TOPLINE

In pediatric eosinophilic esophagitis (EoE), normal-appearing esophageal mucosa frequently harbored microscopic disease, with more than 25% of upper esophageal segments showing histologic abnormalities despite normal endoscopic appearance. Biologic therapy achieved histologic remission in all 9 treated patients, following multiple prior treatment failures.

METHODOLOGY

• Researchers conducted a retrospective chart review of 138 pediatric patients diagnosed with EoE between 2009 and 2023 in Jerusalem, Israel.
• They analyzed presenting symptoms, macroscopic and microscopic findings at different esophageal levels, biopsy sampling practices, and therapeutic trajectories including biologic therapy.
• EoE was defined as compatible symptoms and ≥ 15 eosinophils per high-power field without alternative explanation; a diagnostic subgroup of 112 patients who underwent their initial diagnostic endoscopy at the study center was analyzed separately.
• The mean age at diagnosis was 8.33 years, with 75% male patients; most common presenting symptoms were vomiting (39.28%), dysphagia (32.14%), and food impaction (28.57%).
• Multilevel sampling (≥ 2 esophageal regions) was performed in 100 patients (89.29%); patients underwent a mean of 3.84 endoscopic procedures during follow-up through December 2024.

TAKEAWAY

• Among patients with ≥ 15 eosinophils in one esophageal field, multilevel sampling revealed fewer than 15 eosinophils per high-power field in 21.11% of upper, 7.14% of middle, and 14.14% of lower esophageal samples.
• Macroscopic-microscopic discordance was identified in 19.21% of segments, with histologic abnormalities despite normal endoscopic appearance most common in the upper esophagus (25.56%, P < .001) and less frequently in the lower esophagus (9.9%, P = .002).
• Macroscopic abnormalities were most frequent in the lower esophagus (85.71%), with predominant furrows (69.64%) and exudates (55.36%). Exudates were more frequently present in the lower esophagus despite being absent in the upper esophagus (P < .001).
• Following first-line therapy, histologic remission was achieved in 47.83% of patients. Proton pump inhibitors achieved 55.56% success and elimination diet achieved 53.85% success rates as monotherapy; combination therapy achieved a 37.5% success rate. All patients achieved remission while receiving biologic therapy with subcutaneous dupilumab after multiple prior treatment failures, and 88.89% maintained remission throughout the follow-up.

IN PRACTICE

"These findings reinforce the importance of systematic multi-level biopsy sampling to ensure accurate diagnosis and disease monitoring," the authors wrote.

"Conventional therapies were associated with variable and often modest remission rates. In contrast, biologic escalation was associated with encouraging early response and the absence of microscopic evidence of inflammation on repeated biopsies," they added.

SOURCE

The study was led by Sraya Greenberger, Pediatric Gastroenterology, Hepatology and Nutrition, The Hadassah Medical Organization, Jerusalem, Israel. It was published online on July 30 in the European Journal of Pediatrics.

LIMITATIONS

The study was limited by its retrospective design, reliance on contemporary diagnostic criteria for patient identification, the lack of a control group, variability in quality and completeness of clinical documentation, and the lack of repeat endoscopy in some patients. As a single-center study, the findings may have been influenced by selection bias and were not fully generalizable to other populations.

DISCLOSURES

The study received open access funding from Hebrew University of Jerusalem. The authors reported no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.