Eosinophilic Esophagitis (EoE)
EoE is the most well-known member of a family of allergic enteropathies characterized by infiltration of the GI tract with eosinophils. Related conditions are
The incidence and prevalence of EOE is increasing, although figures are difficult to ascertain because of changes in diagnostic criteria and in awareness.
- Most estimates in the United States range from 40 to 90 cases per 100,000 persons.
- The prevalence of EoE in children with dysphagia and food impaction is high (63-88%). Children with this presentation should be considered for timely endoscopic assessment.
- EoE occurs in approximately 4% of children with celiac disease.
More than 50% of patients with eosinophilic allergic enteropathies have a personal history of allergy, such as eczema, asthma, allergic rhinitis, or multiple food sensitivities.
Symptoms may include:
- Food aversion or refusal
- Failure to progress with food introduction
- Food impaction
- Growth failure
- Chest or abdominal pain
Infants with symptoms of esophageal dysfunction should be considered for esophagogastroduodenoscopy (EGD).
- Where EoE is a clinical possibility (even when normal mucosa is visualized), esophageal biopsy specimens should be obtained.[ref]
Criteria for the diagnosis of EoE:
- Symptoms of esophageal dysfunction
- Co-occurring atopic conditions should increase suspicion for EoE
- Endoscopic findings of rings, furrows, exudates, edema, stricture, narrowing and crepe-paper mucosa should increase suspicion for EoE
- Eosinophils ≥15/hpf (~60/mm2) on esophageal biopsy
- Eosinophilic infiltration should be isolated to the esophagus
- Assessment of non-EoE disorders that cause or potentially contribute to esophageal eosinophilia
Note: The presence of eosinophils at ≥15/hpf is not diagnostic of EoE. For a diagnosis of EoE, patients cannot have another cause of eosinophil infiltration.
A diagnosis of EoE is complicated by its relationship with GERD. EoE and GERD are not necessarily mutually exclusive.
- EoE can lead to secondary reflux because of dysmotility
- GERD can lead to decreased epithelial integrity allowing eosinophilia
Due to the interrelatedness of EoE and GERD, and because no single test can exclude the presence of GERD, a trial of PPI is no longer part of the diagnostic criteria for EoE.
Dietary restriction using elemental formula is the most effective treatment for EoE. However, the utility of elemental diets for infants and toddlers is low because:
- infants often require feeding via a nasogastric tube to ensure nutritional adequacy.
- long-term avoidance of solid food in children under 2 years old or with known feeding dysfunction may lead to delayed oral-motor skill development
- re-introducing foods is a lengthy process, requiring multiple endoscopies with biopsies and several months of continued nutritional support while a normal diet is gradually instituted
- the high cost of elemental formula may not be covered by insurance
Because an elemental diet is difficult to implement and sustain and may have developmental side-effects in infants, proton pump inhibitors (PPI), elimination diets, or topical steroids may be considered.
Long-standing untreated EoE often leads to esophageal strictures.
- Children typically do not have strictures because of a lack of disease progression. They tend to have esophageal narrowing which often responds to anti-inflammatory treatment.
An infant or child with EoE should be referred to the nearest EoE center.