[size=20px]A 2 year old child presents to your clinic with persistent dysphagia following esophageal atresia repair at birth. She had no complications following primary repair. She has been managed with daily PPI therapy but has had persistent dysphagia. Radiographic evaluation of the esophagus shows no evidence of stricture. She undergoes endoscopy which shows evidence of esophagitis along the distal esophagus. Biopsies reveal greater than 15 eosinophils per high power field at each of the biopsy sites. What is the best management strategy for this child?

 

A Increase to twice daily PPI therapy

 

B Refer for esophageal motility study

 

C Laparoscopic Fundoplication

 

D Swallowed viscous corticosteroid therapy

 

E H2 blocker therapy​[/size]

D

b

B

correct answer

D Swallowed viscous corticosteroid therapy

 

This child presents with persistent dysphagia following esophageal atresia repair which is not an uncommon finding. The biopsies on endoscopic evaluation are consistent with eosinophilic esophagitis. This entity has been reported as a cause of dysphagia and esophagitis in children following esophageal atresia repair. Many of these children will also have a history of atopic dermatitis or a family history of similar findings. Recognition of eosinophilic esophagitis is important to ensure appropriate treatment in children who would otherwise be deemed treatment failures for gastroesophageal reflux. In this patient, further increase in medical management of gastroesophageal reflux would not be warranted. Similarly, fundoplication would also not be useful.

 

Eosinophilic esophagitis is found in approximately 0.5 to 1 out of 1000 individuals and affects children of all ages. Unlike food allergies it is not an IgE mediated disease. Environmental exposure is felt to be a significant factor in the epidemiology of the disease and it has been associated with other intestinal conditions such as celiac disease or inflammatory bowel disease. While it has been reported in children with esophageal atresia, the causal factors are not known. Symptoms can mimic gastroesophageal reflux disease and include dysphagia, food intolerance, vomiting and abdominal pain. Evaluation requires endoscopy and biopsy. The diagnosis is made when greater than 15 eosinophils per high power field are found on biopsy. Other causes of esophagitis should be ruled out but PPI therapy is no longer required. Topical cortical steroids or food elimination therapy are the current mainstays of therapy. Repeat endoscopy and biopsy is required to evaluate for resolution of disease.