Patient Presentation
A 9-year-old male came to clinic to establish care. His family had recently moved to the area. Overall he was growing and developing well. His mother was concerned as he had a “sensitive stomach” and seemed to gag and have emesis more easily than she expected. It occurred intermittently usually when he had other illness symptoms but her sister had similar problems as a child and was recently diagnosed with eosinophilic esophagitis. When he was well, he denied any bad taste in mouth, heartburn symptoms, chest pain, abdominal pain and no diarrhea or irregular stools. He ate most foods of all textures and had no irregular eating patterns. He said that sometimes when he was upset or would cry he would throw up. His mother endorsed this and said this was what she had meant by “sensitive stomach.” She also said that he seemed to have a strong gag reflex and gave several examples of this, including that his previous dentist had noted it also. His previous doctor had thought that the emesis was more situational along with a strong gag reflex and was not more concerning. Additional evaluation had not been done.
The past medical history was negative. The family history was positive for the maternal aunt with eosinophilic esophagitis, asthma and allergies. A maternal uncle and mother also had seasonal allergies. The father had gastroesophageal reflux as a child. The review of systems was negative.
The pertinent physical exam showed a healthy appearing male with normal vital signs. Growth parameters were tracking along the 50-75%. HEENT had a sensitive gag reflex but did not provoke emesis. He had some mild dry skin. The rest of his examination was normal.
The diagnosis of a healthy male was made.
The child and parent were counseled about potential ways to avoid triggering the gag reflux. As the child did not seem to have dysphagia, abnormal eating patterns or other gastrointestinal problems the pediatrician noted that eosinophilic esophagitis was a very unlikely cause of the problem. “The eosinophilic esophagitis does occur including in people with more allergy problems and asthma, but he doesn’t have those problems so we can just monitor him for now,” she advised.
Discussion
Eosinophilic esophagitis (EOE) is a clinicopathologic condition of the esophagus where a pediatric or adult patient has clinical symptoms of esophageal dysfunction along with 15 or more eosinophils per high powered field in histological samples. The clinical diagnosis is difficult because many presenting symptoms are consistent with gastroesophageal reflux disease (GERD). Clinical features in children include feeding intolerance or refusal, abdominal pain, emesis or reflux symptoms. Other symptoms include chest pain, diarrhea or failure to thrive. Older children and adolescents may have food impaction or dysphagia similar to adults who report these as their most common symptoms. History may also include strategies to improve symptoms such as “washing the food down” with liquids, avoiding hard food such as meats or cutting the food into smaller pieces, and increasing food mastication to make it softer. Not surprisingly these behavioral changes result in longer meal times.
Endoscopic findings are not specific for EOE. They can include linear furrows, circular rings, stricture, loss of vascular patterns and other findings. Multiple biopsies are needed to make the diagnosis as the eosinophilic infiltration is not uniform. And other diseases can also have esophageal eosinophilia also making the diagnosis more difficult. These include “Crohn’s disease, collagen vascular disease, drug-induced esophagitis, hypereosinophilic syndrome, GERD, and eosinophilic gastroenteritis.” A mild peripheral eosinophilia is more common in children than adults and skin testing for some food allergens is sometimes considered as well.
The pathogenesis appears to be multifactorial and not well understood. “EOE has a strong association with atopy….” Many of these patients have aeroallergen sensitivity and fewer have true food allergy. EOE has an estimated prevalence of about 56-58 cases per 100,000 and is similar for children and adults. High rates are described in Europe and the US and fewer in Asia. There is also data supporting that the diagnosis is increasing since it was first described in 1977. It is more common in males than females.
Learning Point
Treatment for EOE can include PPIs (often used as a first-line treatment), swallowed topical corticosteroids (often using inhaled corticosteroids that are swallowed), and/or food elimination diets. Although true food allergy is less common, treating as if it is a food allergy or sensitivity improves many (but not all) patients’ symptoms. “Multiple studies show that milk tends to be the most common identified trigger in EoE, with wheat, egg, and soy/legumes being other frequent culprits.” In a 2006 study of an empiric 6 food elimination diet in children (milk, soy, egg, wheat, nuts, and seafood) with step-wise reintroduction found that esophageal inflammation was caused by 1 food in 72% of the children, 2 foods in another 8% of children, 3 foods in an additional 8% of children, and 11% tolerated reintroduction of all 6 foods. Newer immunomodulator treatments are also being used for some patients. Oral systemic steroids are also sometimes used but have their own potential side effects.
Longer term, some patients appear to “outgrow” the problem, or the problem is managed without long-term interventions. Some patients do require ongoing treatment along with other management such as esophageal dilation for those patients with significant strictures. Additional other disease (e.g. celiac disease, GERD) or anatomical problems (e.g. tracheoesophageal fistula) may require additional treatment considerations.
Questions for Further Discussion
1. How is GERD diagnosed and treated?
2. What causes abdominal pain?
For recurrent abdominal pain a review can be found here, and
for acute abdominal pain can be found here.
3. What causes failure to thrive?
A review can be found here.
Related Cases
- Disease: Eosinophilic Esophagitis | Esophagus Disorders
- Symptom/Presentation: Abdominal Pain | Vomiting
- Specialty: Gastroenterology | Pathology
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Eosinophilic Esophagitis
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Lehman HK, Lam W. Eosinophilic Esophagitis. Pediatr Clin N Am 66 (2019) 955-965. ClinicalKey. Accessed February 19, 2024. https://www-clinicalkey-com.proxy.lib.uiowa.edu/#!/content/journal/1-s2.0-S088985612100062X
Lehman HK, Lam W. Eosinophilic Esophagitis. Immunol Allegy Clin N Am 41 (2021) 587-598. Accessed February 19, 2024. https://www-clinicalkey-com.proxy.lib.uiowa.edu/#!/content/journal/1-s2.0-S0031395519300835
Hirano K, Furuta GT. Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis . Gastroenterology 158 (2020) 840-851. Accessed February 19, 2024. https://www-clinicalkey-com.proxy.lib.uiowa.edu/#!/content/journal/1-s2.0-S001650851941
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 