Skip to main content

Advertisement

SpringerLink
Log in

Eosinophilic Esophagitis in Children: Endoscopic Findings at Diagnosis and Post-intervention

  • Pediatric Gastroenterology (S Orenstein, Section Editor)
  • Published:
Current Gastroenterology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The goal of this review is to present and summarize studies on endoscopic findings in eosinophilic esophagitis (EoE), at diagnosis and in response to treatment, utilizing rigorous peer-reviewed literature in children wherever possible and to introduce a recently proposed standardized endoscopic evaluation system.

Recent Findings

Gold standard of diagnosis and assessment of response to therapy in EoE requires multiple endoscopies with biopsies for histology, which allows for observation of the esophageal mucosa. Typical endoscopic findings in patients with EoE include edema, exudate, furrowing, concentric rings, and strictures. Endoscopic findings have been broadly characterized into inflammatory features (edema, exudate, furrowing) and fibro-stenotic features (rings, stricture), in order to better reflect their underlying pathophysiology. Recent studies suggest strong correlations between endoscopic findings, through composite scoring systems, and histology, and therefore may be helpful as part of disease surveillance. The EoE Endoscopic Reference Score (EREFS) classification system was proposed in 2013 as an outcome metric for standardization in reporting endoscopic signs of EoE. Subsequent studies support utility of composite scoring, which utility has similarly been seen in pediatric treatment trials.

Summary

Endoscopy in children provides insight into the natural history of EoE, with progressively more fibro-stenotic features occurring over time, giving an additional perspective into esophageal remodeling and response to treatment. Recognition of typical endoscopic findings at diagnosis and upon repeat endoscopy has allowed a clinician to monitor visual changes in esophageal mucosal health. Further studies to assess the role of composite scoring in disease management are needed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: ••Of major importance

  1. Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011;128(1):3–20 e26; quiz 21-22. https://doi.org/10.1016/j.jaci.2011.02.040.

    Article  PubMed  Google Scholar 

  2. Cianferoni A, Spergel J. Eosinophilic esophagitis: a comprehensive review. Clin Rev Allergy Immunol. 2016;50(2):159–74. https://doi.org/10.1007/s12016-015-8501-z.

    Article  CAS  PubMed  Google Scholar 

  3. Liacouras CA, Spergel JM, Ruchelli E, Verma R, Mascarenhas M, Semeao E, et al. Eosinophilic esophagitis: a 10-year experience in 381 children. Clin Gastroenterol Hepatol. 2005;3(12):1198–206. https://doi.org/10.1016/S1542-3565(05)00885-2.

    Article  PubMed  Google Scholar 

  4. •• Kim HP, Vance RB, Shaheen NJ, Dellon ES. The prevalence and diagnostic utility of endoscopic features of eosinophilic esophagitis: a meta-analysis. Clin Gastroenterol Hepatol. 2012;10:988–996 e985. This meta-analysis is a thorough examination of the published literature regarding the utility of endoscopic findings in adults and children with EoE.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Furuta GT, Liacouras CA, Collins MH, Gupta SK, Justinich C, Putnam PE, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007;133(4):1342–63. https://doi.org/10.1053/j.gastro.2007.08.017.

    Article  CAS  PubMed  Google Scholar 

  6. Straumann A, Rossi L, Simon HU, Heer P, Spichtin HP, Beglinger C. Fragility of the esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis? Gastrointest Endosc. 2003;57(3):407–12. https://doi.org/10.1067/mge.2003.123.

    Article  PubMed  Google Scholar 

  7. Gupta SK, Fitzgerald JF, Chong SK, Croffie JM, Collins MH. Vertical lines in distal esophageal mucosa (VLEM): a true endoscopic manifestation of esophagitis in children? Gastrointest Endosc. 1997;45(6):485–9. https://doi.org/10.1016/S0016-5107(97)70178-0.

    Article  CAS  PubMed  Google Scholar 

  8. Lim JR, Gupta SK, Croffie JM, Pfefferkorn MD, Molleston JP, Corkins MR, et al. White specks in the esophageal mucosa: an endoscopic manifestation of non-reflux eosinophilic esophagitis in children. Gastrointest Endosc. 2004;59(7):835–8. https://doi.org/10.1016/S0016-5107(04)00364-5.

    Article  PubMed  Google Scholar 

  9. Dellon ES. Diagnostics of eosinophilic esophagitis: clinical, endoscopic, and histologic pitfalls. Dig Dis. 2014;32(1-2):48–53. https://doi.org/10.1159/000357009.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Landres RT, Kuster GG, Strum WB. Eosinophilic esophagitis in a patient with vigorous achalasia. Gastroenterology. 1978;74(6):1298–301.

    CAS  PubMed  Google Scholar 

  11. Picus D, Frank PH. Eosinophilic esophagitis. AJR Am J Roentgenol. 1981;136(5):1001–3. https://doi.org/10.2214/ajr.136.5.1001.

    Article  CAS  PubMed  Google Scholar 

  12. Fox VL, Nurko S, Furuta GT. Eosinophilic esophagitis: it’s not just kid’s stuff. Gastrointest Endosc. 2002;56(2):260–70. https://doi.org/10.1016/S0016-5107(02)70188-0.

    Article  PubMed  Google Scholar 

  13. Kaplan M, Mutlu EA, Jakate S, Bruninga K, Losurdo J, Losurdo J, et al. Endoscopy in eosinophilic esophagitis: “feline” esophagus and perforation risk. Clin Gastroenterol Hepatol. 2003;1(6):433–7. https://doi.org/10.1016/S1542-3565(03)00222-2.

    Article  PubMed  Google Scholar 

  14. Chen JW, Pandolfino JE, Lin Z, Ciolino JD, Gonsalves N, Kahrilas PJ, et al. Severity of endoscopically identified esophageal rings correlates with reduced esophageal distensibility in eosinophilic esophagitis. Endoscopy. 2016;48(9):794–801. https://doi.org/10.1055/s-0042-107340.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Kwiatek MA, Hirano I, Kahrilas PJ, Rothe J, Luger D, Pandolfino JE. Mechanical properties of the esophagus in eosinophilic esophagitis. Gastroenterology. 2011;140(1):82–90. https://doi.org/10.1053/j.gastro.2010.09.037.

    Article  PubMed  Google Scholar 

  16. Schoepfer AM, Safroneeva E, Bussmann C, Kuchen T, Portmann S, Simon HU, et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology. 2013;145:1230–6. e1231–1232

    Article  PubMed  Google Scholar 

  17. Dellon ES, Kim HP, Sperry SL, Rybnicek DA, Woosley JT, Shaheen NJ. A phenotypic analysis shows that eosinophilic esophagitis is a progressive fibrostenotic disease. Gastrointest Endosc. 2014;79(4):577–585 e574. https://doi.org/10.1016/j.gie.2013.10.027.

    Article  PubMed  Google Scholar 

  18. Menard-Katcher C, Benitez AJ, Pan Z, Ahmed FN, Wilkins BJ, Capocelli KE, et al. Influence of age and eosinophilic esophagitis on esophageal distensibility in a pediatric cohort. Am J Gastroenterol. 2017;112(9):1466–73. https://doi.org/10.1038/ajg.2017.131.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Dellon ES. Diagnosis and management of eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2012;10(10):1066–78. https://doi.org/10.1016/j.cgh.2012.06.003.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. •• Kagalwalla AF, Wechsler JB, Amsden K, Schwartz S, Makhija M, Olive A, Davis CM, et al. Efficacy of a 4-food elimination diet for children with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2017;15:1698–1707 e7. This prospective pediatric study describes the changes in endoscopic findings with diet elimination therapy.

  21. Pentiuk S, Putnam PE, Collins MH, Rothenberg ME. Dissociation between symptoms and histological severity in pediatric eosinophilic esophagitis. J Pediatr Gastroenterol Nutr. 2009;48(2):152–60. https://doi.org/10.1097/MPG.0b013e31817f0197.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Safroneeva E, Straumann A, Coslovsky M, Zwahlen M, Kuehni CE, Panczak R, et al. Symptoms have modest accuracy in detecting endoscopic and histologic remission in adults with eosinophilic esophagitis. Gastroenterology. 2016;150(3):581–590 e584. https://doi.org/10.1053/j.gastro.2015.11.004.

    Article  PubMed  Google Scholar 

  23. Prasad GA, Talley NJ, Romero Y, Arora AS, Kryzer LA, Smyrk TC, et al. Prevalence and predictive factors of eosinophilic esophagitis in patients presenting with dysphagia: a prospective study. Am J Gastroenterol. 2007;102(12):2627–32. https://doi.org/10.1111/j.1572-0241.2007.01512.x.

    Article  PubMed  Google Scholar 

  24. •• Dellon ES, Cotton CC, Gebhart JH, Higgins LL, Beitia R, Woosley JT, et al. Accuracy of the eosinophilic esophagitis endoscopic reference score in diagnosis and determining response to treatment. Clin Gastroenterol Hepatol. 2016;14:31–9. This prospective study in adults assess the utility of the EREFS scoring system in adults.

    Article  PubMed  Google Scholar 

  25. Aceves SS, Bastian JF, Newbury RO, Dohil R. Oral viscous budesonide: a potential new therapy for eosinophilic esophagitis in children. Am J Gastroenterol. 2007;102(10):2271–2279; quiz 2280. https://doi.org/10.1111/j.1572-0241.2007.01379.x.

    Article  CAS  PubMed  Google Scholar 

  26. Fable JM, Fernandez M, Goodine S, Lerer T, Sayej WN. Retrospective comparison of fluticasone propionate and oral viscous budesonide in children with eosinophilic esophagitis. J Pediatr Gastroenterol Nutr. 2018;66:26–32

  27. Hirano I, Moy N, Heckman MG, Thomas CS, Gonsalves N, Achem SR. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut. 2013;62(4):489–95. https://doi.org/10.1136/gutjnl-2011-301817.

    Article  PubMed  Google Scholar 

  28. Dellon ES, Aderoju A, Woosley JT, Sandler RS, Shaheen NJ. Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review. Am J Gastroenterol. 2007;102(10):2300–13. https://doi.org/10.1111/j.1572-0241.2007.01396.x.

    Article  PubMed  Google Scholar 

  29. van Rhijn BD, Warners MJ, Curvers WL, van Lent AU, Bekkali NL, Takkenberg RB, et al. Evaluating the endoscopic reference score for eosinophilic esophagitis: moderate to substantial intra- and interobserver reliability. Endoscopy. 2014;46(12):1049–55. https://doi.org/10.1055/s-0034-1377781.

    Article  PubMed  Google Scholar 

  30. Dellon ES, Katzka DA, Collins MH, Hamdani M, Gupta SK, Hirano I, et al. Budesonide oral suspension improves symptomatic, endoscopic, and histologic parameters compared with placebo in patients with eosinophilic esophagitis. Gastroenterology. 2017;152(4):776–786 e775. https://doi.org/10.1053/j.gastro.2016.11.021.

    Article  CAS  PubMed  Google Scholar 

  31. Wechsler JB, Bolton S, Amsden K, et al. Eosinophilic Esophagitis reference score accurately identifies disease activity and treatment effects in children. Clin gastroenterol hepatol 2017. https://doi.org/10.1016/j.cgh.2017.12.019.

Download references

Author information

Authors and Affiliations

  1. Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    S. M. Bolton, A. F. Kagalwalla & J. B. Wechsler

  2. Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA

    S. M. Bolton, A. F. Kagalwalla & J. B. Wechsler

  3. John H. Stroger Hospital of Cook County, Chicago, IL, USA

    A. F. Kagalwalla

Authors
  1. S. M. Bolton
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. F. Kagalwalla
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. J. B. Wechsler
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. B. Wechsler.

Ethics declarations

Conflict of Interest

Scott Bolton, Kagalwalla Amir, and Joshua Wechsler declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Pediatric Gastroenterology

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bolton, S.M., Kagalwalla, A.F. & Wechsler, J.B. Eosinophilic Esophagitis in Children: Endoscopic Findings at Diagnosis and Post-intervention. Curr Gastroenterol Rep 20, 4 (2018). https://doi.org/10.1007/s11894-018-0607-z

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11894-018-0607-z

Keywords

Search

Navigation