Childhood esophagitis: then and now

Evidence of Disturbed Sleep in Children With Eosinophilic Esophagitis and Persistent Epigastric Pain

Objective

To determine whether the experience of persistent epigastric pain is associated with sleep disturbances in children with eosinophilic esophagitis (EoE). We hypothesized that children with EoE and persistent epigastric pain would (1) self-report greater current and worst pain severity, and (2) experience more disturbed sleep on objective and subjective measures in comparison with children with EoE but no persistent pain and healthy children.

Methods

Fifty children with EoE were recruited for this cross-sectional study, of which 24 (48%) reported experiencing persistent epigastric pain. The remaining 26 (52%) children with EoE denied experiencing persistent pain. An additional 25 healthy children without EoE or persistent pain were included. All children provided severity ratings of current pain and worst pain experienced over the past week. Children then completed 12 consecutive nights of ambulatory sleep monitoring via actigraphy in the home. Caregivers provided information regarding their child's sleep patterns and internalizing symptoms.

Results

Children with EoE and persistent pain reported significantly greater severity of current pain (p < .001) and worst pain over the past week (p < .001) compared with EoE without persistent pain and healthy children. Compared with the other groups, children with EoE and persistent pain also demonstrated greater actigraphic sleep disturbances, lower sleep efficiency (p = .004) and greater wake after sleep onset (p = .034).

Conclusions

This study provides novel evidence that a significant proportion of children with EoE experience persistent symptoms of epigastric pain. Persistent pain was associated with significant sleep disturbances in children with EoE.

Pediatric Esophageal Disorders: Diagnosis and Treatment of Reflux and Eosinophilic Esophagitis

Gastroesophageal reflux (GER) occurs frequently in infants, generally at its worst at 4 months of age, with approximately two-thirds of infants spitting up daily. GER typically improves after 7 months of age, with only ∼5% of infants continuing to have reflux at 1 year of age. The diagnosis can often be made based on clinical symptoms. Upper GI (UGI) study has low sensitivity and specificity and should not be ordered as a diagnostic test for reflux. UGI study is best for evaluating other anatomic causes of vomiting. GER becomes problematic gastroesophageal reflux disease (GERD) when complications are present, including feeding difficulties and poor weight gain. Conservative treatment and thickened formula can be helpful for treating GERD. Proton pump inhibitors (PPIs) are frequently prescribed for treating reflux. However, studies do not show a definite benefit in infants, and there are potential side effects. Older children with GERD may present with regurgitation, heartburn, chest discomfort, dysphagia, abdominal pain, vomiting, poor appetite, or poor weight gain. Upper endoscopy is considered for children with concerning symptoms, persistent symptoms despite treatment, and relapse of symptoms after treatment. Other esophageal disorders can have a similar clinical presentation as GERD, notably eosinophilic esophagitis (EoE). EoE is a chronic immune-mediated disorder of the esophagus, which may present as dysphagia, food impaction, heartburn, vomiting, abdominal pain, feeding difficulties, or failure to thrive. Diagnosis is made histologically by the presence of esophageal eosinophilia on endoscopic biopsies in the correct clinical setting.

Childhood Esophagitis Changes in 30 Years at 1 Center

Eosinophils are nonspecific harbingers of esophageal disease. We report on the incidence and features of esophageal eosinophilia diagnosed at our center in 2011 and compare the findings with previously published results between 1980-1988 and 2000-2002. Eosinophils per high-power field were counted in esophageal biopsies from 675 patients who underwent 710 endoscopic procedures between January 1, 2011, and December 31, 2011. Of these, 209 (33%) patients were infiltrated with eosinophils; the other 466 (67%) showed no pathological changes. The highest concentrations of eosinophils were observed in the distal esophagus. Our findings also indicate that esophageal eosinophilia fluctuates over time.

Esophageal eosinophilia in pediatric patients with celiac disease: is it a causal or an incidental association?

OBJECTIVES

Celiac disease (CD) and eosinophilic esophagitis (EoE) are 2 distinct disease entities affecting the gastrointestinal tract of pediatric patients. Recently it has been suggested that EoE is more prevalent in patients with celiac disease than in the general population. We studied the association between these 2 disease entities in our pediatric patients.

METHODS

We reviewed our hospital files for suspected or confirmed cases of CD. Only cases with both duodenal and esophageal biopsies in pediatric patients were included. A total of 120 patients who met these criteria were included as the disease group. We also selected 100 patients with no clinical suspicion of CD and included them as a control group. Slides were reviewed using established criteria for diagnosis of both conditions. Duodenal biopsies were categorized as positive, negative, and suspicious for CD, whereas esophageal biopsies were classified as either positive or negative for esophageal eosinophilia (EE). Serologic and clinical data were additionally collected.

RESULTS

Sixty-two (62) cases were considered positive for CD in the disease group; among those 4 (6.5%) showed EE. In the control group, 91 cases were negative for CD, histologically, and 7 of those had EE (7.7%). Although 6 patients in the control group were histologically suspicious for CD, none of them had evidence of EE.

CONCLUSIONS

Our findings show that, in our patient population, patients with CD are not more likely to have EE than patients undergoing upper endoscopy for other reasons. Therefore, we suggest that the association between CD and EE is likely incidental and not causal.

Correlation between gastroesophageal reflux disease questionnaire and erosive esophagitis in school-aged children receiving endoscopy

BACKGROUND

The gastroesophageal reflux disease (GERD) questionnaire (GerdQ) is a validated questionnaire that was developed recently to help identify GERD patients. The sensitivity and specificity of GerdQ for the diagnosis of GERD in adult patients were 65% and 71%, respectively. Because the application of GerdQ in pediatric population is largely unknown, the aim of this study is to establish the endoscopic correlation between Chinese GerdQ and grades of erosive esophagitis (EE) in Taiwanese children.

METHODS

Seventy-four children (aged 9-18 years) were evaluated by our version of the Chinese GerdQ prior to receiving esophagogastroduodenoscopy for warning upper gastrointestinal symptoms. Grades of EE were assessed blindly, according to the Los Angeles classification. The sensitivity and specificity of GerdQ for detecting endoscopic EE were analyzed.

RESULTS

In 74 patients, the male to female ratio was 1:1.1 and the mean age was 14.2 ± 2.3 years (age range: 9.2-17.9 years). Thirty-nine percent of the enrolled patients had EE. The sensitivity and specificity of GerdQ (with a cutoff score of ≥7) to identify EE patients were 65.5% and 80%, respectively. The odds ratio of GerdQ for a cutoff score of 7 to identify EE was 7.6 (95% confidence interval = 2.6-21.9, p < 0.001).

CONCLUSION

For the identification of EE in children, the Chinese GerdQ had similar sensitivity and specificity to that used for adults. This questionnaire may be applied as a noninvasive screening tool.

Incidence and prevalence of eosinophilic esophagitis in children

OBJECTIVES

The aim of the present study was to conduct a systematic review with meta-analysis on the epidemiology of eosinophilic esophagitis (EoE) in children.

METHODS

Studies investigating incidence and prevalence of EoE in children (≤ 18 years) were identified in a systematic review of MEDLINE (1950-2011) and Embase (1980-2011). Meta-analyses were performed for incidence and subgroups with ≥ 5 studies: esophagogastroduodenoscopy (EGD) for any indication, histologic esophageal disease, and celiac disease, and EGD for abdominal pain. We used a random effects model, Q statistic to assess heterogeneity, and joinpoint analysis to assess time trends.

RESULTS

We included 25 studies. The incidence of EoE varied from 0.7 to 10/100,000 per person-year and the prevalence ranged from 0.2 to 43/100,000. The incidence and prevalence increased over time. Prevalence was highest in children with food impaction or dysphagia (63%-88%). The pooled prevalence was 3.7% (95% confidence interval [CI] 2.4-5.1) in EGD for any indication, 24% (95% CI 19-28) in histologic esophageal disease, 2.3% (95% CI 1.0-3.6) in celiac disease, and 2.6% (95% CI 1.2-4.1) in EGD for abdominal pain.

CONCLUSIONS

During the last 2 decades, the incidence and prevalence of EoE in children have increased significantly; however, the population-based incidence and prevalence of EoE vary widely across geographic variations, potentially because of variations in case of ascertainment between centers. Because EoE is common among children with food impaction and dysphagia, children with this presenting complaint should be rapidly identified at triage for timely endoscopic assessment.

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.

Esophagitis in children with celiac disease

Objectives. To our knowledge, the occurrence of esophagitis in children with celiac disease (CD) has never been evaluated. The aim of this study is to determine the prevalence of esophagitis in children with CD. Patients and Methods. Between 2003 and 2007, children with biopsy confirmed CD were retrospectively identified. Biopsy reports were reviewed for esophageal inflammation. Biopsy reports of 2218 endoscopies performed during the same period were also evaluated for inflammation. Results. Forty-nine children diagnosed with CD (47% boys). Nineteen of 49 (39%) patients with CD had esophagitis (95% CI 0.23–0.5). Thirty percent of boys and 46% of girls with CD had esophagitis (95% CI 0.12–0.40). Overall, 45% of patients who underwent upper endoscopy had esophagitis. The prevalence of esophagitis in CD (39%) compared to the prevalence of esophagitis (45%) in our practice was not significantly different, P = 0.2526. Conclusion. There was no difference in the prevalence of esophagitis between children diagnosed with CD at the time of their diagnostic EGD and the prevalence of esophagitis in children without CD. A prospective study to determine whether the esophagitis should be treated with acid suppression or whether the esophagitis heals with the gluten-free diet is warranted.

Toward uniformity in the diagnosis of eosinophilic esophagitis (EoE): the effect of guidelines on variability of diagnostic criteria for EoE

OBJECTIVES

Recent consensus guidelines for diagnosis of eosinophilic esophagitis (EoE) have been published. Whether these guidelines have standardized diagnostic criteria for EoE is unknown. We aimed to determine if the EoE guidelines had an impact on the diagnostic criteria reported in the EoE literature, and whether the previously observed variability in diagnostic criteria has become more uniform.

METHODS

Two investigators independently conducted a MEDLINE search from 1 January 2007 through 30 June 2010 for all publications reporting EoE in human subjects, and also searched the proceedings of the 2007-2010 American College of Gastroenterology and American Gastroenterological Association meetings, using a predefined search strategy. Data were extracted from all relevant publications.

RESULTS

Of the 799 publications identified, 149 original reports, 99 reviews, and 165 abstracts were included. In all, 32 original reports (21%) used diagnostic criteria consistent with each of the three components of the consensus guidelines. There was a significant increase when comparing original articles published after the release of the guidelines with those published earlier (31 vs. 6%, P<0.001). The proportion of original articles using 15 eosinophils per high-power field (eos/hpf) as a histological cut-point increased significantly (P=0.001). There was still substantial variability in biopsy protocols and eosinophil count methodology. The majority of original articles did not report microscope high-power field (HPF) area.

CONCLUSIONS

The proportion of original reports with diagnostic criteria consistent with the consensus guidelines has increased significantly. However, the majority of articles still did not conform to all three of the criteria in the guidelines, and biopsy and eosinophil count protocols continue to demonstrate significant variability. Standardization of biopsy and eosinophil count protocols is needed.