I'll be discussing pediatric EOE, we'll review some cases, talk about clinical presentation and approach to management. I have nothing to disclose. The objectives will start off by kind of describing maybe some of the clinical differences and how a pediatric or a child would present compared to maybe an adult patient. And we'll review some of the cases. There'll be unique presentations of EOE, how to address recurrence of dysphagia, the best treatment options for that, and then approach maybe to think about GERD and EOE. To begin with, in terms of thinking about why kids might present differently, it really goes into the natural history of EOE, and that is more of this chronic progression of inflammation into fibrosis if you don't have adequate treatment in that inflammatory kind of stage. So where kids tend to present is either on the beginning side of the natural history where it's primarily inflammatory or with this mixed inflammatory and fibrotic picture. And we really have a unique opportunity to start treatment to identify these patients early and really prevent stricturing. And you see that the graph in the right side on the y-axis, that's percentage of patients without stricture, and it's nearly 100% without stricture in early childhood, and it starts to decline with the duration of untreated EOE here. So we really have an opportunity to identify it in the inflammatory stage and be able to maybe halt some of that progression to fibrosis. The clinical presentation, again, in that natural history and in the development age of a child makes it very difficult to have very clear symptomatology. And so it's quite wide across the board what you'll see in order of symptoms. I like this image where it shows that the age in the x-axis really shows the toddler to elementary school age. It's pretty nonspecific. Maybe the parent will notice picky eating, maybe some feeding difficulties early on, a potential for vomiting or regurgitation to happen, and then maybe this overlap of abdominal pain. And again, part of that is maybe it's more of an inflammatory story, but also in that development age, it's hard to put words to what you're feeling. And so that's also one of the reasons why it's hard to really gauge symptoms in that age. But as they get a bit older into middle school, high school, you can start to see the concordance with maybe what an adult might present with in terms of having dysphagia or food impactions. So I like to really rely heavily on maybe thinking more globally when a pediatric patient presents in terms of not just kind of honing in on if there's dysphagia present, we should be concerned for EOE. Taking in just one aspect of symptoms also can maybe kind of make your thought a little bit narrower in dealing with an adolescent patient. So really thinking of other risk factors I should be thinking. So in the past medical history, there are atopic symptoms in the family history, really diving into ATP, maybe a history of esophageal strictures or parents or grandparents needing esophageal dilation may glue you into some other high risk that maybe you have a heightened clinical suspicion. And so in that case, the diagnostic strategy is pretty much the same. The endoscopic exam, the visual cues, the histologic criteria all match and are what we currently use in terms of diagnosing EOE even in children, but the clinical suspicion is probably the highest. And when we go for an endoscopy, it's going to be pretty atypical symptoms that we're going to be seeing. And oftentimes we use some other ancillary evaluations such as allergy testing, maybe reflux testing and esophagram. And the histologic criteria, again, greater than 15 matches across the board with what you would see in adults. But the EOE histology score I think is something that in pediatric GI we leaned a little bit more heavily on to really help guide a treatment response and seeing that the inflammatory score is actually improving and maybe even clue into some early fibrosis or that mixed inflammatory fibrotic picture. So let's dive into the first case. This is a 10-year-old who's presenting to the GI clinic and the consult is for weight loss. And his past medical history of anxiety, some depression, and a family history, really not specific. His father has GERD, maybe you see in mom's brother, and his sister had the peanut allergy. In looking at the growth curve, his weight loss has happened over the past year, so it's not an acute drop in weight of about 13 pounds. He denies any body image concerns, he's a soccer player, he's really just wanting to be active and has no, again, body image issues, has some abdominal pain and nausea. And it's typically after eating, it's been going on for several months, he doesn't know exactly when, and he said, well, I just stopped kind of eating as much, and it really wasn't noticeable to him or the family until he presented to his pediatrician's visit and they got a weight. So he stopped eating, but really, again, no vomiting, heartburn, no pain or difficulty swallowing, no shortness of breath, no headaches, a little bit of intimate constipation, uses some Miralax for it. So at this point, he's very much like not, the EOE red flags aren't going off, really, and you're thinking, okay, maybe let's kind of haul what he has, what we call ARFID, which is avoidant restrictive food intake disorder. He feels abdominal pain and nausea, so he limits what he's eating to avoid those symptoms. Very clear, classic diagnosis that sometimes we see in kids, but that doesn't tell me what's going on, and so I'm going to dig a bit further. So again, not big EOE flags going off, but this is an EOE talk, so it's going to be EOE in the end, but what we ended up doing is just kind of some ancillary testing, the screening for celiac. We looked at inflammatory markers in the stool, did some basic imaging, had him start some dicyclamine as needed for pain, and then counseled him on high-calorie food intake to see if we can stabilize the weight loss. His testing all came back fine. About a month later, his mom reached out, they had a follow-up with their pediatrician, he's still having weight loss, and now he admitted to not eating at all at school because he doesn't want symptoms, and they've noticed that he's also not eating breakfast on the weekend. He already wasn't eating as much in the weekdays, so definitely still having something going on, and this is where we, again, not a lot of big EOE red flags going off, but as a pediatrician, as a pediatric GI, you're like, well, okay, I think at this point we should definitely get an endoscopy done, and if it looks good, then we'll go all in on our fed and dietician and really push the calories and see what else we can do to help with appetite. So he ended up having an endoscopy, and his endoscopy was pretty classic appearance for EOE. His ERES score was four, so you can see kind of the furrowing, the loss of vascular pattern or edema congestion, those white exudates, doesn't really have a ringed appearance to his esophagus. Again, in pediatric, that's a little bit more of a mixed picture with fibrosis happening, so definitely meets criteria endoscopically for EOE. Histologically also had a criteria met, distal had 60 and proximal at 50 eosinophils, and his EOE histology score was elevated to primarily on the inflammatory side. So we said, okay, great, then your diagnosis is ARFID, that Avoidant Restrictive Food Intake Disorder, secondary to EOE. And this is where treatment comes into play, especially in a child presenting with a food restrictive type of eating or even weight loss, diet is not an option. And we still talk about it, but as the shared decision making, that is where I like laid my foot down. I was like, okay, diet is not going to be an option for you, maybe certainly later. And as a group, we decided on starting him on Budesonide, and he actually did quite well with the Budesonide, his EOE was in remission at our four-month follow-up. His symptoms, he said he doesn't have as much abdominal pain, but not only comes when I'm constipated and it was kind of meeting very classic picture of when kids would have pain when they're constipated, but he wasn't restrictive eating. His weight improved as well, you can see his growth chart here, definitely that decline in when we first met and then has since improved. So in summary, this is a 10-year-old with weight loss and restrictive eating, and his restrictive eating was because of post-perennial abdominal pain. And I think highlights a really atypical presentation of EOE, and his age kind of fits in this kind of age, kind of growth chart or age chart here in symptoms around presenting with like vomiting and maybe some feeding disorder and pain. And so it matches with this like, again, atypical presentation of pediatric patients and his management strategy because of his initial presentation of weight loss and restrictive eating kind of narrowed us to not be able to include diet at the time. I will say a lot of parents come in and want to make sure that we kind of avoid medicines as possible, as much as possible. So diet is usually a sticking point for a lot of parents and in a case similar to his where we're having maybe some restrictive eating or weight loss, I do do a lot of counseling on that even though diet isn't an option right now, if weight is restored and your EOE is in remission, then we can talk about diet and how that might play into your EOE for more of a long-term management. So let's go into the next case. This is a 16-year-old, quite a long case, so you're going to have to bear with me here. So he presented acutely to the ER for a food reaction. And this seems to be something that had started back in 2018 and really kind of diving into the history, get a little bit more understanding. So he has atopic dermatitis. He has a history of anxiety and food allergies. What happened when you look at his food allergies is he has mainly allergies that don't have anaphylactic response, but he has abdominal pain and vomiting. And it's usually one to four hours after eating. And so they, in the past six years, have been kind of on this food allergy pathway where he had allergy testing and his class one to three IgE testing, which is kind of in that mild category, definitely not an anaphylactic category. So he's eliminated dairy, sesame seed, egg, beef, banana, corn, like he's really restrictive and kind of anxious about what he's eating because he's been on this path of like, when I get a symptom, I got to write down the foods and I've got to figure out what that is and I'm going to remove it so I don't have that again. On the day of his presentation, again, he's presenting in the ER, this episode started after eating chicken curry. And this was cooked at home and the family is very sure there were no allergens present. So they're thinking we've probably got another allergy. We're coming into the ER because he's going to have his allergic reaction. He had symptoms of like a water brush, like he was salivating and he felt like he couldn't swallow his saliva and he was vomiting. And in talking with the PEDS team who eventually admitted him, it was more like regurgitation that was happening, like rumination almost. So in the ER, vitals looked great. He looked a little bit anxious. His exam was reassuring. He wasn't vomiting anymore and he felt better in terms of the vomiting standpoint, but he still felt like maybe he was salivating more and things were like bubbling up. They gave him Benadryl. He again felt better. They decided to admit him for observation. The next day is when I was consulted and the pediatric team said, hey, we want you to see this patient. He was able to drink some liquids overnight. No problem. We're going to send him home today. We really think he needs to follow up with GI because he has this like cyclic vomiting pattern. And so we met him and I asked about what his typical episodes were. And he said they start at the mid or the end of the meal. He has salivation, chest tightness and sensation that food's bubbling back up. And what happens is he's been told this was allergy. So he gives himself Benadryl and he goes and lays down and the next day or a few hours later it goes away. And then he writes down what was what he just ate and they start to like really hone in on these foods. And so this whole time he's been suspecting of it being a food allergy. And so he didn't again, this is a taking a step back again. Not everyone's going to present the same way. And his was this like a little bit higher suspicion and maybe there's this clinging to this food allergy. But at some point we wanted to make sure that maybe he doesn't have a swallowing disorder because it was really definitely meal related on when this would happen. And it didn't seem that even with removing these foods, his symptoms went away. So we said before you discharge him, get an esophagram and then we'll see him in the clinic. Well, thanks to Dr. Olson showing us some great esophagram videos. I don't have those, just have still images. But the esophagram here you can show thanks to our arrows that there's a clear filling defect. And in fact, there was even some narrowing too, which could either be fibrosis or even esophagema at that time. So acute inflammation can have that picture too. So then we said, okay, well, don't send him home. Let's go and burn endoscopy because it sounds like maybe he had the food infection. And this is truly what we found. So he did have a piece of chicken actually lodged in the esophagus. So we had it removed and you can see that his esophagus has that classic EOE picture too. So his ERAT score was seven. He has clear ringed appearance. It's definitely a loss of vascular pattern. There's some exudates furrowing as well. And it wasn't a clear stricture, but the food was definitely caught maybe more on the spirotic area where you see those rings. His EOE biopsy has also showed a positive view for esophagitis. His EOE histology score was 18 out of 24. So then we discussed treatment for him. And similarly to our first case is when we said, well, I wonder if in reality, maybe he has this avoidant eating and so maybe diet wouldn't be a great option for him either. So he also started Swallowed Budesonide. Had his follow-up endoscopy two months later, doing great. His ERAT score was down to three. The photos of his endoscopy looked perfect. His biopsies looked better. His EOE histology score is still a little bit high. We'll talk about that, but it was improved overall. So we said, great, stick with what you're doing. You can start to add back these foods. There was a little bit of hesitation to do it right away. So he said, now that I'm feeling better, I know I can add these back in. He added back all the foods. He was feeling great. Four months later, he had an episode similar to what he was explaining before after eating a sausage sandwich, a breakfast sandwich. He was not in Minnesota at the time, so he had his scope repeated locally. And they said there could be a food impaction, so let's just do a scope. He did it. It looked normal. There was no food present. No biopsy was obtained. But clinically and endoscopically, it looked fine. And so this is where it kind of took a pause. This is why I think it's good to think about when someone has recurrence after having remission, what do we think about? For him, the first thing that came to mind was fibrosis and narrowing. He's a type of patient where he presented with this mixed picture. You see those rings present, tell me that there's some fibrosis too. And the EOE histology score also had an elevated grade and stage for his fibrosis too. So it was in the back of our minds that maybe there's a more of a fibrotic picture going on and where we need to maybe do dilation or understand that a bit further. Other things to think about would be esophageal hypersensitivity. He's a kid who's always been worried about eating and had allergy type symptoms and he has a history of anxiety. Maybe he's quite sensitive in the esophagus and this was just nothing. Otherwise, thinking about non-compliance with medication, he certainly didn't have reactivation of what looks like EOE endoscopically, although we don't have biopsies to help, but non-compliance with medication and then having symptom reoccurrence may be just because your EOE is coming back with stopping meds. And then one thing I often hear is like, oh no, it's nothing, I just took a really big bite of food. Or he only has choking only if it's a big bite of food. And so that just a big bite of food is really tough to discern in kids. And so I usually don't play too much into it, but that's something that comes up. So what we think about when we think about fibrosis, so going back to that, what should we do for him? So is there something we can do to identify fibrosis as present? Again, in pediatrics, there's this kind of mixed picture. So not everyone's going to be having fibrosis. Your biopsy can certainly be helpful. The biopsy can give you your EOE histology score that we've been talking about, but that is really limited and it's limited by the quality of your biopsy. You have to have a deep enough biopsy that has a lamina appropriate enough so that the pathologist can accurately identify fibrosis. And so sometimes the quality of your biopsy and your EOE histology score won't have a fibrosis at greater scale because there's not enough there. And we were benefiting from his prior biopsies and the one before that we had enough to show that his fibrosis was actually still present despite our treatment with budesonide. An esophagram can be helpful. Maybe there's some narrowed lumen still there or a stricture present. What I really want to highlight is the use of something called endoflip, which has been really a game changer in EOE, particularly in pediatrics when we have this persistent dysphagia symptoms. Endoflip is a balloon that's filled with the propriety, like a saline type solution, and it's placed in the esophagus and filled while the patient is under anesthesia for an endoscopy. And with this balloon on the inside, there's a sensor that has an impedance and pressure sensors and it's able to really have this topographical map of the esophagus as you fill up this balloon. What we glean from it is when we think about fibrosis, that means that the esophagus is probably a little bit tight. And we have this number that we look on an endoflip called distensibility index, which I described to parents as like, it's a stretchy rubber band where we're checking how stretchy that rubber band is. So if you have a high distensibility, that's a rubber band that you can really stretch. That's an esophagus that's really compatible or compliant. And if you have a really low distensibility, it's kind of that tight, thick rubber band. And specifically for EOE, there's been data that shows a distensibility of less than 4.5 is associated with risk of having a food impaction and need for esophageal dilation. So it's been beneficial to have that quality of like, when I'm worried about fibrosis, I can confirm that potentially with an endoflip if my biopsy hasn't been adequate enough, or maybe using the combination of the two to really say you are more on the fibrotic side. And we've got your information there, but maybe we should do something more about your fibrosis. So what can we do to treat it? In some cases, especially with endoflip, if you're able to identify a narrowed segment where that's a fibrotic segment, you can do dilation. And sometimes for pediatrics, with the benefit of having this neuromedication called dupilumab, in addition to dilation, we'll also start dupilumab as it has been the one to show in some of the studies that it has increased distensibility, so made it more pliable and improved fibrosis. So dupilumab, I think, has been a big benefit for patients with fibrosis, and this is actually something that he ended up starting and is still doing quite well on. So to summarize this case, this is a 16-year-old, again, with allergy-type episodes, had a diagnosis of EOE following a clear food impaction event. I like to bring up anchoring bias in this specific case because it was being passed down the road, subsequent providers at every ER visit that he saw that this was an allergy episode, and being treated with Benadryl and rest and fluids, and then he gets better and then it's fine, and so it made sense. And so when you anchor in on bias and you're unaware of what you're doing, you don't take time to review symptoms and really dive in a bit deeper. And so we had the opportunity to do that and really say, what are these, are you sure these are with allergy episodes? And in doing that and reviewing the symptoms, we're able to uncover EOE and that these symptoms that he was experiencing was truly a food impaction and not allergy. And so that brings me to my third point, which is not all food impactions are the same. Kids will present very differently with it. They may have just persistent throat clearing and not be able to describe what they're actually feeling. So you have to have a heightened suspicion for a food impaction sometimes in younger kids, and they'll present differently. Reoccurrence of symptoms is another thing to highlight in this case. When that happens, check for compliance, consider maybe esophageal hypersensitivity. And in understanding if you have a esophageal hypersensitivity, that would require a repeat scope to say, hey, your esophagus looks great. Or maybe in an endo flip with that to say, you have great sensibility. It's not fibrosis. It's not continued inflammation. I think you have just a hypersensitive esophagus. And sometimes that's the case for kids. And then consider testing if there's a concern for fibrosis, just as we just talked about. And really knowing fibrosis, if it's present or not, can help guide management. So moving on to the very last case, this is a 17-year-old female. She has dysphagia. She has heartburn and she has regurgitation. So she's really on that cusp of like, yeah, this could be very classically presenting EOE. She's used PPI intermittently without help. And she has a history of asthma. She's on an inhaled corticosteroid. She also has atopic dermatitis that flares in the winters. And she has to do a lot of topical therapies for her arms over the winter seasons. Her brother also has atopic dermatitis and asthma. And there's a maternal uncle who had his esophagus stretched. So she had an esophagram. She came to us from her pediatrician who got an esophagram already. That was reported to be normal. And at this point, we said, you definitely need to get an endoscopy. I feel like there's a high suspicion you have EOE. But she was on a PPI for about the past month on a consistent basis daily. So in order to be very clear, we stopped her PPI and waited at least two months before we did her endoscopy. And that's another thing with kids. You really have to have this all or nothing. If you're going to sedate a kiddo, you just want to answer all of the questions. So sometimes, we take the time to stop medicines or maybe change the diet to make sure that we're checking everything at will one time to make sure we can check the boxes. This is also the case for celiac disease in kids on maybe a gluten-free diet. We might add gluten back in before we scope just to make sure we can answer that question and not have to keep scoping and whatnot. So anyway, she underwent a scope, and it was very classic EOE. It stopped her PPI. Her histology showed 30 and greater than 100 eosinophils in her biopsies. Her histology score was 16, and her ERFs were 5. And again, very classic picture of EOE here on her endoscopy. But we ended up starting her on dupilumab rather than diet, PPI, budosonide. We went through the whole script of thinking about this for her. And in the shared decision-making, her brother had restarted that for his atopic dermatitis. She has two diagnoses that are FDA-approved also for dupilumab plus her EOE now. So now all three of these diagnoses could be potentially useful for the treatment using dupilumab. So we started on dupilumab, 300 milligrams weekly. And in our follow-up messaging, in about two months of being on treatment, she was doing quite well. She didn't have any more dysphagia. Every now and then, she'd have some heartburns where she'd take a Tums, and her eczema was much better, which as a 17-year-old female, she was really happy about. And so she was pretty happy and doing well. And then about three months total of being on treatment, she had one episode of dysphagia come back. And this one was different because she had felt food getting stuck, which was a new thing for her. Really, for her, it was just kind of like, I feel like I got to swallow really hard. That was her dysphagia. She'd never had a globus sensation or feeling of food sticking. And this was new. So she said, it lasted for about an hour, and then I felt fine. So in our conversation, I said, well, why don't we have your esophagram here, and then we're due for your endoscopy. So I wanted to repeat her esophagram primarily because I didn't have the images from the prior, and I wanted the test to be done at our institution. And again, thanks to Dr. Olson showing some really great esophagram photos, she had some distal narrowing in her esophagus, and with a barium tablet, it also hung up in that same area. And so we went in for our endoscopy. And actually, it looks pretty good in terms of a repeat look in the proximal esophagus was pretty nice. And you can see, as you look in this picture, a little bit distally, maybe there is going to be some narrowing. So when you get closer to the distal esophagus, there was an area of narrowing, but also these erosions and even some concern for possible looking like Barrett's esophagitis. And so this is what you would classically see like maybe on an adult Barrett's or an adult reflux scurred picture, and it's not classically EOE, although it started off as classic EOE. And her biopsy results actually showed her EOE was doing just fine. So approximately distally, things looked good. There was certainly distal focal inflammation. And at the GE junction, there was intestinal anaplasia, no dysplasia present. So it was consistent with Barrett's and esophagitis. We elected to continue her on Dupixent given that the proximal improvement was there. But this is a really good case to highlight what was really surprising to us in using Dupixent since it's been approved to the past couple of years, is that we kind of forgot about how important GERD can be in patients and this overlap of GERD and EOE that can sometimes occur. And so we decided to start her on high dose PPI, did Rebeprazole, and her repeat endoscopy images here actually looked much better. She still has that Z-line type picture that looked a little bit inflamed, but in general, she didn't have those focal areas. And in the biopsy, it showed improvement as well. Again, no eosinophils in terms of EOE. And so she's quite of a unique case to really think about how Dupixent was really beneficial, but it kind of left GERD unchecked. And I wanted to bring this one up because persistent heartburn or dyspepsia can kind of clue you in, but maybe in thinking about her clinical presentation before, we should have probably had a higher suspicion for GERD as well. Her endoscopic appearance in the beginning was very classic for EOE, but it later on, then the GERD kind of came about because the EOE was then quiet. Also looking back, her eosinophil count, I'm just backing up too, was actually much higher in the distal esophagus as well. Again, you can't go on that completely because your eosinophil biopsies can be somewhat patchy and whatnot, but again, hindsight is 20-20. And now thinking forward for some of our patients that do have this type of presentation where there's some obvious reflux symptoms and finding of EOE, we sometimes have a high suspicion for GERD, we should consider testing at the time of your index endoscopy. And the two options we have are a 24-hour impedance probe test and then a Bravo capsule. Both will give you some details on acid exposure in the esophagus. The impedance probe will tell you non-acidic reflux events as well. And so in some of our patients, again, and kids that kind of present all over the place, but in a teenage patient with clear heartburn and dysphagia and a high suspicion for either GERD or EOE, we've kind of changed our thought process in the EOE clinic to say those patients should probably get an endoscopy plus maybe some consideration for formal reflux testing to rule out reflux before we decide on treatment. And the treatment approach for a patient with EOE and GERD, you know, PPI is a great option. It can be beneficial for both cases. And so I think it's, we've left it up to her to decide if she wants to just go to PPI only and see how things go off of Dupixent. And I think she has more benefit with the Dupixent from her atopic symptoms and decided to stay on Dupixent and PPI at the moment. So those are my three cases. And in thinking about an overview, I want a few takeaways, which is there's going to be nonspecific symptoms in pediatrics, and you're going to have to have a high clinical suspicion. And that's primarily due to the fact that there's progression from an inflammatory to a fibrotic with age. And fibrosis is what we're all trying to avoid in this age group. And leaving this disease unchecked or unidentified increases the risk of fibrosis because you have a longer duration without treatment. So always consider, you know, a high index of suspicion, even if nonspecific symptoms in endoscopy can be really beneficial to ruling out EOE. And we tend to do it in a lot more pediatric patients these days in the realm of having EOE be quite predominant. We want to consider the overlap of EOE and GERD, especially if there's that heart, clear heartburn presenting symptoms, even with the overlap that EOE can present with heartburn alone, especially in kids, again, in a nonspecific way. So having a high index of suspicion and adding on maybe a formal reflux test to help discern that for you. And then the importance of close follow-up. A lot of these, the cases we talked about, we had a close repeat endoscopy to say things are better or worse. And that can really guide your clinical management and help understand recurrence of symptoms that may be related to EOE and may just be related to being a kid. So with that, I will end and I'll take any questions.

pediatric eosinophilic esophagitis

clinical presentation

management strategies

Budesonide

Dupilumab

GERD overlap

endoscopy