Pediatric eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease of the esophagus that has emerged as a major cause of esophageal dysfunction in all ages. Over the past two decades, its frequency has increased worldwide, reflecting both heightened recognition and a rise in occurrence. EoE predominantly affects males and frequently coexists with atopic conditions, underscoring its relationship with allergy. The pathogenesis involves genetic susceptibility, epithelial barrier dysfunction, and dysregulated type 2 immune responses. Variants in genes related to epithelial integrity and immune signaling, such as TSLP and CAPN14, predispose susceptible individuals to aberrant immune responses to food antigens, leading to eosinophil recruitment, mast cell activation, and chronic inflammation, which in turn promotes tissue remodeling and progression toward fibrostenotic disease. Clinical presentation varies with age. Infants and younger children often exhibit feeding difficulties, vomiting, and abdominal pain, whereas older children and adolescents usually present with dysphagia and food impaction. Diagnosis requires integration of clinical symptoms with histologic confirmation of esophageal eosinophilia (≥ 15 eosinophils per high-power field) and exclusion of alternative causes. Management of pediatric EoE aims to achieve and maintain clinical and histologic remission while preventing long-term complications and preserving quality of life. First-line therapeutic options include proton pump inhibitors, swallowed topical corticosteroids, and dietary elimination strategies. Biologic therapy has expanded treatment options for severe or refractory disease. Because symptom improvement alone does not reliably reflect disease control, objective reassessment with endoscopy and biopsies is recommended after treatment and during follow-up. Long-term outcomes of EoE are strongly influenced by diagnostic timing and adequacy of treatment. Early diagnosis, sustained anti-inflammatory therapy, and transition from pediatric to adult care are critical components of an appropriate management. Future directions include the development of precision medicine, identification of biomarkers to guide therapy selection, non-invasive tools for disease monitoring, and strategies aimed at disease modification.