STANFORD, CALIF. — Children or adults whose symptoms of gastroesophageal reflux disease continue despite treatment may have allergic eosinophilic esophagitis, John A. Kerner Jr., M.D., said at a conference on perinatal and pediatric nutrition.
An esophageal biopsy will show major eosinophilic infiltration of the mucosa and submucosa in a patient with allergic eosinophilic esophagitis. The proteins that are implicated in this disorder come from the “usual suspects” in the diet—cow's milk, wheat, soy, peanut, or egg, said Dr. Kerner, professor of pediatrics and director of nutrition at Stanford (Calif.) University Medical Center.
Treatment consists of avoiding the antigens, if they can be identified, switching infants to an elemental formula, and possibly using steroids. Often multiple antigens are involved, with poor correlation with skin tests for allergy, he added.
First identified in a landmark 1995 study of 10 children, allergic eosinophilic esophagitis produces symptoms that look like chronic gastroesophageal reflux disease (GERD). The child may refuse food, fail to thrive, vomit, have abdominal pain, be irritable, and have difficulty sleeping. Symptoms return despite treatment with histamine2-receptor blockers or even fundoplication. Serum IgE levels are normal or slightly elevated, and peripheral eosinophils are uncommon in allergic eosinophilic esophagitis.
Allergic eosinophilic esophagitis can begin anytime from infancy to adolescence. “More and more of the adult literature is pointing out that patients have been missed with this disorder,” Dr. Kerner said.
Older children and adults who have had allergic eosinophilic esophagitis for some time commonly turn up in emergency departments or clinics with esophageal stricture. Biopsies will show “sheets” of eosinophils in these patients, he added.
Seeing more than 20 eosinophils per high-power field in a biopsy is a “classic count” for diagnosing allergic eosinophilic esophagitis, although there is some debate about the exact number needed for diagnosis, Dr. Kerner said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.
Endoscopy will show little circular rings that can be “fairly dramatic” and white plaques composed of eosinophilic complexes.
Restricting consumption of cow's milk will resolve symptoms in approximately 80% of cases. In infants with allergic eosinophilic esophagitis, 80% will improve after switching to a hydrolyzed protein formula such as Alimentum or Nutramigen. Those who don't respond usually do well when switched to an L-amino acid formula. Breast-fed infants with eczema and allergic eosinophilic esophagitis usually need an L-amino acid formula, Dr. Kerner said.
An inhaled steroid will alleviate acute symptoms, but symptoms recur when the inhaled treatment is stopped. When prescribing steroids for this disorder, Dr.Kerner said that he prefers using both inhaled and topical forms. Oral steroids for a systemic effect also are an option, he said.
The first published study of allergic eosinophilic esophagitis described 10 children who had been diagnosed with GERD and whose symptoms persisted despite separate treatments with five antireflux therapies, including Nissen fundoplication in six patients.
After 6 weeks on an L-amino acid-based formula (Neocate or Neocate One), eight patients had no symptoms, and symptoms improved in the other two patients. Esophageal biopsies before and after the 6 weeks of treatment showed that intraepithelial eosinophil counts decreased significantly, from a median of 41 per high-power field to less than 1 per high-power field (Gastroenterology 1995;109:1503–12).
Symptoms returned in all patients, however, after open food challenges. “This is a real disorder,” Dr. Kerner said.
The study showed that chronic GI symptoms and histologic changes of the esophagus that were unresponsive to standard GERD treatments could be improved by using an elemental formula. “This was a breakthrough,” he said.