throat or swallowing difficulty but not make the connection to what you ate or what is happening to you. If these symptoms sound familiar, you may be experiencing burning mouth syndrome or a variation of the oral allergy syndrome. You may find a table of the foods that are known to cross-react with certain pollens or allergens at my website Food Allergies Specialist – the Food Doc.


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www.thefooddoc.com