Eosinophilic esophagitis in children: clinical manifestations

Patient reported data integration for management of Eosinophilic Esophagitis

Eosinophilic Esophagitis (EoE) is an esophageal allergic inflammatory disorder triggered by food proteins. Symptoms of EoE are variable within and between individuals. Presenting symptoms may include dysphagia, food bolus impaction, dyspepsia, or more subtle symptoms such as feeding disorders, regurgitation sensation, or nausea. The development and validation of a pediatric EoE patient self-reported and parent proxy-reported outcome symptom scoring tool was created by Franciosi et al. published in BMJ 2011, titled the Pediatric Eosinophilic Esophagitis Symptom Score (PEESS™ v2.0). To date, its use is largely for research purposes. We propose to evaluate the implementation of the PEESS™ v2.0 in a prospective interventional controlled clinical practice. The study included 620 patients over an 18-month period. Surveys were delivered and administered digitally every month through the MyGeisinger.org Patient Portal. Our analysis demonstrated symptom severity and symptom frequency scores significantly improved over time. However, counter to our hypothesis, patients who completed the PEESS™v2.0 ultimately had higher EoE-related health care utilization of office visits and endoscopies compared with those who did not complete the PEESS™v2.0. This could be related to greater awareness of disease activity and/or increased willingness to seek care. Our study, in the context of mobile health tool and patient-reported outcome trends, represents an opportunity for improved disease monitoring at-home within the field of eosinophilic gastrointestinal diseases.

Eosinophilic Esophagitis in Children and Adults

Adults and children with eosinophilic esophagitis (EoE) have distinct clinical and endoscopic presentations. Recognition of clinical signs, along with laboratory and endoscopic findings, is critical for the identification of patients with EoE because delay in diagnosis has been associated with esophageal remodeling and stricture formation. Clinical presentation varies considerably between adults and children. This is less due to differences in the disease and more due to patient differences. This article describes the similarities and differences in clinical presentation of children and adults with EoE, including areas of epidemiology, clinical and endoscopic presentation, pathophysiology, and treatment.

Pediatric Eosinophilic Esophagitis in Slovenia: Data From a Retrospective 2005-2012 Epidemiological Study

OBJECTIVES

The aim of the present study was to assess the incidence, characteristics, therapeutic approach, and response to therapy of eosinophilic esophagitis (EoE) in a pediatric population from Slovenia.

METHODS

A retrospective study was conducted on a cohort of children newly diagnosed as having EoE, ages 0 to 18 years, residing in Slovenia, in the period between 2005 and 2012. For each child presenting symptoms, family and personal history of allergies, blood, skin and patch allergy tests, endoscopic and histological findings, types of therapy, and therapeutic success were recorded.

RESULTS

In total, 25 patients of EoE were identified during the study period. The mean annual incidence (per 100,000 children) was 0.8 (95% confidence interval [CI] 0.58-1.16). The incidences of EoE increased from 0.2 (0.01-1.36), 0.3 (0.01-1.38), and 0.3 (0.01-1.40) in the period 2005-2007, respectively, to 1.8 (0.72-3.76), 1.0 (0.28-2.60), and 1.8 (0.72-3.65) in the period 2010-2012, respectively (P = 0.002). In 9 patients, symptomatic and histological remissions were achieved with specific food elimination diet: in 8 with 6-food elimination diet and in 1 with an additional budesonide. In majority of patients, budesonide improved only symptoms, but esophageal eosinophilia persisted. Twenty percent of our children had improvement of histology and symptoms of EoE in spite of gradual reintroduction of all food and stopping all medication.

CONCLUSIONS

The annual incidence of childhood EoE in Slovenia is comparable with the reports from the developed European countries, and it increased by 6-folds in the last decade.

Eosinophils in Gastrointestinal Disorders: Eosinophilic Gastrointestinal Diseases, Celiac Disease, Inflammatory Bowel Diseases, and Parasitic Infections

The gastrointestinal (GI) tract provides an intriguing organ for considering the eosinophil's role in health and disease. The normal GI tract, except for the esophagus, is populated by eosinophils that are present throughout the mucosa, raising the possibility that eosinophils participate in innate mechanisms of defense. However, data from clinical studies associates increased numbers of eosinophils with inflammatory GI diseases, prompting concerns that eosinophils may have a deleterious effect on the gut. We present clinical features of 4 disease processes that have been associated with eosinophilia and suggest areas requiring investigation as to their clinical significance and scientific relevance.

Health-related quality of life over time in children with eosinophilic esophagitis and their families

OBJECTIVES

Existing treatments for pediatric eosinophilic esophagitis (EoE) effectively reduce inflammation. The impact of treatment on health-related quality of life (HRQoL) over time for pediatric patients with EoE and their families, however, has not been systematically assessed. We hypothesized that individualized multidisciplinary treatment would improve both child and family HRQoL over time, with improvements associated with decreased symptom severity.

METHODS

Children with EoE treated in 4 tertiary care centers were enrolled. Baseline assessments occurred at the time of patients' first evaluation; follow-up assessments occurred at 2 and 6 months after baseline. Presence and severity of 8 EoE symptoms were measured. HRQoL was measured with the Pediatric Quality of Life Inventory parent proxy report, child self-report (CR), and Family Impact Module (FIM). Statistical analyses used mixed-effects modeling to test changes over time for child and family HRQoL.

RESULTS

Ninety-seven children were enrolled (ages 2-18 years, mean age 7.7 years ± 4.8, 78% boys, 80% white). Baseline mean symptom number was 3.5 (standard deviation 2.3), and symptom severity was 5.5 (standard deviation, 4.5). HRQoL scores were significantly related to symptom scores (P < 0.001). EoE symptom severity decreased during the study (P = 0.03). Pediatric Quality of Life Inventory parent proxy Total and FIM Total scores improved from baseline to 6 months (respectively, adjusted means 78.4 vs 81.0, P = 0.0006; 68.9 vs 70.1, P = 0.03). Interactions with baseline symptom severity revealed that subjects with lowest symptom severity showed the most improved HRQoL scores (P = 0.0013).

CONCLUSIONS

HRQoL improved during the course of evaluation and treatment, with positive changes being strongest for patients with less symptom severity at baseline.

Racial differences in the clinical presentation of pediatric eosinophilic esophagitis

BACKGROUND

Analysis of current data suggests that 80% to 90% of children diagnosed with eosinophilic esophagitis are white. Little data exist regarding the presentation of eosinophilic esophagitis and potential clinical differences in minority children.

OBJECTIVE

This study compared the clinical presentation of eosinophilic esophagitis in African American children with white children treated at an urban allergy referral center.

METHODS

At an urban allergy clinic, a 2-year retrospective chart review was performed of 50 consecutive pediatric patients diagnosed with eosinophilic esophagitis. Presenting symptoms, age at diagnosis, coexisting atopic disease, and laboratory parameters were compared between races.

RESULTS

Most of the 50 children identified were boys (74%), as previously described. However, unlike prior literature, most were nonwhite (42% white, 42% African American, 4% Asian, and 12% other). African American children compared with white children had (1) a significantly higher frequency of failure to thrive (P < .01) and vomiting (P < .01) as presenting symptoms, (2) a higher frequency of comorbid atopic dermatitis (P < .01), (3) a younger mean age of symptom presentation and formal diagnosis (3.7 vs 9.1 years; P < .01), and (4) a trend toward a longer interval between symptom onset and formal diagnosis. However, after adjusting for confounding variables of age and insurance type, several of these racial differences were no longer significant.

CONCLUSION

African American children in this series had a larger burden of eosinophilic esophagitis than previously described as well as differences in clinical presentation compared with white patients. Analysis of these findings suggests that providers be aware of this potential diagnosis in young, atopic African American children with symptoms of esophageal dysfunction.

Adult versus pediatric eosinophilic esophagitis: important differences and similarities for the clinician to understand

Eosinophilic esophagitis (EoE) is recognized as a common, allergy-associated cause of chronic esophageal symptoms affecting both children and adults. Research has begun to shed light on its epidemiology with consistent results from various geographical areas. Differences in clinical presentation, endoscopic aspects and response to treatment have all been reported for patients of different ages, and the question as to whether adult and pediatric EoE are manifestations of a single entity or in fact two distinct disorders has been posed. The most relevant differences between pediatric and adult EoE come from evolutionary changes in the consequences of the disease, including fibrous remodeling, and the ability to express symptoms. However, most studies support a common pathogenesis and similar histopathological features for adult and pediatric patients, being the same diagnostic criteria applied to them. This article comprehensively reviews the most recently published information and addresses important questions about the natural history of EoE.

Eosinophilic gastrointestinal diseases--clinically diverse and histopathologically confounding

Eosinophilic gastrointestinal diseases are a group of chronic diseases characterized by a range of symptoms caused by eosinophilic inflammation of various parts of the gastrointestinal tract. Other causes for eosinophilia need to be ruled out prior to making the diagnosis of EGIDs. The most common form of EGID is eosinophilic esophagitis (EoE), an antigen-driven disease that afflicts children and adults and has been identified across the world. Histological features include dense eosinophilia of the esophageal mucosa, eosinophil degranulation, eosinophil microabscess formation, and other features of epithelial inflammation including basal zone hyperplasia and rete pege elongation. Treatments include dietary exclusions and topical corticosteroids.

Eosinophilic esophagitis in children: frequency, clinical manifestations, endoscopic findings, and seasonal distribution

PURPOSE

Eosinophilic esophagitis (EoE) is a chronic disease characterized by eosinophilic infiltration of the esophageal mucosa, which is associated with clinical and endoscopic manifestations. The objective of our study was to determine the frequency of EoE and to outline the clinical manifestations of EoE in Polish children.

MATERIAL/METHODS

Ten large regional pediatric gastroenterology centers participated in the study. A database of endoscopy reports from January 2004 till December 2009 was reviewed. A total of 35,631 esophagogastroduodenal endoscopy studies in children, aged from 4 months to 18 years, were performed. Data pertaining to the children's age, gender, indications for endoscopy, clinical findings and histopathology diagnosis were made.

RESULTS

In 84 children (20 girls and 64 boys), aged between 4 months and 18 years, EoE was diagnosed. This constituted one case per 424 endoscopic studies. In children with changes in the esophageal mucosa the frequency of EoE was higher and reached one case per 73 children. The most frequent symptoms of EoE differed between the younger (1-6 years old) and older children (aged 13-18 years old). Feeding aversion, vomiting and/or regurgitation were most frequently observed in the younger children, while in older children: abdominal pain, dysphagia and chest pain. Granular mucosa, longitudinal furrows, and mucosal rings belong to the findings most often observed in endoscopic studies. EoE was more frequently diagnosed in the spring (45.2%) and summer (28.5%).

CONCLUSIONS

EoE was diagnosed in every age, with frequency of 1/424 gastrointestinal endoscopies, more frequently in boys than in girls.

Eosinophilic esophagitis after esophageal atresia: is there an association? Case presentation and literature review

Eosinophilic esophagitis (EoE) is a relatively new condition resulting in dysphagia or symptoms resembling gastroesophageal reflux disease, symptoms that also are common in patients with a history of esophageal atresia. We present 2 patients with persistent dysphagia after repair of esophageal atresia that was caused by EoE. Although the exact etiology and pathogenesis of EoE remain unclear, it is now generally accepted that it is the result of a T-helper cell 2-type immune response with a crucial role for the eosinophil-specific chemotaxis factor eotaxin 3 and eosinophils. Because there are genetic similarities between esophageal atresia and EoE, we speculate that patients with esophageal atresia are at increased risk for developing EoE.

Reflectance confocal microscopy for the diagnosis of eosinophilic esophagitis: a pilot study conducted on biopsy specimens

BACKGROUND

Diagnosis of eosinophilic esophagitis (EoE) currently requires endoscopic biopsy and histopathologic analysis of the biopsy specimens to count intraepithelial eosinophils. Reflectance confocal microscopy (RCM) is an endomicroscopy technology that is capable of obtaining high-resolution, optically sectioned images of esophageal mucosa without the administration of exogenous contrast.

OBJECTIVE

In this study, we investigated the capability of a high-speed form of RCM, termed spectrally encoded confocal microscopy (SECM), to count intraepithelial esophageal eosinophils and characterize other microscopic findings of EoE.

DESIGN

A total of 43 biopsy samples from 35 pediatric patients and 8 biopsy samples from 8 adult patients undergoing EGD for EoE were imaged by SECM immediately after their removal and then processed for routine histopathology. Two SECM readers, trained on adult cases, prospectively counted intraepithelial eosinophils and detected the presence of abscess, degranulation, and basal cell hyperplasia on SECM images from the pediatric patients. A pathologist blinded to the SECM data analyzed the same from corresponding slides.

SETTING

The Gastrointestinal Unit, Massachusetts General Hospital.

RESULTS

Eosinophils by SECM demonstrated a higher reflectance than the surrounding cells and other inflammatory cells. There was good correlation between SECM and histology maximum eosinophil counts/high-power field (R = 0.76, P < .0001). Intra- and interobserver correlations for SECM counts were very good (R = 0.93 and R = 0.92, respectively; P < .0001). For the commonly used eosinophil count cutoff of 15 per high-power field, the sensitivity and specificity of SECM for EoE were 100%. The sensitivity and specificity for abscess, degranulation, and basal cell hyperplasia were 100% and 82%, 91% and 60%, and 94% and 80%, respectively. Intra- and interobserver agreements for these microscopic features of EoE were very good (κ = 0.9/0.9, 0.84/1.0, 0.91/0.81, respectively).

LIMITATION

Ex vivo study.

CONCLUSIONS

This study demonstrates that RCM can be used to accurately count intraepithelial eosinophils and identify other microscopic abnormalities associated with EoE on freshly excised biopsy samples. These findings suggest that RCM may be developed into a tool for assessing eosinophilic infiltration in the esophagus in vivo.

Eosinophilic esophagitis: trials and tribulations

Eosinophilic esophagitis (EE) is a recently recognized form of pan-esophagitis, which is characterized by the presence of at least 15 eosinophils per high power field on esophageal histology. EE is closely associated with atopic disorders and occurs predominantly in male patients. Young children are more likely to be sensitized to food allergens whilst aeroallergen sensitization predominates in older children and adults--a pattern reminiscent of the "atopic march". EE presents with a diverse range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or refusal in infancy, in addition to dysphagia and food bolus impaction in older children and adults. The diagnosis may also be ascertained incidentally in patients undergoing gastroscopy for other suspected gastrointestinal conditions, such as gastroesophageal reflux disease or celiac disease. Complications mainly relate to subepithelial remodeling and fibrosis which may result in dysmotility, dysphagia and esophageal strictures. The proportion of EE patients at risk of these complications is unknown due to a paucity of data on the natural history of EE. There are only few randomized controlled trials assessing the efficacy of treatment modalities for EE, which currently either involve food allergen elimination or use of swallowed aerosolized corticosteroids. This article aims to discuss the complex issues of the diagnosis and long-term management that confront clinicians who care for children with EE.

Emerging management concepts for eosinophilic esophagitis in children

Eosinophilic esophagitis (EoE) is a newly recognized condition that appears to be increasing in incidence for as yet unknown reasons. It can occur at any age and presents both to gastroenterologists and allergists. Clinical manifestations range from gastrointestinal symptoms (vomiting, feeding difficulties, dysphagia or food bolus impaction) to co-existing atopic conditions (asthma, allergic rhinitis or eczema). The diagnosis requires demonstration of at least 15 eosinophils per high power field on esophageal histology, usually in the context of resistance to proton pump inhibitor treatment or a normal 24-h esophageal pH monitoring study. The differential diagnosis between EoE and gastroesophageal reflux disease (GERD) can be problematic as there is significant clinical overlap between both conditions. Although difficult-to-manage esophageal strictures are well recognized in patients with long-standing EoE, little is known about risk factors for the development of this complication. There is a paucity of data on both the natural history and optimal long-term management of EoE. Current treatment options include food allergen elimination diets, use of topical aerosolized corticosteroids, or a combination of the two. Pediatric case studies have been provided to illustrate the complexity of decision points that often arise in the management of these patients. This paper aims to discuss the various strategies currently available to clinicians in the management of EoE and highlights gaps in the current evidence base that urgently require further research.

Gastrointestinal manifestations of food allergies

The rates of eosinophilic gastrointestinal disorders appear to be increasing. The most common of these is eosinophilic esophagitis (EoE) which is a clinicopathologic condition consisting of characteristic symptoms and endoscopic features accompanied by a pan-esophageal, acid resistant epithelial eosinophilia of greater than equal to 15 per high power field. Typical symptoms include dysphagia and abdominal pain. Typical endoscopic features include pallor, plaques, furrows, concentric rings. Complications include food impactions and strictures. EoE resolution with food elimination diets provides evidence that EoE is a food-antigen driven process. In vitro and microarray studies have identified specific immunologic factors underlying EoE pathogenesis. Other gastrointestinal manifestations of food intolerances/allergy include food protein induced enterocolitis syndrome.

Gastroesophageal reflux, eosinophilic esophagitis, and foreign body

Even though chest pain in children is a common complaint, an underlying gastrointestinal cause is rare. The four common gastrointestinal conditions that present with chest pain include eosinophilic esophagitis, gastroesophageal reflux disease, esophageal dysmotility, and foreign body ingestion. Other than ingestion of certain foreign bodies, most of these conditions are not life-threatening. Associated symptoms and history may be helpful in distinguishing these disorders, but further evaluation is often indicated to identify the precise cause.

Eosinophilic esophagitis

Eosinophilic esophagitis is specific disease that involves an isolated esophageal eosinophilic inflammation and clinical symptoms that do not respond to acid-suppression therapy or are associated with normal esophageal pH monitoring. To establish the diagnosis, upper endoscopy with esophageal biopsies is required. Referral to an allergist and food allergen testing is recommended. Dietary and topical corticosteroid therapies are commonly used and are effective in the majority of patients.

Updates on pediatric feeding and swallowing problems

PURPOSE OF REVIEW

There is increased recognition in the range of feeding and swallowing problems that occur in conjunction with congenital and acquired pediatric conditions. Differential diagnosis and management of these problems is often not straightforward and requires consideration and collaboration between multiple disciplines that are involved in the care of this special population. This article reviews recent investigations across disciplines regarding the cause and evaluation of pediatric feeding and swallowing issues, intervention efficacy, and available evidence to guide clinical practice.

RECENT FINDINGS

Knowledge of the basis for feeding issues associated with a variety of causes has advanced. Recent investigations of specific feeding and swallowing issues accompanying prematurity, selected diagnoses, and congenital syndromes are described. Significant advancements in the objective analysis of nonnutritive sucking have been made and provide increased understanding of the precursors for transition to oral feeding. Preliminary evidence regarding the effectiveness of selected clinical interventions to treat feeding and swallowing issues is highlighted.

SUMMARY

Research is increasingly available to guide practitioners in evidence-based evaluation and management of pediatric feeding and swallowing issues. These continued advancements increase our understanding of the causes of pediatric dysphagia, the efficacy of treatment, and underscore the opportunities for continued research for best practice in clinical evaluation and management.

Clinical Immunology Review Series: An approach to the patient with allergy in childhood

Allergic conditions are common, with asthma being the most common chronic illness in childhood in most developed countries. Some 80% of asthmatic children are sensitized to aeroallergens, usually indoor animal dander and house dust mite. Some 80% of asthmatics also have rhinitis. Rhinitis and eczema receive less medical attention than asthma, but they can cause longterm morbidity and have substantial direct and indirect economic costs. Food allergy and anaphylaxis are increasingly recognised and are usually easily diagnosed and managed.Clinicians can use in vivo and in vitro measurements of allergen-specific immunoglobulin E to better time reintroduction of implicated foods. Specific parenteral and sublingual immunotherapy is widely practiced internationally but is uncommon in the UK. It may alter the natural history of aeroallergen reactive diseases in the upper and lower airways. Specific oral tolerance induction represents the current cutting edge in clinical allergy research. It remands resource intensive at present and cannot be adopted into routine clinical practice at this time.