Original articleInterventionConservative long-term treatment of children with eosinophilic esophagitis
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.
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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
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2014, Current Problems in Pediatric and Adolescent Health CareCitation 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
Disclosures: Authors have nothing to disclose.