Endoscopy #2 - Preview

While upper endoscopies are fairly routine outpatient procedures there are risks involved. Please pray for Oliver and his Doctors when he goes in for his next (of many, many more to come) endoscopy.

Oliver's health hasn't been the best over the last little bit. He isn't sleeping well at night and he is back to throwing up fairly regularly. The worst part is he's not drinking very much of his formula. We told the doctor we were ready to perform another endoscopy and we have one scheduled for Dec 1st. We are excited about this date because it means we'll hit our maximum out of pocket expenses with the insurance and this endoscopy will cost us less than the last one did. In January all of that resets, of course.

What does this mean?

• A more accurate diagnosis. For his second endoscopy Oliver will be on his Proton Pump Inhibitor (PPI) which is an important condition for an actual diagnosis of EoE. PPIs are commonly prescribed for acid reflux. Acid Reflux can weaken the esophagus and result in the presence of some eosinophils in the esophagus - usually a very small amount. In order to rule out reflux as the cause for the eosinophils found in the last endoscopy Oliver has been on a PPI ever since. I hope we'll be able to take him off of it after the next scope because long term use of PPIs can have some negative side effects. It's a difficult dance because it is very possible and quite common for a child to have both EoE and some type of GERD. If there are no eosinophils in the biopsy of his esophagus (this would be good news, mostly) we won't know if it is because of the PPI or because of the diet change. If there are eosinophils we can be sure that he has EoE but we still won't really know if he needs the PPI. The one thing we will know is that he is still reacting to something. It could be food or environmental, but most likely it will be a food.
• A snapshot of his current condition. Oliver has been off of his Corticosteroids (the flovent) for quite a while (which is why we think that his symptoms have returned). This is important because the steroids not only mask the symptoms but also can prevent the formation of the eosinophils. If he were on the steroids the results of the biopsy wouldn't accurately inform us as to whether or not his diet is helping his condition. Since Oliver doesn't communicate well with us the results of the biopsy are very important.
• A tool to plan the next stage of treatment. Alison and I suspect that Oliver's diet still includes some food(s) to which he reacts. These symptoms were masked when he was taking the steroids but now that he is off of the steroids they are manifesting themselves. The results of the biopsy will confirm or contest this hypothesis.

What do we do if he scopes clean?

First, this is not the outcome we expect. In many ways this would be good news, but it also comes with complications. First we have to remove the PPI and scope again in a couple of months to determine whether it was the PPI or the diet which caused the reduction. Either one would be a great thing. Knowing which one it is would be an even better thing.

But, if the eosinophils are gone, why is still irritable and throwing up? This would open up a new mystery.

What do we do if he still has eosinophils?

This is the big question, what to do next? We will need to eliminate more foods from his diet if the biopsy reveals eosinophils in the esophagus. Which foods?

• Our GI has proposed we do another round of RAST tests to see if Oliver demonstrates a sensitivity to anything new. I don't like the idea because RAST testing is considered the least effective of the three allergy testing methods in identifying foods which have a non-IgE mediated reaction like EoE. I would prefer skin prick testing, or better yet, atopic patch testing.
• Another option is to simply remove some popular "offenders" like corn and beef. This wouldn't leave much for him to eat.
• The most drastic action is to remove all proteins and put him on a pure elemental diet. This is tempting only because it would increase the likelihood that insurance would cover the costs of his formula. We really don't want Oliver to have an aversion to foods so we would like to keep him eating some foods if we can, but we also acknowledge that many EoE patients end up on a pure elemental diet at some point, either as a tool in identifying "safe" foods or because they haven't found they can tolerate any foods at all.

What do we do in the meantime?

We want the endoscopy with biopsy to provide the most valuable set of information possible for us. In order for this to happen we need to make sure Oliver is on his PPI and off his steroids. Also, we need to be super vigilant and make sure he doesn't eat any of the 7 foods we have eliminated. (Milk, Wheat, Soy, Egg, Peanut, Chicken, Beans) If he were to sneak a Cheez-It from his brother during the week before his endoscopy, this would greatly reduce the information we can learn about his current diet. Strict adherence to his diet leading up to his endoscopy is really important. Too bad Oliver doesn't understand that. Hopefully his brothers do.