This chronic immune-mediated disorder is characterized byinfiltration of eosinophils into mucosa of the esophagus. It isthought to be triggered by non–IgE-mediated allergic reactions toingested foods or aeroallergens. EoE may have a familial connection; no specific gene has yet been identified. Incidence appears to be increasing with estimated prevalence of more than 4 per10,000 children. It may be more common in males than females.
The presentation of EoE often varies with age. In young children, it may present with oral aversion, vomiting, and failure to thrive. In school-age children, it may present with vague abdominal pain or vomiting. In adolescents and adults, it presents with dysphagia and food impactions. These symptoms are attributed to the inflammatory response in the esophagus leading to edema and poor esophageal motility.
Diagnosis requires multilevel esophageal biopsies via flexible endoscopy with the finding of more than 15 eosinophils per high-power field (Fig. 128-1). Treatment with high-dose proton pump inhibitor therapy is recommended to exclude the possibility that findings are secondary to severe acidic esophageal injury. Gross findings at endoscopy include normal appearance, esophageal furrowing, trachealization, and eosinophilic abscesses (Fig. 128-2). A barium study may reveal
Table 128-1 Treatment of Gastroesophageal Reflux THERAPIES COMMENTS CONSERVATIVE THERAPIES Towel on caregiver’s shoulder Cheap, effective. Useful only for physiologic reflux
Thickened feedings Reduces number of episodes, enhances nutrition
Smaller, more frequent feedings Can help some. Be careful not to underfeed child
Avoidance of tobacco smoke and alcohol Always a good idea. May help reflux symptoms
Abstaining from caffeine Inexpensive, offers some benefit
Positional therapy—upright in seat, elevate Prone positioning with head of crib or bed up is helpful, but not for young infants because of risk of SIDS
Weight loss when indicated Increased weight (especially abdominal) increases intra-abdominal pressure, leading to reflux
H2 receptor antagonist Reduces heartburn, less effective for healing esophagitis
Metoclopramide Enhances stomach emptying and LES tone. Real benefit is often minimal
Feeding jejunostomy Useful in child requiring tube feeds. Delivering feeds downstream eliminates GERD
GERD, Gastroesophageal reflux disease; LES, lower esophageal sphincter; SIDS, sudden infant death syndrome.
Figure 128-1 Histologic image of eosinophilic esophagitis. Note the large number of eosinophils within the lamina propria.
a food impaction in an acutely symptomatic patient or esophageal stricture in someone with chronic disease.
Exposure to identified causative antigens needs to be eliminated. Identification can be difficult, as typical allergy testing (skin prick, RAST, and immunocap assays) only identifies IgE-mediated antigens. Atopic patch testing may be more reliable but is not standardized and can be difficult to perform. One approach is to eliminate cow’s milk, soy, wheat, eggs, peanuts, and fish/shellfish from the diet, as these are the most
Figure 128-2 Endoscopic picture of eosinophilic esophagi-tis. White plaques on the surface are collections of eosinophils (eosinophilic abscesses). Linear furrowing is also seen.
common causative dietary antigens. Repeat endoscopies are often necessary to document efficacy of these eliminations. An elemental diet can also be used and is very effective, but often requires either nasogastric or gastrotomy administration because of its poor palatability.