Eosinophilic Esophagitis in Children: Clinical Findings and Diagnostic Approach

Abstract

: Eosinophilic esophagitis (EoE) is an emerging chronic immune and antigen-mediated clinicopathologic disease. During the last 2 decades, the incidence of this condition in children have increased significantly, thanks to more awareness of practitioners and higher use of diagnostic endoscopy. We have analysed paediatric literature on EoE focusing on epidemiology, pathophysiology, clinical findings and diagnostic approach. EoE is pathogenically related to a Th2 inflammation characterized by a mixed IgE and non IgE-mediated reaction to food and/or environmental agents. This leads to esophageal dysfunction and remodeling accompanied by subepithelial fibrosis. EoE presents with a diverse range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or feeding refusal in infants and toddlers, as well as heartburn, dysphagia and food bolus impaction in older children and adults. The diagnostic suspicion is based on the presence of chronic symptoms of esophgeal disfunction and esophageal eosinophilia characterised histologically by a significant eosinophilic infiltration of the oesophageal mucosa (>15 eosinophils per high powered field). In this review we will provide an update on clinical presentation and diagnostic approach to EoE in children. We emphasized the relevant aspects of the new clinical condition termed “PPI responsive esophageal eosinophilia”, as entities distinct from EoE and the role of PPI trial in diagnostic workup, therefore we proposed a new diagnostic algorithm.

The incidence of eosinophilic oesophagitis in 2007–2017 among children in North Denmark Region is lower than expected

“…This suggests that many children with EoE aged 0–2 years are not found in NDR despite suffering from the disease [ 3 , 15 ]. Regarding complications, food impaction was overrepresented in our study population compared to the literature [ 4 ]. This suggests that the children were diagnosed late, since food impaction is a late-stage manifestation of EoE [ 17 ].…”

“…Adults with EoE most often present with dysphagia and food impaction, whereas clinical manifestations among children are less specific and vary with age. Infants and toddlers may suffer from food refusal and failure to thrive, school-aged children from vomiting or pain located to the abdomen, chest, or throat and adolescents may display food avoidance and clinical manifestations may resemble that of adults [ 3 , 4 ]. EoE symptoms in children thus differ from that of adults, which challenges the diagnostic process in children.…”

Esophageal Dysphagia in Children: State of the Art and Proposal for a Symptom-Based Diagnostic Approach

“…While FBI mostly concerns infants and toddlers with no underlying esophageal disfunction, food impaction is the most common cause of acute EO in older children and teenagers. The latter is usually the presenting symptom of an esophageal disorder, among which EoE is the most frequent (6,26). Less frequent causes consist of peptic-, caustic-or radiation-induced strictures, Schatzki's rings, esophageal diverticula, achalasia, and postsurgical complications (15).…”

Increase of foreign body and harmful substance ingestion and associated complications in children: a retrospective study of 1199 cases from 2005 to 2017

“…Caustic agent ingestion is associated with high morbidity depending on the extend of injury at initial endoscopic evaluation [3,8]. Food bolus impaction in children and adolescents may be a clinical feature of an underlying eosinophilic oesophagitis and not only needs a therapeutic but also a diagnostic endoscopy [20]. Depending on the objects and agents a variety of complications is associated ranging from mucosal abrasions, lacerations, perforations, mediastinitis, peritonitis, strictures to death [2,21,22].…”