Nieman: Persistent choking could be a sign of something more serious

A seven-year-old child sees his doctor because food keeps getting stuck in his throat. He finds it hard to eat without also needing a glass of water to, as he puts it, “wash it down.”

Over the past few months, he also experienced some vomiting and upper abdominal pains.

Because he tends to be nervous, and especially now that the time has come to return to school after a peaceful summer holiday, his parents wonder if the difficulty in swallowing may be related to “nerves.”

The doctor, being a diagnostic sleuth with decades of experience, explains that there is indeed a mind-body connection, but asks about frequent choking during meals. The father and mother are divorced, and it seems that at Dad’s house, choking on food is more common. The father is a chef who loves to cook a wide variety of foods.

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Ultimately, the doctor gets a consultation with a gastroenterologist who makes the final diagnosis: eosinophilic esophagitis (commonly abbreviated as EoE).

The prevalence of EoE is becoming increasingly common. There has been a five-fold increase since 2009.

My first encounter with EoE took place in a restaurant in Ottawa where I was seated next to an astute gastroenterologist who heard a child choking on his food a few feet away.

He jumped to the child’s rescue, asked the parents a few questions, and returned to our table a few minutes later, explaining to us that dysphagia (difficulty swallowing) can be due to a condition where the esophagus reacts to foods and then causes a wide range of symptoms such as vomiting, food impaction, chest pain, heartburn and abdominal pain.

The mechanism by which EoE manifests can be complex. It is not easy to diagnose in the average medical clinic.

The presence of a type of cell, called eosinophils, reflects the allergy component of our immune system. And yet, only 50 to 60 per cent of patients with EoE have elevated markers for an allergy (elevated immunoglobulin E levels).

When blood is taken in these patients, only 40 to 50 per cent will show a mildly elevated count of eosinophils.

Seeing an allergist instead of a gastroenterologist may add a few more pieces to the puzzle, but it rarely provides a final diagnosis of EoE. An allergist may help sort through food allergies and suggest dietary changes, but in the end the root issue of EoE may be missed.