Generic placeholder image

Current Pediatric Reviews

Author(s): Arianna De Matteis, Giuseppe Pagliaro, Vito Domenico Corleto, Claudia Pacchiarotti, Emilio Di Giulio, Maria Pia Villa, Pasquale Parisi, Francesca Vassallo, Chiara Ziparo and Giovanni Di Nardo*

DOI: 10.2174/1573396315666191004110549

DownloadDownload PDF Flyer Cite As
Eosinophilic Esophagitis in Children: Clinical Findings and Diagnostic Approach

Page: [206 - 214] Pages: 9

  • * (Excluding Mailing and Handling)

Abstract

Eosinophilic esophagitis (EoE) is an emerging chronic immune and antigen-mediated clinicopathologic disease. During the last 2 decades, the incidence of this condition in children has increased significantly, thanks to practitioners for creating the awareness and higher use of diagnostic endoscopy. We have analysed paediatric literature on EoE focusing on the epidemiology, pathophysiology, clinical findings and diagnostic approach.

EoE is pathogenically related to a Th2 inflammation characterized by a mixed IgE and non-IgEmediated reaction to food and/or environmental agents. This leads to esophageal dysfunction and remodeling accompanied by subepithelial fibrosis. EoE can be presented with several range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or feeding refusal in infants and toddlers, as well as heartburn, dysphagia and food bolus impaction in older children and adults. The diagnostic suspicion is based on the presence of chronic symptoms of esophgeal dysfunction and esophageal eosinophilia characterised histologically by a significant eosinophilic infiltration of the oesophageal mucosa (>15 eosinophils per high powered field). In this review, we will provide an update on clinical presentation and diagnostic approach to EoE in children. We emphasized on the relevant aspects of the new clinical condition termed “PPI responsive esophageal eosinophilia”, as entities distinct from EoE and the role of PPI trial in the diagnostic workup, therefore we proposed a new diagnostic algorithm.

Keywords: EoE, gastroesophageal reflux disease, proton pump inhibitors, subepithelial fibrosis, dysphagia, gastrointestinal.

Graphical Abstract

[1]
Kelly KJ, Lazenby AJ, Rowe PC, Yardley JH, Perman JA, Sampson HA. Eosinophilic esophagitis attributed to gastroesophageal reflux: improvement with an amino acid-based formula. Gastroenterology 1995; 109(5): 1503-12.
[http://dx.doi.org/10.1016/0016-5085(95)90637-1] [PMID: 7557132]
[2]
Dellon ES. Eosinophilic esophagitis. Gastroenterol Clin North Am 2013; 42(1): 133-53.
[http://dx.doi.org/10.1016/j.gtc.2012.11.008]
[3]
Furuta GT, Liacouras CA, Collins MH, et al.
[4]
Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128(1): 3-20.
[5]
Lucendo AJ, Molina-Infante J, Arias Á, et al. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J 2017; 5(3): 335-58.
[http://dx.doi.org/10.1177/2050640616689525]
[6]
Dellon ES, Hirano I. Epidemiology and Natural History of Eosinophilic Esophagitis. Gastroenterology 2018; 154(2): 319-32.
[http://dx.doi.org/10.1053/j.gastro.2017.06.067]
[7]
Arias Á, Pérez-Martínez I, Tenías JM, Lucendo AJ. Systematic review with meta-analysis: the incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies. Aliment Pharmacol Ther 2016; 43(1): 3-15.
[http://dx.doi.org/10.1111/apt.13441]
[8]
Dalby K, Nielsen RG, Kruse-Andersen S, et al. Eosinophilic oesophagitis in infants and children in the region of southern Denmark: a prospective study of prevalence and clinical presentation. J Pediatr Gastroenterol Nutr 2010; 51(3): 280-2.
[http://dx.doi.org/10.1097/MPG.0b013e3181d1b107] [PMID: 20512060]
[9]
Soon IS, Butzner JD, Kaplan GG, deBruyn JC. Incidence and prevalence of eosinophilic esophagitis in children. J Pediatr Gastroenterol Nutr 2013; 57(1): 72-80.
[10]
Dellon ES, Jensen ET, Martin CF, Shaheen NJ, Kappelman MD. Prevalence of eosinophilic esophagitis in the United States. Clin Gastroenterol Hepatol 2014; 12(4): 589-96.e1.
[http://dx.doi.org/10.1016/j.cgh.2013.09.008] [PMID: 24035773]
[11]
Franciosi JP, Tam V, Liacouras CA, Spergel JM. A case-control study of sociodemographic and geographic characteristics of 335 children with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2009; 7(4): 415-9.
[http://dx.doi.org/10.1016/j.cgh.2008.10.006] [PMID: 19118642]
[12]
Syed AA, Andrews CN, Shaffer E, Urbanski SJ, Beck P, Storr M. The rising incidence of eosinophilic oesophagitis is associated with increasing biopsy rates: a population-based study. Aliment Pharmacol Ther 2012; 36(10): 950-8.
[http://dx.doi.org/10.1111/apt.12053] [PMID: 22994460]
[13]
Vanderheyden AD, Petras RE, DeYoung BR, Mitros FA. Emerging eosinophilic (allergic) esophagitis: increased incidence or increased recognition? Arch Pathol Lab Med 2007; 131(5): 777-9.
[PMID: 17488165]
[14]
D'Alessandro A, Esposito D, Pesce M, Cuomo R, De Palma GD, Sarnelli G. 2015.
[15]
Inage E, Furuta GT, Menard-Katcher C, Masterson JC. Eosinophilic esophagitis: pathophysiology and its clinical implications. Am J Physiol Gastrointest Liver Physiol 2018; 315(5): G879-86.
[http://dx.doi.org/10.1152/ajpgi.00174.2018] [PMID: 30212252]
[16]
Cianferoni A. Wheat allergy: diagnosis and management. J Asthma Allergy 2016; 29(9): 13-25.
[17]
Rothenberg ME, Spergel JM, Sherrill JD, et al. Common variants at 5q22 associate with pediatric eosinophilic esophagitis. Nat Genet 2010; 42(4): 289-91.
[http://dx.doi.org/10.1038/ng.547] [PMID: 20208534]
[18]
Li M, Hener P, Zhang Z, Ganti KP, Metzger D, Chambon P. Induction of thymic stromal lymphopoietin expression in keratinocytes is necessary for generating an atopic dermatitis upon application of the active vitamin D3 analogue MC903 on mouse skin. J Invest Dermatol 2009; 129(2): 498-502.
[http://dx.doi.org/10.1038/jid.2008.232] [PMID: 18650845]
[19]
Soumelis V, Reche PA, Kanzler H, et al. Human epithelial cells trigger dendritic cell mediated allergic inflammation by producing TSLP. Nat Immunol 2002; 3(7): 673-80.
[http://dx.doi.org/10.1038/ni805] [PMID: 12055625]
[20]
Sherrill JD, Gao PS, Stucke EM, et al. Variants of thymic stromal lymphopoietin and its receptor associate with eosinophilic esophagitis. J Allergy Clin Immunol 2010; 126(1): 160-5.e3.
[http://dx.doi.org/10.1016/j.jaci.2010.04.037] [PMID: 20620568]
[21]
Blanchard C, Wang N, Stringer KF, et al. Eotaxin-3 and a uniquely conserved gene-expression profile in eosinophilic esophagitis. J Clin Invest 2006; 116(2): 536-47.
[http://dx.doi.org/10.1172/JCI26679] [PMID: 16453027]
[22]
Sleiman PM, Wang ML, Cianferoni A, et al. GWAS identifies four novel eosinophilic esophagitis loci. Nat Commun 2014; 5: 5593.
[http://dx.doi.org/10.1038/ncomms6593] [PMID: 25407941]
[23]
Alexander ES, Martin LJ, Collins MH, et al. Twin and family studies reveal strong environmental and weaker genetic cues explaining heritability of eosinophilic esophagitis. J Allergy Clin Immunol 2014; 134(5): 1084-1092.e1.
[http://dx.doi.org/10.1016/j.jaci.2014.07.021] [PMID: 25258143]
[24]
Jensen ET, Hoffman K, Shaheen NJ, Genta RM, Dellon ES. Esophageal eosinophilia is increased in rural areas with low population density: results from a national pathology database. Am J Gastroenterol 2014; 109(5): 668-75.
[http://dx.doi.org/10.1038/ajg.2014.47] [PMID: 24667575]
[25]
Jensen ET, Kappelman MD, Kim HP, Ringel-Kulka T, Dellon ES. Early life exposures as risk factors for pediatric eosinophilic esophagitis. J Pediatr Gastroenterol Nutr 2013; 57(1): 67-71.
[http://dx.doi.org/10.1097/MPG.0b013e318290d15a] [PMID: 23518485]
[26]
van Nimwegen FA, Penders J, Stobberingh EE, et al. 2011.
[27]
Liacouras CA, Spergel JM, Ruchelli E, et al. Eosinophilic esophagitis: a 10-year experience in 381 children. Clin Gastroenterol Hepatol 2005; 3(12): 1198-206.
[28]
Gonsalves N. Food allergies and eosinophilic gastrointestinal illness. Gastroenterol Clin North Am 2007; 36(1): 75-91.
[http://dx.doi.org/10.1016/j.gtc.2007.01.003]
[29]
Kagalwalla AF, Shah A, Li BU, et al. Identification of specific foods responsible for inflammation in children with eosinophilic esophagitis successfully treated with empiric elimination diet. J Pediatr Gastroenterol Nutr 2011; 53(2): 145-9.
[http://dx.doi.org/10.1097/MPG.0b013e31821cf503] [PMID: 21788754]
[30]
Markowitz JE, Spergel JM, Ruchelli E, Liacouras CA. Elemental diet is an effective treatment for eosinophilic esophagitis in children and adolescents. Am J Gastroenterol 2003; 98(4): 777-82.
[http://dx.doi.org/10.1111/j.1572-0241.2003.07390.x] [PMID: 12738455]
[31]
Straumann A, Kristl J, Conus S, et al. Cytokine expression in healthy and inflamed mucosa: probing the role of eosinophils in the digestive tract. Inflamm Bowel Dis 2005; 11(8): 720-6.
[http://dx.doi.org/10.1097/01.MIB.0000172557.39767.53] [PMID: 16043986]
[32]
Blanchard C, Stucke EM, Rodriguez-Jimenez B, et al. A striking local esophageal cytokine expression profile in eosinophilic esophagitis. J Allergy Clin Immunol 2011; 127(1): 208-17.
[33]
Kinoshita Y, Furuta K, Ishimura N, Ishihara S. Elevated plasma cytokines in Japanese patients with eosinophilic esophagitis and gastroenteritis. Digestion 2012; 86(3): 238-43.
[http://dx.doi.org/10.1159/000341421] [PMID: 22964662]
[34]
Spergel JM, Rothenberg ME, Collins MH, et al. Reslizumab in children and adolescents with eosinophilic esophagitis: results of a double-blind, randomized, placebo-controlled trial. J Allergy Clin Immunol 2012; 129(2): 456-63.
[35]
Assa’ad AH, Gupta SK, Collins MH, et al. An antibody against IL-5 reduces numbers of esophageal intraepithelial eosinophils in children with eosinophilic esophagitis. Gastroenterology 2011; 141(5): 1593-604.
[http://dx.doi.org/10.1053/j.gastro.2011.07.044] [PMID: 21835135]
[36]
van Rhijn BD, Weijenborg PW, Verheij J, et al. Proton pump inhibitors partially restore mucosal integrity in patients with proton pump inhibitor-responsive esophageal eosinophilia but not eosinophilic esophagitis. Clin Gastroenterol Hepatol 2014; 12(11): 1815-23.e2.
[http://dx.doi.org/10.1016/j.cgh.2014.02.037] [PMID: 24657840]
[37]
Katzka DA, Tadi R, Smyrk TC, et al. Effects of topical steroids on tight junction proteins and spongiosis in esophageal epithelia of patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2014; 12(11): 1824-9.e1.
[http://dx.doi.org/10.1016/j.cgh.2014.02.039] [PMID: 24681080]
[38]
Lim DM, Narasimhan S, Michaylira CZ, Wang ML. TLR3-mediated NF-kappaB signaling in human esophageal epithelial cells. Am J Physiol Gastrointest Liver Physiol 2009; 297(6): G1172-80.
[http://dx.doi.org/10.1152/ajpgi.00065.2009] [PMID: 19779021]
[39]
Mulder DJ, Lobo D, Mak N, Justinich CJ. Expression of toll-like receptors 2 and 3 on esophageal epithelial cell lines and on eosinophils during esophagitis. Dig Dis Sci 2012; 57(3): 630-42.
[http://dx.doi.org/10.1007/s10620-011-1907-4] [PMID: 21960283]
[40]
Aceves SS, Ackerman SJ. Relationships between eosinophilic inflammation, tissue remodeling, and fibrosis in eosinophilic esophagitis. Immunol Allergy Clin North Am 2009; 29(1): 197-211.
[http://dx.doi.org/10.1016/j.iac.2008.10.003]
[41]
Tomasek JJ, Gabbiani G, Hinz B, Chaponnier C, Brown RA. Myofibroblasts and mechano-regulation of connective tissue remodelling. Nat Rev Mol Cell Biol 2002; 3(5): 349-63.
[http://dx.doi.org/10.1038/nrm809]
[42]
Aceves SS, Newbury RO, Dohil R, Bastian JF, Broide DH. Esophageal remodeling in pediatric eosinophilic esophagitis. J Allergy Clin Immunol 2007; 119(1): 206-12.
[http://dx.doi.org/10.1016/j.jaci.2006.10.016] [PMID: 17208603]
[43]
Kapel RC, Miller JK, Torres C, Aksoy S, Lash R, Katzka DA. Eosinophilic esophagitis: a prevalent disease in the United States that affects all age groups. Gastroenterology 2008; 134(5): 1316-21.
[http://dx.doi.org/10.1053/j.gastro.2008.02.016] [PMID: 18471509]
[44]
Prasad GA, Alexander JA, Schleck CD, et al. Epidemiology of eosinophilic esophagitis over three decades in Olmsted County, Minnesota. Clin Gastroenterol Hepatol 2009; 7(10): 1055-61.
[http://dx.doi.org/10.1016/j.cgh.2009.06.023] [PMID: 19577011]
[45]
Hruz P, Straumann A, Bussmann C, et al. Escalating incidence of eosinophilic esophagitis: a 20-year prospective, population-based study in Olten County, Switzerland. J Allergy Clin Immunol 2011; 128(6): 1349-1350.e5.
[http://dx.doi.org/10.1016/j.jaci.2011.09.013] [PMID: 22019091]
[46]
Gomez Torrijos E, Gonzalez-Mendiola R, Alvarado M, et al. 2018.
[47]
Posten S, Adamiak T, Jensen M. Pediatric Eosinophilic Esophagitis. S D Med 2018; 71(8): 362-6.
[PMID: 30110527]
[48]
Mansoor E, Cooper GS. The 2010-2015 Prevalence of Eosinophilic Esophagitis in the USA: A Population-Based Study. Dig Dis Sci 2016; 61(10): 2928-34.
[http://dx.doi.org/10.1007/s10620-016-4204-4] [PMID: 27250980]
[49]
Fahey LM, Liacouras CA. Eosinophilic Gastrointestinal Disorders. Pediatr Clin North Am 2017; 64(3): 475-85.
[http://dx.doi.org/10.1016/j.pcl.2017.01.009]
[50]
Assa’ad AH, Putnam PE, Collins MH, et al. Pediatric patients with eosinophilic esophagitis: an 8-year follow-up. J Allergy Clin Immunol 2007; 119(3): 731-8.
[http://dx.doi.org/10.1016/j.jaci.2006.10.044] [PMID: 17258309]
[51]
Gill R, Durst P, Rewalt M, Elitsur Y. Eosinophilic esophagitis disease in children from West Virginia: a review of the last decade (1995-2004). Am J Gastroenterol 2007; 102(10): 2281-5.
[http://dx.doi.org/10.1111/j.1572-0241.2007.01352.x] [PMID: 17573789]
[52]
Weiler T, Mikhail I, Singal A, Sharma H. Racial differences in the clinical presentation of pediatric eosinophilic esophagitis. J Allergy Clin Immunol Pract 2014; 2(3): 320-5.
[http://dx.doi.org/10.1016/j.jaip.2014.01.011] [PMID: 24811024]
[53]
Kubik M, Thottam P, Shaffer A, Choi S. The role of the otolaryngologist in the evaluation and diagnosis of eosinophilic esophagitis. Laryngoscope 2017; 127(6): 1459-64.
[http://dx.doi.org/10.1002/lary.26373] [PMID: 27900765]
[54]
Bohm M, Jacobs JW Jr, Gupta A, Gupta S, Wo JM. Most children with eosinophilic esophagitis have a favorable outcome as young adults. Dis Esophagus 2017; 30(1): 1-6.
[http://dx.doi.org/10.1111/dote.12454] [PMID: 26822685]
[55]
Vigier C, Henno S, Willot S, et al. 2017.
[56]
Homan M, Blagus R, Jeverica AK, Orel R. Pediatric Eosinophilic Esophagitis in Slovenia: Data From a Retrospective 2005-2012 Epidemiological Study. J Pediatr Gastroenterol Nutr 2015; 61(3): 313-8.
[http://dx.doi.org/10.1097/MPG.0000000000000797] [PMID: 26020481]
[57]
Alves Marcelino JL, Cardoso de Aguiar R, Cabral Duarte F, Célia Costa A, Pereira-Barbosa MA. Pediatric eosinophilic esophagitis in Portugal. Eur Ann Allergy Clin Immunol 2017; 49(2): 66-74.
[PMID: 28294586]
[58]
Gómez Torrijos E, Sánchez Miranda P, Donado Palencia P, et al. Eosinophilic Esophagitis: Demographic, Clinical, Endoscopic, Histologic, and Atopic Characteristics of Children and Teenagers in a Region in Central Spain. J Investig Allergol Clin Immunol 2017; 27(2): 104-10.
[http://dx.doi.org/10.18176/jiaci.0112] [PMID: 27727140]
[59]
Sun MF, Gu WZ, Peng KR, et al. Eosinophilic esophagitis in children: analysis of 22 cases 2017.
[60]
La Orden Izquierdo E, Gutiérrez Junquera C, Mahillo-Fernández I, Subiza Garrido-Lestache J, Román Riechmann E. Increasing Incidence of Pediatric Eosinophilic Esophagitis in the Southwest of Madrid, Spain. J Investig Allergol Clin Immunol 2019; 29(1): 24-9.
[http://dx.doi.org/10.18176/jiaci.0280] [PMID: 29897337]
[61]
Saeed A, Assiri AM, Al Asmi M, Ullah A. Trend, clinical presentations and diagnosis of eosinophilic esophagitis in Saudi children. Saudi Med J 2018; 39(7): 668-73.
[http://dx.doi.org/10.15537/smj.2018.7.22425] [PMID: 29968888]
[62]
Sorser SA, Barawi M, Hagglund K, et al. Eosinophilic esophagitis in children and adolescents: epidemiology, clinical presentation and seasonal variation. J Gastroenterol 2013; 48(1): 81-5.
[http://dx.doi.org/10.1016/j.jped.2013.03.001] [PMID: 23642431]
[63]
Rezende ER, Barros CP, Ynoue LH, Santos AT, Pinto RM, Segundo GR. Clinical characteristics and sensitivity to food and inhalants among children with eosinophilic esophagitis. BMC Res Notes 2014; 7: 47.
[http://dx.doi.org/10.1186/1756-0500-7-47] [PMID: 24443803]
[64]
Hoofien A, Dias JA, Malamisura M, et al. Pediatric Eosinophilic Esophagitis: Results of the European Retrospective Pediatric Eosinophilic Esophagitis Registry (RetroPEER). J Pediatr Gastroenterol Nutr 2019; 68(4): 552-8.
[http://dx.doi.org/10.1097/MPG.0000000000002215] [PMID: 30540712]
[65]
Romano C, Chiaro A, Lucarelli S, et al. Mucosal cytokine profiles in paediatric eosinophilic oesophagitis: a case-control study. Dig Liver Dis 2014; 46(7): 590-5.
[http://dx.doi.org/10.1016/j.dld.2014.03.003] [PMID: 24704289]
[66]
Liacouras CA, Spergel J, Gober LM. Eosinophilic esophagitis: clinical presentation in children. Gastroenterol Clin North Am 2014; 43(2): 219-29.
[http://dx.doi.org/10.1016/j.gtc.2014.02.012] [PMID: 24813511]
[67]
Rodrigues M, D’Amico MF, Patiño FR, Barbieri D, Damião AO, Sipahi AM. Clinical manifestations, treatment, and outcomes of children and adolescents with eosinophilic esophagitis. J Pediatr (Rio J) 2013; 89(2): 197-203.
[http://dx.doi.org/10.1016/j.jped.2013.03.001] [PMID: 23642431]
[68]
Dellon ES, Farrell TM, Bozymski EM, Shaheen NJ. Diagnosis of eosinophilic esophagitis after fundoplication for ‘refractory reflux’: implications for preoperative evaluation. Dis Esophagus 2010; 23(3): 191-5.
[http://dx.doi.org/10.1111/j.1442-2050.2009.01019.x] [PMID: 19863640]
[69]
Rea F, Caldaro T, Tambucci R, et al. Eosinophilic esophagitis: is it also a surgical disease? J Pediatr Surg 2013; 48(2): 304-8.
[70]
Hurtado CW, Furuta GT, Kramer RE. Etiology of esophageal food impactions in children. J Pediatr Gastroenterol Nutr 2011; 52(1): 43-6.
[http://dx.doi.org/10.1097/MPG.0b013e3181e67072] [PMID: 20975581]
[71]
Cheung KM, Oliver MR, Cameron DJ, Catto-Smith AG, Chow CW. Esophageal eosinophilia in children with dysphagia. J Pediatr Gastroenterol Nutr 2003; 37(4): 498-503.
[http://dx.doi.org/10.1097/00005176-200310000-00018] [PMID: 14508223]
[72]
Ettyreddy AR, Sink JR, Georg MW, Kitsko DJ, Simons JP. Association between Eosinophilic Esophagitis and Esophageal Food Impaction in the Pediatric Population. Otolaryngol Head Neck Surg 2018; 159(4): 750-4.
[http://dx.doi.org/10.1177/0194599818779049] [PMID: 29807494]
[73]
Roy-Ghanta S, Larosa DF, Katzka DA. Atopic characteristics of adult patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2008; 6(5): 531-5.
[http://dx.doi.org/10.1016/j.cgh.2007.12.045] [PMID: 18304887]
[74]
Simon D, Marti H, Heer P, Simon HU, Braathen LR, Straumann A. Eosinophilic esophagitis is frequently associated with IgE-mediated allergic airway diseases. J Allergy Clin Immunol 2005; 115(5): 1090-2.
[http://dx.doi.org/10.1016/j.jaci.2005.01.017] [PMID: 15867873]
[75]
Miehlke S, Hruz P, Vieth M, et al. A randomised, double-blind trial comparing budesonide formulations and dosages for short-term treatment of eosinophilic oesophagitis. Gut 2016; 65(3): 390-9.
[http://dx.doi.org/10.1136/gutjnl-2014-308815] [PMID: 25792708]
[76]
Spergel JM, Brown-Whitehorn TF, Cianferoni A, et al. Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet. J Allergy Clin Immunol 2012; 130(2): 461-7.e5.
[http://dx.doi.org/10.1016/j.jaci.2012.05.021] [PMID: 22743304]
[77]
Miehlke S. Clinical features of Eosinophilic esophagitis in children and adults. Best Pract Res Clin Gastroenterol 2015; 29(5): 739-48.
[http://dx.doi.org/10.1016/j.bpg.2015.09.005]
[78]
Dellon ES, Liacouras CA, Molina-Infante J, et al.
[79]
Hirano I. Eosinophilic esophagitis and gastroesophageal reflux disease: there and back again. Clin Gastroenterol Hepatol 2011; 9(2): 99-101.
[http://dx.doi.org/10.1016/j.cgh.2010.11.001] [PMID: 21070874]
[80]
Franciosi JP, Liacouras CA. Eosinophilic esophagitis. Immunol Allergy Clin North Am 2009; 29(1): 19-27.
[http://dx.doi.org/10.1016/j.iac.2008.09.001]
[81]
Carr S, Chan ES, Watson W. Eosinophilic esophagitis 2018.
[82]
Nielsen JA, Lager DJ, Lewin M, Rendon G, Roberts CA. The optimal number of biopsy fragments to establish a morphologic diagnosis of eosinophilic esophagitis. Am J Gastroenterol 2014; 109(4): 515-20.
[http://dx.doi.org/10.1038/ajg.2013.463] [PMID: 24445569]
[83]
Steiner SJ, Kernek KM, Fitzgerald JF. Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis. J Pediatr Gastroenterol Nutr 2006; 42(5): 506-9.
[http://dx.doi.org/10.1097/01.mpg.0000221906.06899.1b] [PMID: 16707971]
[84]
Spergel JM, Dellon ES, Liacouras CA, et al. Summary of the updated international consensus diagnostic criteria for eosinophilic esophagitis: AGREE conference. Ann Allergy Asthma Immunol 2018; 121(3): 281-4.
[http://dx.doi.org/10.1016/j.anai.2018.05.035] [PMID: 30030146]
[85]
Dellon ES, Speck O, Woodward K, et al. Clinical and endoscopic characteristics do not reliably differentiate PPI-responsive esophageal eosinophilia and eosinophilic esophagitis in patients undergoing upper endoscopy: a prospective cohort study. Am J Gastroenterol 2013; 108(12): 1854-60.
[http://dx.doi.org/10.1038/ajg.2013.363] [PMID: 24145677]
[86]
Warners MJ, van Rhijn BD, Curvers WL, Smout AJ, Bredenoord AJ. PPI-responsive esophageal eosinophilia cannot be distinguished from eosinophilic esophagitis by endoscopic signs. Eur J Gastroenterol Hepatol 2015; 27(5): 506-11.
[http://dx.doi.org/10.1097/MEG.0000000000000331] [PMID: 25822858]