Eosinophilic disorders are characterized by increased levels of eosinophils in one or more places in the digestive tract. Eosinophils are white blood cells that play a role in fighting parasites and allergic reactions. The esophagus, stomach, small intestine and large intestine (colon) may be affected.
The Pediatric Gastroenterology and Allergy sections at Riley Hospital at IU Health are excited to offer a combined, multidisciplinary clinic for patients with eosinophilic gastrointestinal disorders. Families can consult with a gastroenterologist, an allergist and a dietitian, each of whom bring years of experience in managing these issues, at one visit. This clinic helps streamline care for families dealing with complex issues, and has been met with much appreciation.
The most common disorder is eosinophilic esophagitis, which is highlighted below.
Eosinophilic Esophagitis (EE)
EE is a condition where an above normal amount of the white blood cell eosinophil is found in the esophagus (food pipe). EE is thought to be an allergic reaction, most likely to a food(s). There is some evidence to suggest that the allergic substance may be present in the environment. Many patients with EE also suffer from other allergic diseases such as asthma, eczema and sinus disease.
Symptoms
The symptoms of this condition vary and include vomiting, refusing to feed, failure to thrive, abdominal pain, heartburn and the sensation that food is stuck in the esophagus (dysphagia). In some cases, this may result in choking episodes. Many times these symptoms are thought to be due to gastroesophageal reflux disease (GERD) and the patient is treated with medications for GERD with minimal or no improvement.
Exams and Tests
Upper GI endoscopy (EGD)
Diagnosis of EE is established by examining, under a microscope, biopsies (very small pieces of the tissue lining) taken during an upper GI endoscopy. The endoscopy may show certain findings such as vertical lines and white specks. In patients with EE, the biopsies reveal many eosinophils in the esophageal lining.
This test allows your child's pediatric gastroenterologist to examine the lining of the esophagus, stomach and duodenum (first part of small bowel) using a camera in a flexible tube called bv an endoscope. The procedure is done in the operating room under general anesthesia so your child will not feel any pain. The pediatric GI specialist will pass the endoscope through the child's mouth and examine the esophagus, stomach and the duodenum. After examining the upper GI tract, the doctor will collect biopsies (very small pieces of the tissue lining), which will be sent to a pathologist to examine under a microscope.
Before the procedure your child's pediatric GI specialist will talk with you and your child and answer your questions. Some children may get a medication to help them relax before being taken to the operating room area. After the procedure, your child will be taken to the recovery room, allowed to fully awaken, and then be brought out to you. The doctor will discuss the preliminary findings of the procedure and show pictures taken during the procedure. Your child will be allowed to go home in a couple of hours after the procedure but must be fully awake and able to drink liquids before being discharged home. The total time spent at the hospital will depend on the testing and the time for your child to wake up. It is best to expect to spend 4-5 hours at the hospital.
Esophageal pH probe
If results from the biopsy samples suggest EE, your child may undergo a pH probe test to test for the presence of gastroesophageal reflux.
For this test, a small plastic tube will be passed through the nose and into the esophagus. At the end of the tube sensors that detect acid reflux will be positioned at specific spots along the esophagus. Placing the tube only takes a few minutes and can be done in clinic without sedation, though some children may have the pH probe placed in the operating room under general anesthesia if the test is done in coordination with Upper GI endoscopy (see above).
Once the tube is positioned, it is securely taped to the child's face. This probe will remain in place for 24-26 hours and record the occurrence of acid reflux on a small recorder worn by the child. For young children, soft arm restraints may be placed to avoid having the child pull the probe out of his/her nose. The child is sent home with the probe and is allowed to eat and drink with the tube in place. During the study, it is important for the child to have a normal activity and schedule as much as possible so as to get an accurate reading. There will be some additional instructions for the recording device that will be explained at the time of the procedure; you also will need to maintain a diary which will be explained to you. Your child will return to the hospital the next day to have the probe pulled out.
Impedance Probe
This test is used to detect both acid and non-acid reflux. A small plastic tube will be passed through the nose and into the esophagus. At the end of the tube sensors will be positioned at specific spots along the esophagus. Placing the tube only takes a few minutes and can be done in clinic without sedation, though some children may have the pH probe placed in the endoscopy suite while under general anesthesia for endoscopic exam such as an upper GI endoscopy (see above).
Once the tube is positioned, it is securely taped to the child's face. This probe will remain in place for 24-26 hours and record the occurrence of acid reflux on a small recorder worn by the child. For young children, soft arm restraints may be placed to avoid having the child pull the probe out of his/her nose. The child is sent home with the probe and is allowed to eat and drink with the tube in place. During the study, it is important for the child to have normal activity in order to get an accurate reading. There will be some additional instructions for the recording device that will be explained at the time of the procedure; you also will need to maintain a diary which will be explained to you. Your child will return to the hospital the next day to have the probe pulled out.
Bravo pH Study
This test is similar to the esophageal pH probe except it uses a small capsule rather than a long tube and is done only in the operating room in conjunction with an Upper GI Endoscopy. The capsule is attached to the lining of the esophageal wall and sends data on acid reflux, by wireless technique, to a small recorder that the child will wear. The recording lasts for 48 hours and you will need to bring back the recorder to our office. The capsule will fall off of the esophagus after a few days and pass out in stool. You should not try to retrieve the capsule from the stool. If you have not seen the capsule pass after two weeks, the physician may use a chest x-ray to ensure that the capsule has detached from the esophagus.
The advantages of the Bravo test over the esophageal pH probe are that there is no tube sticking out of the nose and that the child does not know there is a capsule inside. The Bravo test is generally not done under the age of four years as there is a risk that the capsule may get stuck in the bowels.
Allergy Testing
We recommend all children diagnosed with eosinophilic esophagitis be evaluated for food and environmental allergies.
Treatment
On completion of the evaluation, your child's pediatric GI specialist will discuss various treatment options that include use of medications (such as swallowing an anti-inflammatory medicine called corticosteroid through an inhaler) and may recommend dietary changes. Diet changes may include avoiding the foods the child has tested allergic to, avoiding foods that commonly cause allergies (e.g., milk, soy, corn, eggs, nuts, fish and wheat), or a strict diet. Dietary changes should be done only under proper supervision of your child's doctor. He/she will have a pediatric dietician meet with you.
Your child's pediatric gastroenterologist may schedule repeat Upper GI endoscopy to assess healing of the esophagus. It is important you maintain these appointments.
EE Research
Our Division has a strong interest in advancing our understanding of esophageal diseases, including EE. You and your child may be offered participation in our research studies. These studies may help improve our care of children with similar problems. We encourage you to ask plenty of questions in order to make an informed decision.
Points to Remember
- EE is sometimes misdiagnosed as GERD.
- Medications and dietary changes can make your child feel better.
- Other parts of the digestive tract may be affected by an increased level of eosinophils. Esoinophilic Gastroenteritis (EGE) refers to the stomach and small intestine and Eosinophilic Colitis (EC) refers to the large intestine (colon).
For More Information
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition - NASPGHAN.org
Allergy and Asthma Network-Mothers of Asthmatics - aanma.org
Asthma and Allergy Foundation of America - aafa.org
American Academy of Allergy, Asthma and Immunology - www.aaaai.org
American Partnership for Eosinophilic Disorders - www.APFED.org
Food Allergy and Anaphylaxis Network - www.foodallergy.org
Campaign Urging Research for Eosinophilic Disease - www.curedfoundation.org