Eosinophilic Oesophagitis in children

Eosinophilic Oesophagitis (EoE) is a relatively new disease causing significant upper gastrointestinal morbidity in children. The diagnosis is based on symptoms of oesophageal dysfunction in association with presence of at least 15-eosinophil/high power field in oesophageal biopsy specimen and exclusion of other causes of oesophageal eosinophilia.

 

Incidence of EoE is approximately 1 new case per 10,000 per year and this is thought to be an underestimate. There has been a steady rise in the incidence over the last decade. A seventeen-fold rise in prevalence of biopsy proven EoE over a decade was demonstrated for children of Western Australia in 2006. This parallels with rise in allergies.

 

Children present with variable symptoms compared to adults where dysphagia is a universal presentation. Constellation of symptoms is age dependent. Younger children experience vomiting, regurgitation, water brash and decreased appetite. Infants and toddlers are more likely to present with difficulty feeding, manifest as gagging, choking, refusal of certain foods (mainly solids) and vomiting. Dysphagia and food bolus impaction is not commonly seen until adolescence. Children with EoE are usually slow eaters, avoid certain meats, cut meat in small pieces and consume a lot of water with their meals. There is higher rate of atopy (asthma, eczema, hay fever and allergies) in children with EoE when compared to children without EoE. Children with some other medical disorders are known to have increased risk to develop EoE such as tracheoesophageal fistula, Down syndrome, heart defects and connective tissue disorders.

 

Symptoms of EoE overlap with Gastroesophageal reflux disease (GERD). There can be significant delay in diagnosis, a study in adults documented delay of up to 6 years from onset of symptoms and this is more in children. Risk of complications (oesophageal stricture) increases with duration of untreated disease. Gastroscopy and biopsies remains the only test to confirm the diagnosis. Macroscopic appearance in younger children show inflammatory changes (loss of vascularity, linear furrowing and white exudate), where as older children and adolescents may demonstrate additional fibrotic features (Trachealization, crepe-paper oesophagus and strictures). There are a proportion of children who may have macroscopically normal oesophageal mucosa and diagnosis is made on histology.

 

Topical corticosteroids and dietary elimination is the mainstay of treatment for children with EoE. Six-food elimination diet has been superior to skin prick directed elimination diets in children and adults. New pharmacological modalities including biologic therapy are being explored as a result of improved understanding of pathophysiology.

 

Eosinophilic Oesophagitis has emerged as an important clinical entity due to rise in incidence and high index of suspicion helps with early diagnosis. Gastroscopy in required to confirm the diagnosis. Treatment is required to prevent

 

complications. Insight in the natural history and long-term outcome is emerging. Future research is being directed to better understand pathophysiology, assess efficiency of non-invasive diagnostic test and individualized approach to treatment.

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