GERD vs. EoE: Differences in Treatment

Eosinophilic esophagitis is a chronic immune condition that develops when a specific type of white blood cell — known as an eosinophil — builds up in the esophagus. As a result, the esophagus becomes inflamed and causes reactions to allergens, foods, or acid reflux.

Gastroesophageal reflux disease, on the other hand, is a condition caused by stomach acid entering the esophagus. This results in acid reflux that occurs at least a couple of times per week.

Since EoE and GERD have many of the same symptoms, they are often confused with one another. The methods of diagnosing these conditions and their treatments are similar as well.

How Are Eosinophilic Esophagitis and GERD Diagnosed?

Symptoms of EoE and GERD are similar, so making an accurate diagnosis of one or the other can be difficult. These symptoms include:

• Trouble swallowing, known as dysphagia
• Chest or abdominal pain, primarily caused by heartburn
• Regurgitation of undigested food

People with EoE usually have difficulty swallowing. They might also experience food impaction, which occurs when food becomes stuck in the esophagus after swallowing.

The main symptom of GERD is heartburn. With longstanding heartburn, narrowing or strictures of the esophagus can lead to difficulty swallowing.

Both EoE and GERD can be diagnosed with an upper gastrointestinal (GI) endoscopy. In this procedure, a thin, flexible tube with a camera and light attached to the end is placed down into the esophagus. This helps doctors look for any abnormalities.

For people with EoE, the esophagus will develop bumpy rings or become narrow (known as a stricture), while GERD causes irritation and redness from stomach acid. It can be difficult to tell the difference, and a doctor may diagnose GERD instead of EoE.

To help differentiate between the two conditions, the doctor will also take a small piece of tissue during the upper endoscopy for an esophageal biopsy. A pathologist will look at the tissue under a microscope. The presence of eosinophils can confirm a diagnosis of EoE.

While EoE and GERD have similar symptoms, effective treatments vary between the two conditions. Some treatments that work for GERD may not always be effective for EoE.

First-Line Treatments for GERD

GERD is caused by stomach acid entering the esophagus, leading to heartburn and potential tissue damage. The main goal of treating GERD is to lower the amount of stomach acid produced or block its effects.

Proton Pump Inhibitors

The most common first-line treatment for GERD is proton pump inhibitors. These drugs work by limiting the amount of acid produced by the lining of the stomach, which can help alleviate GERD symptoms. PPIs are available over the counter or by prescription. Examples include:

• Lansoprazole (Prevacid)
• Omeprazole (Prilosec)
• Esomeprazole (Nexium)
• Pantoprazole (Protonix)

PPIs are also used as a first-line treatment for EoE to reduce inflammation in the esophagus, often taken twice a day. However, because EoE is inherently an allergic condition caused by an overactive immune system, PPIs may not improve symptoms for some people.

Antacids

Antacids are typically chewable tablets that neutralize stomach acid to help alleviate symptoms. These do not reduce the amount of stomach acid your body makes.

H2 Blockers

Similar to PPIs, H2 blockers also reduce stomach acid production to help treat GERD. Examples include famotidine (Pepcid or Zantac) and nizatidine (Axid).

Treatments for EoE

Treatments for EoE can include diet changes, medication, and procedures. Since EoE is a chronic immune condition, these treatments may be ongoing to help manage symptoms and control flares.

Dietary Changes

Your physician may want you to see an allergist to determine if you have any food allergies contributing to EoE. Recommended dietary changes may include eliminating any foods that trigger an allergic reaction.

Dietary therapy may have fewer side effects than taking medications or receiving endoscopic treatments. However, getting the nutrition you need could be difficult if you’re restricted from several large food groups, like wheat and dairy products. Your doctor or a dietitian can help you design a balanced diet.

Biologics

Currently, the only medication approved by the U.S. Food and Drug Administration (FDA) specifically for treating EoE is the biologic Dupixent, a formulation of dupilumab. Approved in May 2022, Dupixent is used to treat EoE in adults and children ages 12 and up who weigh at least 88 pounds. This medication works by limiting inflammation in the esophagus, alleviating EoE symptoms.

In EoE, eosinophils found in the esophagus release inflammatory mediators known as cytokines. Biologic therapies target eosinophils, other immune cells that interact with them, or the cytokines they release. This category of medications has a lot of potential to treat EoE, but biologics are not approved to treat GERD.

Steroids

While there is only one FDA-approved medication for treating EoE, other medications are prescribed off-label for treatment. Topical steroids are often used as a first-line treatment in favor of dietary therapy, specifically because diet changes may require multiple endoscopies over a short amount of time to assess how effective they are.

The two most commonly prescribed topical steroids for treating EoE are fluticasone and budesonide. These corticosteroids help reduce inflammation in the esophagus and may alleviate swallowing difficulties in as quickly as a few days.

Topical steroids can be either drunk as a liquid or placed in the mouth using an inhaler and then swallowed. Budesonide is given orally but has a bitter taste, so many people mix it into a smoothie with sweeteners such as honey or syrups. Fluticasone is placed in the mouth by using an inhaler twice daily.

While steroids may help treat EoE symptoms, they’re not helpful for GERD. Moreover, certain steroids may actually worsen heartburn in some people.

Endoscopic Procedures

Endoscopy is useful for diagnosing EoE, but it can also be used to treat symptoms of the condition.

Food Impaction

Between 33 percent and 55 percent of children and adults with EoE experience food impaction. This is when food becomes firmly stuck in the esophagus, preventing it from moving into the stomach. Food impaction is a medical emergency, and removal requires an endoscopy with specialized tools.

Strictures

Adults and children with EoE can develop strictures in the esophagus. This occurs when the esophagus narrows, mainly due to inflammation and fibrosis. Fibrosis develops as a result of chronic inflammation, where the healing process replaces the cells that line the esophagus with collagen. As a result, the esophagus becomes scarred, thicker, and less flexible, leading to difficulty swallowing and, potentially, food becoming stuck.

To help widen these strictures, the esophagus can be dilated during an endoscopy. This dilation is done using wire dilators or balloons to widen the opening.

Which Treatment Option Is Right for You?

EoE is a complex disease that can be difficult to treat. Talk to a health care provider who specializes in gastroenterology about your options and which may work best for you. Some treatments, such as PPIs (which are also used for GERD), may not be as effective for you as for others. Each case of EoE is unique, so it’s important to work with your doctor to find which treatments are most effective.

Talk With Others Who Understand

On myEoEcenter, the site for people with eosinophilic esophagitis and their loved ones, people come together to learn about EoE and share their stories with others who understand life with EoE.

Were you misdiagnosed with GERD before EoE? What treatments have you tried for eosinophilic esophagitis? Share your experience in the comments below.