Endoscopic Evaluation of Patients With Food Allergy for Eosinophilic Esophagitis Before Oral Immunotherapy.

Abstract

In recent years, it has been argued that eosinophilic esophagitis (EoE) seen in the early period of oral immunotherapy (OIT) may exist before OIT. We sought to evaluate the presence of EoE before initiating OIT and identify risk factors (during fetal development, infancy, and environmental exposures) for its development. A total of 48 patients who underwent endoscopic evaluation before OIT were enrolled. We scored endoscopic findings using the EoE Endoscopic Reference Score (EREFS) and histopathologic evaluation using the Eosinophilic Esophagitis Histologic Scoring System. The Index of Severity for EoE was used to evaluate disease activity. There were pathologic endoscopic findings in 36 patients (75%), and the median EREFS was 2 (minimum of 0 to maximum of 7). Only seven patients (14.5%) had normal histology, 16 (33.3%) had esophageal eosinophilia (EE), and five (10.4%) had low-grade eosinophilia (5 to 15 eosinophils/hpf). Although all children were asymptomatic, only four patients (8.3%) had normal endoscopic and histopathologic findings. Furrows, total EREFS, and both inflammatory and fibrostenotic scores on the Index of Severity for EoE were statistically significantly higher in the EE group (P = .013, P = .008, P < .01, and P = .005, respectively). We found an approximately five times increased risk of EE (odds ratio = 5.444; 95% CI, 1.290-22.976; P = .021) when patients had any three risk factors combined among fetal and infant period factors (maternal fever, cesarean delivery, formula feeding, antibiotic use, and neonatal intensive care admission). Given the significantly increased risk of EE in children with a combination of early life risk factors, a risk-stratified approach to endoscopic evaluation may be warranted before OIT initiation.