Purpose of the Study
To describe a group of children with gastroesophageal reflux disease (GERD) and persistent esophageal eosinophilia despite traditional antireflux therapy.
From a total of 1809 children evaluated prospectively over a 2.5-year period for symptoms of GERD, 20 were identified with persistent symptoms and esophageal eosinophilia despite aggressive therapy with omeprazole and cisapride.
The 20 children were treated with 1.5 mg/kg/d of oral methylprednisolone for 4 weeks. All patients underwent an extensive evaluation before treatment, including questionnaires about symptoms, blood counts, serum chemistries, immunoglobulin E (IgE) level, pH probe, and endoscopy. After treatment the questionnaires and endoscopy with biopsies of the esophagus, stomach, and duodenum were repeated.
Histologic findings in pretreatment esophageal biopsies in the 20 children diagnosed with primary eosinophilic esophagitis revealed significantly greater eosinophilia (34.2 ± 9.6 eosinophils per high power field [HPF]) compared with biopsies from children with GERD who responded to medical therapy (2.26 ± 1.16 eosinophils per HPF, P < .001). After corticosteroid therapy, 19 of 20 children with primary eosinophilic esophagitis had dramatic clinical and histological improvement (1.5 ± 0.9 eosinophils per HPF). After 12 months of follow-up, 10 patients had remained asymptomatic and 9 redeveloped symptoms. In those with a recurrence of symptoms, treatment with an elemental diet lead to an improvement in 7, while 2 remained symptomatic and required further corticosteroid therapy.
Children with GERD who were unresponsive to aggressive medical treatment and who displayed significant esophageal eosinophilia had both clinical and histologic improvement after oral corticosteroid therapy.
This is a very useful study from a large pediatric gastroenterology clinic. It points out that the presence of significant eosinophilia in the esophagus may be a very different entity than standard GERD. Although the major conclusion that corticosteroids are helpful in this population is justified, from an allergist's viewpoint I would rather look for a dietary cause before embarking on a course of steroids. Their approach, however, of looking for food allergy only in those whose symptoms recurred after steroid therapy is also reasonable, especially because they found that a relatively short course of corticosteroid therapy was effective. In any event, we should not lose sight of the fact that the presence of significant eosinophilia is commonly associated with allergy, no matter where the eosinophils are located.