Pediatric eosinophilic esophagitis: diagnostic and therapeutic insights from a 15-year retrospective study

Eosinophilic Esophagitis (EoE) is a chronic inflammatory disorder with variable macroscopic and microscopic findings and clinical presentations, complicating management. This study examines esophageal sampling practices, segmental disease patterns, and longitudinal treatment trends and outcomes in pediatric EoE. We retrospectively reviewed charts of 138 pediatric EoE patients diagnosed between 2009 and 2023. EoE was defined as compatible symptoms and ≥ 15 eosinophils per high-power-field without alternative explanation. Diagnostic endoscopy was defined as the first endoscopy performed for evaluation of symptoms showing ≥ 15 eosinophils. Data included demographics, symptoms, macroscopic/microscopic findings, sampling methods, and treatments. Mean age at diagnosis was 8.33 ± 5.37 years, 75% male. Most common presenting symptoms were vomiting (39.28%), dysphagia (32.14%) and food impaction (28.57%). Among 112 diagnostic endoscopies, macroscopic abnormalities were most frequent in the lower esophagus (85.71%), with furrows (69.64%) and exudates (55.36%) predominating. Multi-level sampling in patients with ≥ 15 eosinophils in one field, revealed < 15 eosinophils in 21.11% of upper, 7.14% of middle, and 14.14% of lower esophageal samples. Microscopic findings despite normal endoscopic appearance were most common in the upper (26.4%, p < 0.001), and less frequently in the lower (9.8% p = 0.002) esophagus. Remission following first-line therapy was achieved in 44 patients (48.35%). Biologic therapy was initiated after multiple prior treatment failures and resulted in histologic remission in all treated patients (n = 9). CONCLUSIONS: Findings indicate greater disease severity distally and underscore the need for multi-regional sampling, even in normal-appearing areas. Therapeutic responses are heterogenous and limited, and biologic therapies show promise but require validation in larger studies. WHAT IS KNOWN: • Pediatric eosinophilic esophagitis (EoE) is a chronic immune-mediated disease with variable endoscopic findings, requiring both compatible clinical features and histologic evidence of ≥15 eosinophils per high-power field. • Empiric elimination diets and proton pump inhibitors are considered first-line treatments, with variable remission rates. WHAT IS NEW: • Pan-esophageal multi-level biopsies, including from normal-appearing mucosa, improve diagnostic accuracy. • While first-line therapies show mild success rates, real-world data demonstrate complete histologic remission with biologic therapy, supporting its promise for pediatric EoE.