KEYSTONE, COLO. – Parents often fail to acknowledge the earliest signs of a child’s eosinophilic esophagitis, such as vomiting, coughing, choking, or refusing certain foods, because the brevity of such manifestations make them seem relatively unimportant.
Due to the pathologic similarities it shares with gastroesophageal reflux disease (GERD), a more common malady, physicians may be just as likely to miss early signals of eosinophilic esophagitis – often waiting until the child begins to lose weight before making the proper call, warned Dr. F. Dan Atkins, medical director of the pediatric day program at National Jewish Health in Denver.
"Oftentimes we have to get to the point where the child is failing to thrive before we say that there is something really wrong here," he said at a meeting on allergy and respiratory diseases. "We tend to ascribe the majority of their symptoms to the more common GERD that we see."
Eosinophilic esophagitis and GERD are both characterized by abnormal eosinophil counts, and can manifest at the same time. In one scenario, peptic erosion in the esophagus may lead to increased allergen sensitivity and promote the onset of eosinophilic esophagitis. In other cases, stiffening of the esophagus can damage the lower esophageal sphincter and stimulate the onset of GERD in tandem with eosinophilic esophagitis.
"I kind of think about this just like that group we see in asthma," Dr. Atkins said at the meeting, which was sponsored by National Jewish Health. "There are some people who have vocal cord dysfunction and some people who have asthma, and then some who have a combination of both."
The study of eosinophilic esophagitis has accelerated in recent years. It is a T cell–mediated sickness in which eosinophils invade the esophagus, creating rigidity, along with ring structures, ridges, or furrows in the wall of the organ. Symptoms include eating-related pain in children and adults and dysphagia in adults. Due to its frequent misdiagnosis, the condition has often been treated improperly with proton-pump inhibitor (PPI) therapy. Signs of normal pH in the digestive tract and lack of response to PPI therapy are usually sufficient to rule out GERD (Gastroenterology 2007;133:1342-63). The physician can then biopsy multiple sites at the upper and lower esophagus for confirmation of 15 eosinophils per high-power field, indicating the presence of eosinophilic esophagitis, said Dr. Atkins, also of the department of pediatrics at the University of Colorado, Denver.
In a review that included 500 children over the past 4 years, Dr. Atkins and his associates identified 33 eosinophilic esophagitis patients in an attempt to quantify feeding dysfunctions. Over the course of a year’s observation, 88% of this group demonstrated sensitivity to food allergens and 94% exhibited a variety of maladaptive eating behaviors. Failure to thrive was evident in 21%. About 70% of the children ultimately required feeding therapy.
"When we looked at the learned maladaptive behaviors they had, a large number of them had selected out their diet. Usually what they’re doing is avoiding all foods that have significant texture. So they don’t eat meats, they don’t like breads, and they don’t like foods that distend their esophagus," he said.
Children can have signs of eosinophilic esophagitis at any age, including their first year. Evidence of the cytokine eotaxin-3 is especially notable because it is the protein particularly implicated in the recruitment of eosinophils to the esophagus. Physicians and parents should be alert to early vomiting and choking, as well as complaints of epigastric or chest pain, he advised.
The psychology associated with eating disorder therapy doesn’t make the management of eosinophilic esophagitis any easier. Continual shunning of a three-meal-per-day eating pattern changes the child’s attitude toward food in general. Those kids who do not manifest symptoms until several days after eating a favorite food to which they are sensitized will typically protest when told to stay away from it, and psychological feeding dysfunctions often continue even after inflammation has subsided.
Just as in asthma patients, eosinophilic esophagitis carries with it a risk of progression to esophageal fibrosis. "That’s what we’re trying to prevent, particularly in children," Dr. Atkins added. "We’d like to prevent the occurrence of these esophageal strictures over time."
Dr. Atkins is a consultant to Sunovion Pharmaceuticals and an investigator for AstraZeneca.