(reprinted from The Pediatric Feeding and Dysphagia Newsletter, July 07, vol 8, no. 1, pg 6-8. )
Esophagitis (inflammation and swelling of the esophagus) is known to occur as a manifestation of gastroesophageal reflux disease. Treatment of GERD is necessary to heal injury, reduce inflammation and swelling of the esophageal mucosa, and to help relieve associated pain and discomfort with feeding and swallowing. Usually feeding problems associated with esophagitis gradually resolve in the absence of other premorbid oral motor and underlying sensory issues.
What’s the difference then, between esophagitis and eosinophilic esophagitis?
Eosinophilic Esophagitis (EE) as a disease was described as long ago as the 1970’s, but only in the last decade has it been recognized as a separate entity from gastroesophageal reflux disease (Liacouras, 2003). In the past, the presence of esophageal eosinophilia in conjunction with esophagitis was attributed to gastroesophageal reflux disease. It is now known that there is a definite difference between reflux esophagitis and eosinophilic esophagitis, primarily in relation to etiology.
Patients with EE may present with clinical signs and symptoms very similar to GERD. However, eosinophilic esophagitis (EE) requires a different treatment approach for resolution. Infants and children with EE typically do not respond to conventional drug therapy for GERD, which generally includes acid suppression and pro-motility agents (Liacouras, 2004). Untreated EE has been suggested to have significant and serious implications including progressive difficulty with swallowing, development of motor dysfunction in the esophagus, formation of esophageal strictures, esophageal scarring and food impaction.
What are “Eosinophils” and what do they do?
Eosinophils are a type of white blood cell, though they are the least common of the white blood cells, and amount to a small percentage of white blood cell volume overall. Eosinophils may occur at very low volumes in numerous tissues, but normally not in the esophageal region (Ferguson & Foxx-Orenstein, 2007). Eosinophils are only a problem when they increase during an infection, or as a result of an allergic reaction. Eosinophils then release toxins which damage tissue in the area they reside such as the lungs or digestive tract. In EE, high numbers of eosinophils are found only in the esophagus. What results is often swelling, defined as “-itis” – such as esophagitis.
What Causes Eosinophilic Esophagitis?
The exact cause of eosinophilic esophagitis remains unknown though an association with allergies (food & environmental) has been described. Others hypothesize that eosinophils are recruited to the esophagus following an acute infectious process, and subsequently result in the development of EE. Food additives and/or exposure to pesticides have also been described, and a genetic link to EE has also been suggested. Once in the esophagus, the eosinophils may cause ongoing inflammation, which in turn causes the development of dysphagic symptoms.
How is EE diagnosed?
The diagnosis of EE is made following an upper endoscopy by a gastroenterologist. During the endoscopy, the gastroenterologist examines the esophagus, stomach, and the first part of the small bowel (duodenum) through an endoscope. Multiple tissue samples (biopsies) are taken, and later examined by a pathologist. The number of eosinophils is determined and the esophageal tissue is examined for swelling, injury, or thickening.
What is the treatment for EE?
At this time, treatment approaches for EE may vary according to the practitioner. Once the diagnosis of EE is confirmed, food allergy testing is usually recommended. Once food allergens are identified, an elimination diet (all “positive” foods on allergy testing removed from diet) may be advised. In other cases, an elemental diet (all proteins removed) and the use of a special amino acid based formula is recommended. If esophageal rings or strictures have formed as a result of the eosinophilic esophagitis, esophageal dilation is required. Pharmacologic treatment (oral corticosteroid) and acid suppression is also utilized. Follow-up endoscopy at intervals to determine the effectiveness of treatment may be necessary.
What is the Role of the Feeding Therapist?
Feeding practitioners should be aware that signs and symptoms of EE will vary but often include unexplained oral feeding difficulty, discomfort with swallowing, a history of reflux that does not respond to the usual therapy, failure to thrive, and a history of allergic disease including eczema and asthma (Pentiuk, Miller & Kaul, 2007). Specific signs and symptoms prompting the initial referral for a feeding evaluation by the pediatric SLP often include feeding refusal, difficulty swallowing, and oral aversion. The referral to the speech pathologist may occur before the EE is diagnosed, during the treatment for EE, or for persisting feeding and swallowing problems once the EE is resolved.
The feeding therapist should be aware that the inflammatory component of EE likely will result in swallowing discomfort, and that children may begin to exhibit a learned aversion to feeding in order to avoid the discomfort. This conditioned response may continue even after the EE is resolved. Children that are put on elemental diets for treatment of EE may have difficulty tolerating the taste of the formula and achieving adequate volume of overall formula intake can be a challenge. The taste of the formula may exacerbate aversive responses toward oral feeding. At times, the use of a nasogastric tube to assist with achieving fluid goals is necessary.
Some children have hypersensitive gag reflexes, and the physical presence of the tube can stimulate this response. The use of the NG supplemental feeding may potentially have an effect on the normal hunger satiation cycle, depending upon the schedule that is put into place. The significant restrictions that are necessary in regard to type of foods allowed in the child’s diet may prevent exposure to certain textures that help with development of efficient oral motor skills for feeding. The speech pathologist has much to offer patients with EE by implementing oral motor and feeding treatment strategies that address both sensory and motor issues that may be present. Collaboration with other professionals such as psychology, occupational therapy, and the gastroenterologist is key to implementing an effective therapy plan.
What is the research consensus about EE?
Research specific to EE has been accumulating in the last decade, yet the specific epidemiology and clinical end points for medial treatment remain unknown. Further research is needed to establish evidence-based protocols for management. The speech pathologist can make additional contributions to the research database in regard to the efficacy of treatment strategies utilized in the treatment of the sensorimotor feeding problems that may accompany EE.
**Claire Miller is a clinical/research pediatric speech pathologist at Cincinnati Children’s Hospital Medical Center. She was recently named the program coordinator for the Children’s Hospital Medical Center Interdisciplinary Feeding Team. Contact her at claire.miller@cchmc.org
References:
Liacouras, C. (2003). Eosinophilic esophagitis in children and adults. Journal of Pediatric Gastroenterology and Nutrition, 37: S23-S28.
Liacouras, C. & Ruchelli, E. (2004). Eosinophilic esophagitis. Current Opinion in Pediatrics, 16(5):560-566.
Ferguson, D. & Foxx-Orenstein. (2007). Eosinophilic esophagitis: an update. Diseases of the Esophagus, 20: 2- 8.
Pentiuk, S., Miller, C.K., Kaul, A. (2007). Eosinophilic esophagitis in infants and toddlers. Dysphagia, 22:44-48.
As always a thorough review of EE. Did anyone listen to Fresh Air on NPR yesterday. Dr. Marin Blaser talked about probiotics, use of antibiotics, need for more vaginal deliveries. However, most interesting was about Helicobacter pylori a cause of ulcers. He stated that it is being eliminated in our guts and as it is extinguished the rates of reflux and asthma have increased. I was racing to a visit and really need to listen to it again. Here is the link http://www.npr.org/programs/fresh-air/2014/04/14/302988620/fresh-air-for-april-14-2014?showDate=2014-04-14.