Integrating PEESS, EREFS, and endoscopic ultrasonography in the multimodal management of pediatric eosinophilic esophagitis: A 4-year retrospective institutional experience

Pediatric eosinophilic esophagitis (EoE) is a chronic, immune-mediated disorder defined by esophageal dysfunction and eosinophilic infiltration of the esophageal mucosa. Its incidence is increasing, particularly among children. However, assessing disease severity and monitoring treatment response over time remain challenging. Conventional histological methods often fail to capture ongoing inflammation or predict symptom recurrence. This study aimed to evaluate the utility of a multimodal approach incorporating clinical symptom scoring (Pediatric Eosinophilic Esophagitis Symptom Score [PEESS]), endoscopic findings (Eosinophilic Esophagitis Reference Score [EREFS]), and subepithelial imaging (endoscopic ultrasonography [EUS]) for the diagnosis, treatment monitoring, and long-term follow-up of pediatric EoE. We conducted a retrospective review of 23 pediatric patients diagnosed with EoE between 2018 and 2022 at a tertiary care center. Diagnosis was based on clinical presentation, endoscopic appearance, and histological confirmation (≥15 eosinophils/high-power field). All patients received a combination of proton pump inhibitors, topical corticosteroids, and personalized elimination diets. PEESS and EREFS scores were assessed before and after treatment. EUS was performed in a subset of patients to evaluate esophageal wall changes. The median age at diagnosis was 11 years. Atopic comorbidities were identified in 82.6% of patients. Post-treatment, both PEESS and EREFS scores showed significant improvements. Histological remission was achieved in 95.6% of cases. Among the 8 patients who underwent EUS, persistent esophageal wall thickening was observed despite mucosal healing, suggesting ongoing subepithelial inflammation. Long-term dietary management without steroids was successful in a subset of patients after initial remission. PEESS and EREFS are valuable, complementary tools for assessing treatment response in pediatric EoE. EUS provides additional insights into residual disease activity beyond mucosal healing. This multimodal evaluation may facilitate personalized, less-invasive, and more effective long-term management of pediatric EoE.