Eosinophilic esophagitis in children needing emergency endoscopy for foreign body and food bolus impaction

Esophageal food bolus impaction in children: A 15-year experience and a review

OBJECTIVES

We aimed to analyze the episodes of esophageal food bolus impaction (EFI) occurred over a time of 15 years in children admitted to a large pediatric emergency department (PED), documenting their clinical presentation, underlying pathology, management, biopsy rate, and follow-up visits. Additionally, to combine our institutional experience with the existing literature, a comprehensive review was conducted.

METHODS

We reviewed the medical records of all children presenting to our PED with EFI from 2010 to 2024. The comprehensive review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement for systematic reviews. Electronic databases including PubMed/Medline and EMBASE were screened. The data obtained was synthesized to map out the actual status and current literature on pediatric EFI.

RESULTS

We identified 54 cases of EFI. Overall, 22 patients (41%) had underlying pathology. Previous episodes were reported in 14 cases (26%). Urgent endoscopy was performed in 31 cases (57%). The presence of underlying pathology was associated with the need for endoscopic removal (p = 0.013), as well as the history of previous episodes (p = 0.016). Biopsies were performed in 14 cases (26%). Pediatric gastroenterologists showed a higher rate of performed biopsies compared to surgeons, as well as higher rate of follow-up visits. An underlying disease was found during later clinical follow-up in 5 out of 54 cases of EFI (9%). A comprehensive review of 16 studies revealed high rates of underlying pathology and low rates of biopsies and follow-up visits among children with EFI.

CONCLUSION

Increased vigilance in identifying underlying pathologies in children with EFI is crucial. The importance of performing biopsies, regardless of prior anatomical conditions, and the need for ongoing follow-up to ensure timely and accurate diagnoses should be addressed through shared protocols.

Esophageal food bolus impaction in pediatric age

OBJECTIVES

Esophageal food impaction (EFI) is the sudden onset of dysphagia that occurs when a food bolus becomes lodged in the esophagus, requiring endoscopic removal. Scientific data on the prevalence and causes of EFI in children is lacking. The aim of this study was to provide further insights into EFI episodes in children.

METHODS

We have prospectively enrolled all children admitted for a first episode of EFI between March 2018 and March 2023. A fluoroscopic contrast study was performed in all patients to confirm the boluses and assess their position. Boluses were extracted by esophagogastroduodenoscopies, and esophageal biopsies were routinely obtained for histologic evaluation.

RESULTS

Over the study period, 41 children were admitted for a first episode of food impaction. Drooling was the most commonly reported symptom. Half children experiencing a first episode of food bolus were diagnosed with EoE (20/41, 48.8%). Almost a fourth of the episodes subtended a different condition, such as esophageal anastomotic, peptic or congenital strictures, stricturing caustic esophagitis, esophageal duplication, and achalasia. In the last fourth of patients the cause of EFI was not identified and thus probably related to quick eating and inadequate chewing of food.

DISCUSSION

Our study represents the largest known series of pediatric patients evaluated for food bolus impaction. Our main finding is the high frequency of EoE, which accounts for a half of EFI episodes in pediatric age, especially in older children. This finding highlights the importance of obtaining esophageal biopsies after the endoscopic bolus removal in children with EFI to provide a complete diagnostic evaluation.

Incidence and evolution of foreign body impaction in the upper gastrointestinal tract and its relationship with eosionophilic oesophagitis

BACKGROUND

Foreign body impaction is a frequent indication of urgent endoscopy. One of the reasons for impaction is eosinophilic oesophagitis (EE). To analyse characteristics of oesophageal foreign body impactions and their relationship with eosinophilic oesophagitis.

METHODS

In this retrospective study, urgent endoscopies in a tertiary care centre were analysed. We included all urgent endoscopies due to bolus and foreign body impactions performed between September 1^st 2018 and September 1^st 2020. We reviewed clinical data of all patients who were diagnosed with EE and compared it to impactions that were due to other motives. The mean follow-up time was 18.7 months.

RESULTS

693 urgent endoscopy procedures were performed. 239 (34%) of these were due to foreign body ingestion. Mean age of the patients was 63 years old and 135 (63%) were men. EE was diagnosed in 36 (17%) patients. The factors associated with EE were age, to be younger than 50 years (OR, 7.3; 95% CI, 1.1-48.4; P=0.04), asthma/rhinitis/atopic dermatitis (OR, 8.9; 95% CI, 2.3-35.3; P= 0.002), findings in the endoscopy as trachealization (OR, 9.7; 95% CI, 1.3-70.9; P= 0.03) and psychotropic/ calcium channel blocker drugs (OR, 0.09; 95% CI, 0.009-0.9; P= 0.04). 15 (7%) patients died. In 6 of them death was impaction-related. None patients with EE died.

CONCLUSIONS

Foreign body impaction in the upper gastrointestinal tract due to EE is a frequent cause of urgent endoscopy. Being under 50 years of age, having asthma/rhinitis/atopic dermatitis, trachealization on the esophagus and not taking psychotropic/calcium channel blocker drugs are factors associated with the diagnosis of EE. Mortality in the follow-up of patients without EE is important.

Long-term Follow-up for Missed Cases of Eosinophilic Esophagitis in Children With Previous Foreign Body in the Esophagus

OBJECTIVES

A foreign body impacted in the esophagus could be a sign of eosinophilic esophagitis (EoE). Our aim was to investigate if children previously diagnosed with a foreign body in the esophagus had a missed diagnosis of EoE.

METHODS

In this population-based longitudinal study, all children (0-18 years) diagnosed with a foreign body in the esophagus in Stockholm, Sweden 2006 to 2016, were identified. In addition to a review of medical files, each family was contacted (n = 325) and asked standardized questions. Children with symptoms indicating EoE were offered esophagogastroduodenoscopy (EGD).

RESULTS

We found 325 pediatric cases of foreign body. Two hundred and seven (64%) underwent an endoscopy at the event, 3 of these had biopsies taken, whereby 2 were diagnosed with EoE. Six additional patients were diagnosed with EoE between the initial event and the study follow-up. Children with persisting symptoms suggestive of EoE at the follow-up (n = 21), were offered EGD whereof 7 accepted. Four new cases of EoE were found. Hence, 12 (3.7%) of the children with a previous foreign body, either spontaneously released or endoscopically removed, were diagnosed with EoE. In the structured interview, dysphagia, food impactions and drinking excessively with meals, as well as food allergies, were significantly more common in EoE patients.

CONCLUSIONS

Children with a foreign body in the esophagus are at risk of having EoE. Biopsies should be taken during foreign body removal and questions about swallowing problems and allergic diseases should be carefully explored also in children who do not need EGD because of spontaneous release.

Endoscopic management of foreign body ingestion in children

Introduction

Foreign body ingestion is common in children. Most accidental ingestions are passed spontaneously without intervention. Some cases of ingestion require intervention in a timely fashion to reduce risks and morbidities.

Aim

To analyse the clinical presentation, aetiology, and outcome of children presenting with foreign body ingestion, who required endoscopic intervention at a tertiary hospital (King Abdullah University Hospital, Irbid, Jordan).

Material and methods

Records of all patients with ingested foreign bodies requiring endoscopic retrieval over a 3-year period were reviewed retrospectively. Data on age, sex, type of ingested foreign body, presentation, type of intervention, stuck and retrieval location, outcome, and complications were collected.

Results

Of the sixty-three patients identified, 32 (50.8%) were male. Mean patient age was 7.7 ±3.4 years (range: 1 month-17.4 years). Most patients (74.6%) presented asymptomatically after the family or the child reported ingestion. Coins were the most commonly retrieved foreign bodies (37, 58.7%). The oesophagus was the most common site of retrieval (45, 71%). A rat tooth forceps was most commonly used to retrieve coins, followed by a net basket. Endoscopy was effective in managing the foreign body in 57 (90.5%) cases. Surgery was needed in 1 (1.6%) patient, a 1-month-old infant with a plastic tube in his stomach. All patients tolerated the procedure well with no complications. Interestingly, 7 (11.1%) male patients showed endoscopic features of eosinophilic oesophagitis; eosinophilic oesophagitis was confirmed histopathologically in three of them.

Conclusions

Endoscopic intervention is effective and well tolerated in the management of ingested foreign bodies in the upper gastrointestinal system. Parents and children should be cautioned against playing with coins, to reduce the incidence of foreign body ingestion.

Pediatric Eosinophilic Esophagitis Endotypes: Are We Closer to Predicting Treatment Response?

Eosinophilic esophagitis (EoE) is a chronic, food antigen-driven gastrointestinal disease that is characterized by esophageal eosinophilia. Currently, there are no Food and Drug Administration (FDA)-approved treatments for EoE, but the two most commonly prescribed therapies include topical corticosteroids and food elimination diets. Clinical trials have revealed a significant proportion of cases that are resistant to topical corticosteroids, and although we define EoE as a food antigen-driven disease, not all patients with EoE respond to elimination diets or even elemental diets. The varied response to treatments highlights the heterogeneity of EoE and the need for new treatment strategies. Despite the clinical differences in treatment response, predicting the outcome remains difficult since factors including age, histologic severity at diagnosis, atopic history, and anthropometrics are not predictive of treatment response. In our practice at an academic pediatric referral center, we observe distinct clinical EoE phenotypes, including cases with atopy, connective tissue disorders, or responsiveness to a proton pump inhibitor. Similar to the work in progress with asthma, stratification of patients with EoE by clinical phenotypes and/or molecular endotypes will likely assist with therapy selection and prediction of natural history. Molecular analysis with gene expression panels also shows promise in helping us classify patients based on molecular endotypes. In additional to the clinical and molecular classifications, more accurate histologic diagnostic criteria for EoE may help us tease out small differences between patient cohorts. Despite the leaps in knowledge over the past decade regarding EoE pathogenesis, it remains a challenge to predict the response to treatment. Future studies focused on molecular, genetic, and immunologic analyses of larger patient cohorts are needed to assist in identifying EoE phenotypes and endotypes as we attempt to improve patient outcomes in pediatric EoE.

The role of endoscopy in eosinophilic esophagitis: from diagnosis to therapy

Eosinophilic esophagitis (EoE) has arisen as a common disorder in current clinical and endoscopic gastroenterology practice. Areas covered: A comprehensive review of the literature to summarize and update different aspects related with the use of endoscopy in the diagnostic workout and treatment of pediatric and adult EoE patients is conducted. Expert commentary: Endoscopic features in EoE are frequently subtle, so were inadverted in some initial reports of the disease. Literature has described a wide number of EoE-associated features, systematized in the EREFS classification, which standardized the grade and severity of exudates, rings, edema, furrows, and strictures. The insufficient reliability of these features to predict eosinophilic inflammation still makes biopsies essential in diagnosing or monitoring EoE. EoE causes half of the food impactions requiring endoscopy; food impaction leads to EoE diagnosis in up to half of cases. Long term consequences of EoE include esophageal remodeling leading to strictures and narrowing, thus impairing symptoms and needs dilation. Recognizing the risks from dilation in EoE required carrying out a safe technique to avoid the high complication rate reported in the early literature. Endoscopic dilation should be considered in patients with esophageal narrowing and dysphagia/food impaction unresponsive to diet or drugs-based anti-inflammatory treatment.

Esophageal Food Impaction and Eosinophilic Esophagitis: A Retrospective Study, Systematic Review, and Meta-Analysis

BACKGROUND

Esophageal food impaction (EFI) can be the initial presentation of eosinophilic esophagitis (EoE). EoE is characterized by persistent esophageal eosinophilia (EE). Both EFI and EE are related to a variety of conditions. To date, the relationship between EFI, EE, and EoE remains unclear.

AIMS

To review our institutional experience with EFIs and combine our knowledge with the existing literature to conduct a systematic review and meta-analysis for delineating the relationship between EFI, EE, and EoE.

METHODS

We reviewed medical records of 72 children with EFI presenting to our emergency center between 2007 and 2013. PubMed, EMBASE, and Scopus databases were screened from inception until July 2014 to identify studies linking EFI and EoE. Included studies were methodically assessed for the quality and strength of association between EFI and EoE.

RESULTS

Our institutional experience highlighted the possibility of proton-pump inhibitor therapy-responsive EE (PPI-REE) as an underrecognized risk factor for EFI. A systematic review of 14 studies, including ours, revealed that most studies did not eliminate other causes of EFI or EE. The meta-analysis revealed that esophageal biopsies were obtained from 54% (40-68) of individuals presenting with EFI, and the overall EoE-attributable EFI among those who were biopsied was 54% (43-65). Substantial heterogeneity was noted among the studies.

DISCUSSION

PPI-REE is an underestimated risk factor for EFI. The quality of existing evidence linking EFI and EoE is limited by several important factors. Future studies with robust design are warranted to delineate the relationship between EFI, EE, and EoE.

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.

Eosinophilic esophagitis: historical perspective on an evolving disease

Initial case series describing children and adults with symptoms related to esophageal dysfunction and dense esophageal eosinophilia lead to recognition of a "new" disease, eosinophilic esophagitis (EoE). Clinical, basic, and translational studies have provided a deeper understanding of this somewhat enigmatic disease that mechanistically is defined as an antigen-driven condition limited to the esophagus. This article summarizes many of the key historical features of EoE and provides a glimpse of potential future developments.

Diagnostic and therapeutic challenges in pediatric eosinophilic esophagitis: past, present and future

In this paper, we will discuss the nuances of pediatric eosinophilic esophagitis based on symptoms, diagnostics and therapy. The diagnostics will include endoscopy, histology and anesthesia. Therapeutics will include the diet, drugs and 'distress'. Future directions in terms of clinical presentation and diagnostics will be discussed and important issues such as repeated exposure to anesthetic agents and effects of therapy on growth and psychological distress will be listed.

Epidemiology of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is an allergy-associated disease defined clinically by esophagus-related symptoms in combination with a dense esophageal eosinophilia, both of which are unresponsive to prolonged acid suppression with proton pump inhibitors. Over the last two decades EoE has increasingly been recognized in various geographical areas (mostly industrialized countries) with high socioeconomic development. The prevalence rate is increasing and reaches up to 50 patients per 100,000 inhabitants in some indicator regions. Whether this increased prevalence is due to a real increase in incidence, a result of increased awareness by health care providers or because of the nonfatal nature of EoE adding more and more cases to the patient pool is still a matter of controversy. Several studies have consistently demonstrated a male predominance in EoE, with a male-to-female risk ratio of 3:1. The average age at diagnosis ranges between 30 and 50 years and suggests that EoE is a disease of the middle-aged man. It can affect patients of every race, but the disease is more common among Caucasians. In both children and adults, EoE has been clearly associated with allergies to food and aeroallergens, and most EoE patients present with a personal allergic background (e.g. asthma, rhinoconjunctivitis or oral allergy syndrome). In conclusion, knowledge of epidemiologic parameters of EoE is crucial for identifying risk factors as well as pathogenic mechanisms, planning preventive measures and determining optimal treatment strategies.

Updates in pediatric gastrointestinal foreign bodies

Although most ingested foreign bodies in children pass spontaneously, certain foreign bodies can be harmful and they require special attention and emergent medical intervention to prevent significant morbidity and mortality. This article presents an overview of the epidemiology, diagnosis, management, and complications of foreign body ingestions in children. Particular attention is paid to coins, sharp objects, long objects, food bolus, caustic liquids, batteries, and magnets.