A Review of Tertiary Referrals for Management of Pediatric Esophageal Eosinophilia

Abstract

Background: Eosinophilic esophagitis is a chronic, immune-mediated disease characterized by symptoms of esophageal dysfunction and ≥15 eosinophils/high-powered field (eos/hpf). Proton pump inhibitor responsive esophageal eosinophilia (1) is an entity of esophageal eosinophilia that responds to PPI therapy and is thought to be clinically and histologically similar to EoE. Current guidelines suggest therapy with PPI prior to endoscopy and use of PPI as first line for esophageal eosinophilia. In order to gain a better understanding of community practice patterns and to try differentiate between these two entities, we sought to evaluate the clinical presentations, treatment and final diagnoses of patients presenting to our institution for second opinions of esophageal eosinophilia.Methods: A search of our electronic medical record yielded a list of patients presenting for a second opinion of esophageal eosinophilia. Charts were reviewed for clinical information.Results: A total of 187 charts were included. Patients ranged from 1-19 years old with 75% being male and 74% being Caucasian. Of the patients who had documentation of their medications at the time of initial endoscopy, 70% were not on any PPI prior to their endoscopy, and 94% were on <2 mg/kg/day. Of the 19 patients who had full response to PPI therapy and were diagnosed with PPI-REE, close to half had previously been treated with diet, steroids, or both. Patients with final diagnosis of EoE had significantly higher eos/hpf on initial endoscopy compared to those with diagnosis of PPI-REE (51.9 ± 30.6 v. 35.8 ± 16.4. p = 0.027), as well as higher likelihood of having IgE-mediated food allergy (79 v. 47%, p = 0.003).Conclusions: Diagnostic and therapeutic algorithms are needed for esophageal eosinophilia to prevent misdiagnosis and unnecessary procedures and therapies.

Eosinophilic Esophagitis as a Side Effect of Food Oral Immunotherapy

“…There are three main clinically accepted clinical treatment strategies for EoE: proton pump inhibitors (PPIs), corticosteroid treatment, and dietary elimination. Mechanical dilation is an option in patients with irreversible fibrosis [ 57 ].…”

Food allergy and eosinophilic gastrointestinal disorders

“…In our center, 37% of children with a diagnosis of EoE and unresponsive to therapy with diet or steroids had a complete or near-complete response when treated with a PPI. 9 This demonstrates that PPIs are not always interchangeable with other treatments for EoE and sometimes are only treating GERD.…”

<p>Eosinophilic esophagitis: early diagnosis is the key</p>

“…Given safety profile PPI are chosen often as first-line therapy. In case of failure, diet therapy or steroids can be initiated 10,11. Overall, the advantages of the diet treatment compared to swallowed steroid are to achieve the remission of the disease without using drugs.…”