Eosinophilic esophagitis in children and adults.

G&H How do the presenting symptoms of children with eosinophilic esophagitis compare to those in adults with this disease?GTF The presenting symptoms of patients with eosin-ophilic esophagitis vary between children and adults. In children, symptoms may be nonspeciﬁc such as abdomi-nal pain or those symptoms associated with gastroesopha-geal reﬂux disease (GERD), including vomiting, nausea, or heartburn. Less commonly described are nondescript signs and symptoms of feeding diﬃculties in younger children. Finally, if children’s GERD-like symptoms are not improving with antireﬂux treatments such as proton pump inhibitors or Nissen fundoplication, eosinophilic esophagitis should be strongly considered.In contrast, most adults with eosinophilic esophagi-tis present in a typical fashion with either food impaction or dysphagia. Desai and associates showed that eosino-philic esophagitis was the main cause of food impaction seen in a suburban private practice setting. Increasing numbers of studies from various centers across the world have shown that dysphagia is another common symptom associated with eosinophilic esophagitis. A smaller group of patients may present with chest pain likely related to esophageal spasm.G&H Is eosinophilic esophagitis more prevalent in children than in adults?GTF Eosinophilic esophagitis has an interesting history in that Straumann and colleagues and Atwell and associ-ates originally described it in adults in the early 1990s. Over the next decade, pediatricians then took the lead in the identiﬁcation of clinical features and treatment of the disease. Recently, studies in adults have re-emerged, emphasizing the importance of this disease. Thus, we do not yet have long-term studies on the exact incidence, prevalence, or natural history of the disease in either of these patient populations, though data from Rothenberg and colleagues suggest a prevalence of 1–4 per 10,000 children. Similar ﬁndings will likely emerge from adults during the next decade. The American Partnership for Eosinophilic Diseases (APFED.org) recently sponsored successful eﬀorts to adopt an ICD-10 code for eosinophilic esophagitis (new code: 530.13). These codes are important for practitioners to use for tracking both incidence and epidemiology as well as for billing appropriately for this disease. G&H What is the current understanding of the cause of eosinophilic esophagitis? GTF As in many diseases, a genetically predisposed host encounters an environmental trigger, leading to symptoms and disease phenotype. This paradigm appears to hold true for many of the patients with eosinophilic esophagi-tis. One landmark study identiﬁed speciﬁc gene patterns associated with eosinophilic esophagitis in children, in particular the gene eotaxin-3. Eotaxin 3 is a molecule that is critical for eosinophil migration to tissue spaces. One could speculate that when an exogenous food or aeroallergen encounters the esophageal mucosa, eotaxin 3 production is stimulated, leading to eosinophilic inﬂam-mation with large numbers of eosinophils and eosinophil microabscess formation. This inﬂammatory pattern pro-vides the histologic hallmark of the disease. G&H Could you explain the difficulties of confirming a diagnosis of eosinophilic esophagitis in patients?GTF Since eosinophilic esophagitis is a relatively new disease with only recently identiﬁed diagnostic guidelines, clinicians must rely on both clinical and histologic data