Original article
Intervention
Conservative long-term treatment of children with eosinophilic esophagitis

https://doi.org/10.1016/j.anai.2012.02.024Get rights and content

Abstract

Background

Current treatments of eosinophilic esophagitis (EoE), including restrictive diets or glucocorticoids, provide only transient improvement. Proton pump inhibitor (PPI) use in EoE does not lead to histologic improvement; however, the long-term use of PPI on symptoms and prevention of complications has not been evaluated.

Objective

To evaluate the use of PPI as maintenance therapy in children with EoE.

Methods

Eosinophilic esophagitis was diagnosed based on initial endoscopic biopsies and persistent eosinophilic inflammation despite PPI therapy. Inclusion criteria included diagnosis of EoE and PPI use as primary maintenance treatment. Patients were excluded if they were treated with dietary or glucocorticoid therapy. Histologic evidence of inflammation as well as degree of subepithelial fibrosis at presentation was compared with most recent biopsies while receiving PPI therapy.

Results

Thirty-eight patients (30 males and 8 females; average age 6.7 ± 5.4 years) fulfilled inclusion criteria. Duration of follow-up was 3.0 ± 2.4 years. At presentation, vomiting was significantly more frequent in the younger patients, whereas dysphagia occurred more frequently in the older patients. At follow-up, 26 patients were asymptomatic, and the remaining 12 patients' symptoms were significantly improved. No complications of stricture or food impaction were seen. Significant eosinophilic inflammation persisted in 28 patients. No difference in degree of subepithelial fibrosis at diagnosis compared with most recent biopsies. The z-scores of the treated EoE patients significantly improved.

Conclusion

Patients with EoE treated with PPIs show an improvement in symptoms and z-scores despite persistent eosinophilic inflammation. PPI treatment may be useful maintenance therapy in children with EoE.

Introduction

Eosinophilic esophagitis (EoE) is an increasingly recognized disorder characterized by eosinophilic inflammation and clinical symptoms of esophageal disease. Children may present with a spectrum of symptoms, including frequent regurgitation, vomiting, abdominal pain, heartburn, dysphagia, chest pain, food intolerance, and food impaction.[1], [2], [3]

Eosinophilic esophagitis has distinctive endoscopic and histologic features. On gross inspection by endoscopy, common findings characteristic of EoE are rings with strictures, linear furrowing, erythema, edema, corrugation, nodularity, and plaques that consist of eosinophilic microabscesses.4 A subset of patients may have an unremarkable endoscopy with normal-appearing mucosa but demonstrate histologic features of EoE on biopsy.5 The gold standard for the diagnosis of EoE is endoscopy, with biopsy specimens of the esophagus demonstrating infiltration of the esophagus with eosinophils. Biopsy findings of an increased number of eosinophils per high-power field (HPF) are characteristic of EoE, with a cutoff of >15 eosinophils/HPF most commonly used.6 For the diagnosis of EoE, these findings are present in the absence of pathologic gastroesophageal reflux as evidenced by a normal pH monitoring study of the distal esophagus or a lack of response to proton-pump inhibitors (PPI).

Current medical therapies for EoE include topical or systemic corticosteroids,[7], [8], [9], [10] mast cell inhibitors, leukotriene receptor antagonists, and immune modulators.[11], [12] Dietary or environmental exposures often contribute to EoE. Patients are often referred for food allergy testing and placed on restrictive or elemental diets.[13], [14] Each of these treatments has its limitations and side effects. Furthermore, despite a temporary improvement in symptoms and histology, patients often rebound in symptoms and pathologic findings on endoscopy upon discontinuation of treatment.

The natural history of untreated EoE in the pediatric population is not entirely established. Untreated EoE is thought to lead to esophageal remodeling, progressing to esophageal dysmotility, strictures, scarring, and food impaction. The effect of treatment of EoE has been studied only in the context of short-term outcome. This natural progression of EoE has not been fully demonstrated in the pediatric population.

The use of PPIs does not lead to histologic improvement in patients with EoE.15 However, symptomatic improvement has been noted in children on PPI therapy. The aim of our study was to evaluate the use of long-term PPI treatment as maintenance therapy in children with EoE.

Section snippets

Methods

A historical pre–posttreatment study design was performed based on a chart review of patients who were diagnosed with EoE at Cohen Children's Medical Center from January 1995 to December 2009. Patients who had at least 2 endoscopies with a histologic diagnosis of EoE were included in the study. Inclusion criteria included diagnosis of EoE based on symptoms and initial endoscopic biopsy specimens demonstrating greater than 15 eosinophils/HPF. In addition, all patients had persistent eosinophilic

Results

Forty-seven patients met inclusion criteria for EoE (average age, 6.4 ± 5.3 years; 38 males). Of the 47 patients, 6 had been placed on dietary restrictions, and 3 had received corticosteroids. The remaining 38 patients were included in the study. Of the 38 patients studied, the average age at presentation was 6.7 ± 5.4 years (median, 5.1 years), with 30 males and 8 females.

All patients had 2 or more endoscopies. The average number of endoscopies performed was 3.7. The interval between

Discussion

This study describes 38 pediatric patients diagnosed with EoE and treated conservatively with PPI monotherapy. In our group of children with EoE treated with PPIs, we noted an improvement in symptoms over time, although often without histologic resolution of esophageal eosinophilia. Among the long-term side effects of EoE is esophageal strictures; this is thought to be attributable to increased collagen deposition with subepithelial fibrosis. In our patients, we did not find any increase in

References (23)

  • S.P. Pentiuk et al.

    Eosinophilic esophagitis in infants and toddlers

    Dysphagia

    (2007)
  • Cited by (25)

    • Non-IgE mediated food hypersensitivity

      2016, Revue Francaise d'Allergologie
    • Interactions between gastro-oesophageal reflux disease and eosinophilic oesophagitis

      2015, Best Practice and Research: Clinical Gastroenterology
    • Eosinophilic Esophagitis: An Autoimmune Esophageal Disorder

      2014, Current Problems in Pediatric and Adolescent Health Care
      Citation Excerpt :

      Additionally, a long-term side effect of EoE is the formation of strictures. Levine et al.32 found no increase in fibrosis while on PPI therapy, despite persistent eosinophilic inflammation. Corticosteroids improve the clinicopathologic features of EoE in most patients; however, when discontinued, the disease almost always recurs.33

    View all citing articles on Scopus

    Disclosures: Authors have nothing to disclose.

    View full text