Pediatric Esophagitis Clinical Presentation
- Author: Gayle H Diamond, MD; Chief Editor: Carmen Cuffari, MD more...
Reflux (peptic) esophagitis
Typically, emesis is effortless and is accompanied by frequent regurgitation in infants. Less commonly, however, emesis may be forceful and projectile. Hematemesis may also be observed. Hiccoughs that last a long time and hard swallows are subtle signs of gastroesophageal reflux disease (GERD) in infants and young children.
Nonspecific signs such as crying, irritability, sleep or feeding problems, arching of the back, and colic may suggest esophageal pain in infants. Infants may also demonstrate head tilting that can mimic torticollis, neck cocking, and opisthotonic posturing with arching of the back (Sandifer syndrome) or other neurobehavioral manifestations.
Apnea, chronic respiratory illnesses (pneumonia, wheezing, stridor), and asthma exacerbation may be associated with chronic GERD. Food aversion and failure to thrive or weight loss are frequent manifestations. Anemia due to iron deficiency may result from occult blood loss.
Abdominal pain, dysphagia, heartburn, and chest or epigastric pain may occur in older children and adolescents.
Corrosive (caustic) esophagitis
Coughing, crying, and vomiting following ingestion may be initial symptoms of corrosive esophagitis. Dysphagia, refusal to drink, and mouth or chest pain with drooling and salivation may follow. Respiratory distress and stridor can result from airway obstruction and glottic edema.
To help determine the potential for morbidity, always try to obtain the original container or exact product name of the caustic substance ingested. Do not be falsely reassured by the quantity of the ingestion. Significant burns have followed minimal exposures, such as licking the bottle cap of a container that holds an alkali and eating from an unwashed spoon that had been used to measure liquid lye.
Dysphagia and chest pain may occur after ingestion of pill forms of antibiotics (eg, doxycycline, clindamycin, tetracycline) or medications including ferrous sulphate, potassium chloride, quinidine, and anti-inflammatory agents.
Mouth ulcers, thrush, fever blisters, or skin lesions (viral) may be the presenting concerns. Odynodysphagia, refusal to drink, and dysphagia may occur, especially with viral and fungal esophagitis. Fever, dyspnea, or atypical chest pain may also occur.
In immunocompetent patients, herpes simplex virus (HSV) infection can present as fever, odynodysphagia, and acute-onset retrosternal pain. Oropharyngeal lesions are usually absent. Rarely, HSV, cytomegalovirus (CMV), and HIV can cause an asymptomatic esophagitis.
Eosinophilic esophagitis can occur at any age. In infants and young children, eosinophilic esophagitis presents with symptoms similar to those of GERD (including regurgitation, irritability, food refusal, and failure to thrive in infants) but fails to respond to aggressive antireflux therapy. Dysphagia, food impaction, and chest pain may occur in older children and adolescents.
Eosinophilic esophagitis is often seen in patients with atopy who have asthma, eczema, or chronic rhinitis or in those who have a family history of atopic disease.
Retrosternal chest pain and dysphagia occur. Strictures that present as dysphagia can occur up to 10 years after the treatment.
Assess vital signs. Patients may exhibit tachypnea, increased work of breathing, tachycardia, fever, or hypoxia, especially following caustic ingestions.
Carefully examine the oropharynx for thrush (suggestive of candidal esophagitis), dental enamel and dentine erosions (suggestive of acid gastroesophageal reflux [GER]), burns, erythema, plaques, and ulcerations. Oral candidiasis is not predictive of esophageal involvement, except in the immunocompromised child. Nevertheless, extensive esophagitis may be present without oral candidiasis in immunocompromised patients.
Immunosuppressed patients with infectious esophagitis caused by herpes simplex (HSV) typically have vesicular lesions in the oropharynx. However, immunocompetent patients with esophagitis from HSV—the only viral pathogen that commonly causes esophagitis in immunocompetent hosts—usually have no oropharyngeal lesions.
Oral findings may also be absent in corrosive esophagitis, even in patients with more severe esophageal or gastric burns. In one study of patients with a history of caustic ingestion, almost 50% of patients with no oral lesions had esophageal burns, whereas only slightly more than 50% of patients with oral lesions also had esophageal lesions.
Examination of the skin may reveal eczema. The respiratory examination may reveal signs of asthma or reactive airway disease.
In newborns who have esophagitis as a complication of congenital infections, intrauterine growth retardation, lymphadenopathy, hepatitis, organomegaly, and central nervous system abnormalities can be observed.
Check stools for heme positivity in any child with possible esophagitis.
Complications of Esophagitis
Bleeding or upper airway obstruction with hemodynamic compromise and perforation of the esophagus or stomach are the most significant immediate complications. Over the long term, all types of esophagitis can be complicated by the development of strictures. After radiation therapy, strictures can occur within 1-10 years after the initial treatment.
Apnea, chronic respiratory illnesses (including asthma), and failure to thrive are not rare complications of reflux esophagitis. GERD can be complicated by Barrett esophagus and, subsequently, by adenocarcinoma, although these 2 conditions are rare in the pediatric population. Enamel and dentine erosions can complicate GERD.
The long-term complications of corrosive esophagitis include perforation, secondary bacterial infections (aspiration pneumonia, peritonitis, mediastinitis, sepsis), altered motility, and obstruction with stricture formation.
Complications of infectious esophagitis include abnormal motility, obstruction, ulceration, perforation, fistula formation, secondary bacterial infections, and hemorrhage.
Long-term complications of eosinophilic esophagitis include progressive fibrostenotic disease. This can in turn lead to food impactions and may necessitate the need for endoscopic dilatation, which puts patients at risk for perforation and mediastinitis.[24, 26]
Jensen ET, Kappelman MD, Kim HP, Ringel-Kulka T, Dellon ES. Early Life Exposures as Risk Factors Forpediatric Eosinophilic Esophagitis: A Pilot and Feasibility Study. J Pediatr Gastroenterol Nutr. 2013 Mar 19. [Medline].
Homan M, Orel R, Liacouras C. Caustic ingestion: a possible cause of eosinophilic esophagitis?. Pediatrics. 2013 Apr. 131(4):e1284-7. [Medline].
Al-Hussaini A, Al-Idressi E, Al-Zahrani M. The role of allergy evaluation in children with eosinophilic esophagitis. J Gastroenterol. 2013 Jan 11. [Medline].
[Guideline] Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007 Oct. 133(4):1342-63. [Medline].
Liacouras CA, Ruchelli E. Eosinophilic esophagitis. Curr Opin Pediatr. 2004 Oct. 16(5):560-6. [Medline].
Noel RJ, Tipnis NA. Eosinophilic esophagitis -- a mimic of GERD. Int J Pediatr Otorhinolaryngol. 2006 Jul. 70(7):1147-53. [Medline].
Freedberg DE, Lamousé-Smith ES, Lightdale JR, Jin Z, Yang YX, Abrams JA. Use of Acid Suppression Medication is Associated With Risk for C. difficile Infection in Infants and Children: A Population-based Study. Clin Infect Dis. 2015 Sep 15. 61 (6):912-7. [Medline].
Cohen S, Bueno de Mesquita M, Mimouni FB. Adverse effects reported in the use of gastroesophageal reflux disease treatments in children: a 10 years literature review. Br J Clin Pharmacol. 2015 Aug. 80 (2):200-8. [Medline].
Terrin G, Passariello A, De Curtis M, Manguso F, Salvia G, Lega L, et al. Ranitidine is associated with infections, necrotizing enterocolitis, and fatal outcome in newborns. Pediatrics. 2012 Jan. 129 (1):e40-5. [Medline].
Spergel JM, Brown-Whitehorn TF, Cianferoni A, Shuker M, Wang ML, Verma R, et al. Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet. J Allergy Clin Immunol. 2012 Aug. 130 (2):461-7.e5. [Medline].
Esophageal reflux. Walker WA, Goulet O, Kleinman RE, et al, eds. Pediatric Gastrointestinal Disease. 4th ed. Lewiston, NY: BC Decker; 2004. 400-24.
Ruchelli ED, Liacouras CA. Esophageal disorders in childhood. Russo P, Ruchelli E, Piccoli DA, eds. Pathology of Pediatric Gastrointestinal and Liver Disease. New York, NY: Springer-Verlag; 2004. 37-46.
Committee on Infectious Diseases. Candidiasis. 2006 Red Book: Report of the Committee on Infectious Diseases. American Academy of Pediatrics; 2006. 242-6.
Committee on Infectious Diseases. Cytomegalovirus infection. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. American Academy of Pediatrics; 2006. 273-7.
Committee on Infectious Diseases. Antifungal drugs for systemic fungal infection. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. American Academy of Pediatrics; 2006. 774-6.
Committee on Infectious Diseases. Antiviral drugs for non-human immunodeficiency virus infections. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. American Academy of Pediatrics; 2006. 785-9.
Committee on Infectious Diseases. Herpes simplex. In: 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. American Academy of Pediatrics; 2006. 361-71.
Rodrigues F, Brandao N, Duque V, et al. Herpes simplex virus esophagitis in immunocompetent children. J Pediatr Gastroenterol Nutr. 2004 Nov. 39(5):560-3. [Medline].
Henderson CJ, Abonia JP, King EC, Putnam PE, Collins MH, Franciosi JP, et al. Comparative dietary therapy effectiveness in remission of pediatric eosinophilic esophagitis. J Allergy Clin Immunol. 2012 Jun. 129 (6):1570-8. [Medline].
Assa'ad AH, Gupta SK, Collins MH, Thomson M, Heath AT, Smith DA, et al. An antibody against IL-5 reduces numbers of esophageal intraepithelial eosinophils in children with eosinophilic esophagitis. Gastroenterology. 2011 Nov. 141 (5):1593-604. [Medline].
Xinias I, Maris T, Mavroudi A, Panteliadis C, Vandenplas Y. Helicobacter pylori infection has no impact on manometric and pH-metric findings in adolescents and young adults with gastroesophageal reflux and antral gastritis: eradication results to no significant clinical improvement. Pediatr Rep. 2013 Feb 5. 5(1):e3. [Medline].
Ramakrishnan JB. The role of food allergy in otolaryngology disorders. Curr Opin Otolaryngol Head Neck Surg. 2010 Feb 17. [Medline].
Papadopoulou A, Koletzko S, Heuschkel R, et al. Management guidelines of eosinophilic esophagitis in childhood. J Pediatr Gastroenterol Nutr. 2014 Jan. 58 (1):107-18. [Medline].
Straumann A, Conus S, Degen L, Felder S, Kummer M, Engel H, et al. Budesonide is effective in adolescent and adult patients with active eosinophilic esophagitis. Gastroenterology. 2010 Nov. 139 (5):1526-37, 1537.e1. [Medline].
Rodrigues M, D'Amico MF, Patiño FR, Barbieri D, Damião AO, Sipahy AM. Clinical manifestations, treatment, and outcomes of children and adolescents with eosinophilic esophagitis. J Pediatr (Rio J). 2013 Mar-Apr. 89(2):197-203. [Medline].
Haddad I, Kierkus J, Tron E, Ulmer A, Hu P, Silber S, et al. Maintenance of efficacy and safety of rabeprazole in children with endoscopically proven GERD. J Pediatr Gastroenterol Nutr. 2014 Apr. 58 (4):510-7. [Medline].
Vandenplas Y, Badriul H, Verghote M, Hauser B, Kaufman L. Oesophageal pH monitoring and reflux oesophagitis in irritable infants. Eur J Pediatr. 2004 Jun. 163(6):300-4. [Medline].
Gold BD. Gastroesophageal reflux disease: could intervention in childhood reduce the risk of later complications?. Am J Med. 2004 Sep 6. 117 Suppl 5A:23S-29S. [Medline].
Boccia G, Manguso F, Miele E et el. Maintenance therapy for erosive esophagitis in children after healing by Omeprazole: is it advisable?. Am J Gastroenterol. Jun 2007. 102(6):1291-7. [Medline].
Dellon ES. Epidemiology of eosinophilic esophagitis. Gastroenterol Clin North Am. 2014 Jun. 43 (2):201-18. [Medline].
Cianferoni A, Spergel J. Eosinophilic Esophagitis: A Comprehensive Review. Clin Rev Allergy Immunol. 2015 Jul 22. [Medline].
Kim KY, Jang JY, Kim JW, Shim JJ, Lee CK, Dong SH, et al. Acid suppression therapy as a risk factor for Candida esophagitis. Dig Dis Sci. 2013 May. 58 (5):1282-6. [Medline].
Daniell HW. Acid suppressing therapy as a risk factor for Candida esophagitis. Dis Esophagus. 2015 Apr 1. [Medline].
Gupta SK, Vitanza JM, Collins MH. Efficacy and safety of oral budesonide suspension in pediatric patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2015 Jan. 13 (1):66-76.e3. [Medline].
Spergel JM. Eosinophilic esophagitis in adults and children: evidence for a food allergy component in many patients. Curr Opin Allergy Clin Immunol. June 2007. 7(3):274-8. [Medline].
Dutt P, Shukla JS, Ventateshaiah SU, Mariswamy SJ, Mattner J, Shukla A, et al. Allergen-induced interleukin-18 promotes experimental eosinophilic oesophagitis in mice. Immunol Cell Biol. 2015 Nov. 93 (10):914. [Medline].
Liacouras CA, Wenner WJ, Brown K, Ruchelli E. Primary eosinophilic esophagitis in children: successful treatment with oral corticosteroids. J Pediatr Gastroenterol Nutr. 1998 Apr. 26(4):380-5. [Medline].
Blanchard C. Molecular pathogenesis of eosinophilic esophagitis. Curr Opin Gastroenterol. 2015 Jul. 31 (4):321-7. [Medline].
Zhang S, Wu X, Yu S. Prostaglandin D2 receptor D-type prostanoid receptor 2 mediates eosinophil trafficking into the esophagus. Dis Esophagus. 2014 Aug. 27 (6):601-6. [Medline].
Mavi P, Niranjan R, Dutt P, Zaidi A, Shukla JS, Korfhagen T, et al. Allergen-induced resistin-like molecule-α promotes esophageal epithelial cell hyperplasia in eosinophilic esophagitis. Am J Physiol Gastrointest Liver Physiol. 2014 Sep 1. 307 (5):G499-507. [Medline].
Noel RJ, Rothenberg ME. Eosinophilic esophagitis. Curr Opin Pediatr. Dec 2005. 17(6):690-4. [Medline].
Dellon ES, Kim HP, Sperry SL, Rybnicek DA, Woosley JT, Shaheen NJ. A phenotypic analysis shows that eosinophilic esophagitis is a progressive fibrostenotic disease. Gastrointest Endosc. 2014 Apr. 79 (4):577-85.e4. [Medline].
Chan SK, Mahmoudi M. Eosinophilic esophagitis. Compr Ther. 2009 Fall-Winter. 35(3-4):160-6. [Medline].