Introduction

Long-standing inflammation leads to esophageal remodeling with stricture formation in adult patients with eosinophilic esophagitis (EoE). In contrast, it has long been considered that children with EoE had predominantly inflammatory changes. Recent studies have shown that fibrous remodeling is also present in children with EoE and strictures can be even present at disease onset in some cases. Proton pump inhibitors (PPI) are the most widely used first-line treatment for EoE in children. The ability of PPI to reverse the endoscopic features of inflammation and fibrosis in the pediatric population with EoE is still unknown.

Aims & Methods

To investigate the effect of a short course of PPI treatment in reducing endoscopic findings indicative of esophageal inflammation and fibrosis in pediatric patients with EoE (aged below 16y). A cross-sectional analysis of the EoE CONNECT registry retrieved prospective data from pediatric patients recruited at 22 hospitals (located in Spain, Italy and France) who received PPI in monotherapy to induce remission of EoE and had changes in symptoms, histology and endoscopy assessed. The EoE Endoscopic Reference Score (EREFS) was used to grade endoscopic features. Rings and strictures were classified as fibrotic features while edema, furrows and exudates were defined as inflammatory ones. Clinico-histological remission (CHR) was defined as the simultaneous combination of symptomatic remission or improvement and histological remission (defined as peak eosinophil count <15 eosinophils/high power field).

Results

Overall, 252 pediatric EoE patients received PPI to induce disease remission. Age (mean±SD) at diagnosis was 11,5±4,3 and 198 (79%) were male. Mean treatment length with PPI was 91 days (range 67-131). CHR was achieved in 105 out of 252 pediatric patients treated with PPI (41,7%). Overall, EoE therapy led to significant reductions in mean±SD EREFS total score from baseline in the whole series of PPI treated patients (2.69 ±1.50 vs. 1.43±1.44; p<0.001), despite over half of patient did not achieve CHR. Reductions in EREFS total score from baseline were even greater among patients who achieved CHR of EoE (2.58±1.59 vs. 0.45±0.66; p<0.001). When changes in EREFS inflammatory subscore components were analyzed in PPI-responder patients (those who achieved CHR), edema (0,66±0,48 vs. 0.11±0.28, p<0,001), furrows (0,72±0,51 vs 0.21±0.21, p<0,001) and exudates features (0,69±0,48 vs. 0.06±0.18, p<0,001) all reduced from baseline. More importantly, the EREFS fibrotic subscore also reduced in PPI responders for rings (0,18±0,38 vs. 0.03±0.17, p=0,01); as for strictures preventing the passage of the endoscope, these were present at baseline in only two pediatric patients and disappeared after PPI therapy.

Conclusion

Our results provide evidence on the effectiveness of anti-inflammatory therapy with PPI to reverse fibrotic, aside of inflammatory features, of EoE in those pediatric patients who achieved CHR after an average of 3-month length induction treatment.

References

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