Pediatric eosinophilic esophagitis: a review for the clinician

Eosinophilic esophagitis (EoE) is a chronic clinical-pathologic disease characterized by eosinophilic infiltration of the esophageal epithelium with esophageal dysfunction symptoms.EoE can occur at any age and has different clinical manifestations depending on the age onset.To date, esophago-gastroduodenal endoscopy (EGD) with biopsy is the gold-standard for EoE diagnosis.According to the recent consensus guidelines, proton pump inhibitors, corticosteroids and elimination diets could be a first-line therapy option. The aim of the treatment is clinical and histological remission for preventing long-lasting untreatable fibrosis.A multidisciplinary approach (allergist, gastroenterology, dietitian, and pathologist) is recommended for managing patients affected by EoE, given the complexity of its treatment.This review will provide a practical guide to assist pediatricians treating children with EoE.Moreover, it highlights the unmet needs in diagnosis and treatment that require urgent attention from the scientific community in the aim of improving the management of patients with EoE.

173 CATERPILLAR SIGN: NOVEL ENDOSCOPIC FINDING IN PATIENTS WITH EOSINOPHILIC ESOPHAGITIS

Pathological identification of esophageal eosinophilia (EE) is considered to be most important and critical step for diagnosis of eosinophilic esophagitis (EoE). Although several endoscopic findings related with EoE have been reported, it is still difficult to exclude other causes of EE, such as gastroesophageal reflux disease. Here, we noted a novel endoscopic finding related with EoE termed ‘Caterpillar sign’. The aim of this study was to evaluate its clinical significance for the diagnosis of EoE. Methods One hundred and seventy-four patients who were endoscopically suspected with EoE at our hospital and affiliated institutions were enrolled. EoE was defined clinically by symptoms of esophageal dysfunction and histologically by the presence of EE [≧15 eosinophils/high power field (HPF)]. Endoscopic findings at baseline were retrospectively reviewed. ‘Caterpillar sign’ was defined as a stair-like, fragile, slight mucosal protruded lesion sandwiched between longitudinal furrows, such as the Caterpillar traces remaining on the ground (Figure). Furthermore, the clinicopathological features of patients having ‘Caterpillar sign’ were evaluated. Results One hundred and seventy-four patients (92 males, 82 females with mean age of 49.7) suspected with EoE were evaluated, of whom 60 (34.5%) was finally diagnosed as EoE. ‘Caterpillar sign’ was found in 48 patients (80.0%). Sensitivity and Specificity of ‘Caterpillar sign’ for the diagnosis of EoE was 0.80 (95% confidence interval [CI] 0.72–0.85) and 0.94 (95% CI 0.90–0.97), respectively. Furthermore, the presence of ‘Caterpillar sign’ was associated with degree of eosinophil infiltration (Caterpillar sign positive: 42.9 ± 49.3/HPF vs. Caterpillar sign negative: 6.7 ± 24.4/HPF, p < 0.0001). Conclusion This novel finding termed ‘Caterpillar sign’ was clinically useful for the definitive diagnosis of EoE and associated with degree of eosinophil infiltration.

The Impact of Medications on Esophageal Motility

The purpose of this review is to highlight the impact of common medications on esophageal motility. Esophageal motility is mediated through a complex network of neural innervation. Opioids lead to excitatory esophageal motor abnormalities termed opioid-induced esophageal dysfunction or OIED. Prokinetics have mixed effects on esophageal motility. Nitrates and calcium channel blockers relax esophageal smooth muscle, but they are limited clinically due to side effects. Sildenafil also relaxes smooth muscle, but it is costly. Peppermint oil may reduce distal esophageal spasm. Anticholinergics, selective serotonin reuptake inhibitors, estrogen, and cannabis need further study to evaluate their effects on esophageal motility.

Eosinophilic Vulvar Leukoderma

We report the case of a 54-year-old woman with asthma and atopic dermatitis who presented a white spot on the genitalia. Histologic examination showed numerous eosinophils in the epithelium and the dermis. Eosinophilic esophagitis is defined as an esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by an eosinophil-predominant inflammation. We discuss the possible relationship between the two diseases.

Eosinophilic esophagitis: A potential complication of sublingual immunotherapy

Introduction. Eosinophilic esophagitis (EoE) represents chronic, a local immune-mediated disease with symptoms of esophageal dysfunction and histologically eosinophil-predominant inflammation and requires immediate endoscopy. Male gender is a strong risk factor. Case report. We presented a case of a 25-year-old young man with a history of allergic rhino-conjunctivitis, asthma, and intermittent severe feeding disturbance. The patient had begun sublingual immunotherapy therapy, containing specific soluble allergens for ambrosia. Six weeks after starting the ambrosia sublingual immunotherapy he developed burning epigastric pain, dysphagia, and odynophagia. Six days later, he was admitted to an emergency department due to choking on a solid of food. Esophageal histopathological findings were in favor of EoE. Sublingual immunotherapy was discontinued. He feels well now. Conclusion. The majority of cases of Eosinophilic esophagitis are diagnosed in spring or fall, 1-2 months following the peak of pollen season. Dysphagia, chest pain, food sticking, and bolus obstruction are the most common symptoms. Endoscopic findings are Schatzki ring, edema, exudates, furrows, and strictures. Six biopsies should be taken from areas with endoscopic mucosal abnormalities, and infiltration of eosinophils (more than 15 eosinophils/HRI) (HRI - high resolution imaging) is necessary for the diagnosis confirmation. Treatment options are proton pump inhibitors - oral dispersible tablets of budesonide or fluticasone propionate, an elimination diet. Sublingual immunotherapy should be discontinued. Family physicians should be aware of this complication in evaluating patients with dysphagia.

Eosinophilic esophagitis: clinical, endoscopic, histologic and therapeutic differences and similarities between children and adults

In the absence of secondary causes, eosinophilic esophagitis (EoE) is a chronic, local, progressive, T-helper type 2 immune-mediated disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. In the last 20 years, the incidence and prevalence of EoE have risen sharply, and the chances of encountering affected patients in clinics and endoscopy rooms have increased. Nevertheless, it is estimated that the mean diagnostic delay of EoE is 4–6 years in both children and adults. Unfortunately, the longer the disease stays unrecognized, the likelier it is for the patient to have persistent or increased esophageal eosinophilic inflammation, to complain of non-resolving symptoms, and to develop fibrotic complications. Early detection depends on the recognition of initial clinical manifestations that vary from childhood to adulthood and even among patients of the same age. The disease phenotype also influences therapeutic approaches that include drugs, dietary interventions, and esophageal dilation. We have herein reviewed epidemiologic, clinical, endoscopic, and histologic features and therapeutic options of EoE focusing on differences and similarities between children and adults that may certainly serve in daily clinical practice.