Eosinophilic esophagitis occurs in patients of every age, who can present with various symptoms including heartburn, abdominal pain, and nausea in addition to the more commonly seen dysphagia.
“Many physicians often think of eosinophilic esophagitis [EE] as a disease diagnosed in children and young adults,” wrote Dr. Robert Kapel of Danbury (Conn.) Hospital and his colleagues. “Our series demonstrates that EE is a disease which spares no age group.”
The investigators wrote that their series of 363 EE cases from 26 U.S. states is the largest yet, and they describe a disease entity with a more varied age of onset and symptomatic presentation than previously thought. “Our study highlights the need to consider this disease in patients with presentations other than dysphagia, as well as in older patients,” they said.
Dr. Kapel and his coauthors extracted their data from a national database referred to Caris Diagnostics which contains information on all patients and, which provides gastroenterology services to freestanding endoscopy centers around the country. From January 2002 through May 2006, the database included 414,600 GI pathology cases from 217 centers. Almost all of the cases (98%) were adults.
The investigators searched these cases for confirmed diagnoses of EE based on eosinophil counts on pathology slides. Cases were defined as having a mean eosinophil count of 20 in five high-powered fields, or, when five fields were unavailable, a mean of 30 or more eosinophils in two to four fields.
By using these criteria, the investigators found 363 cases of EE. The ages of cases varied widely, from 14 months to 98 years, with a mean of 38 years. A total of 321 EE patients were adults.
Most of the EE cases were male (74%). In fact, gender was a very strong predictor of EE, in that males had a threefold increased risk, compared with females. Age did not alter this risk factor; among the 42 pediatric cases, 33 (79%) were male, while among the adults, 74% were male.
The diagnosis of EE was significantly more common in children, amounting to 3% of the pediatric GI cases overall, versus 0.4% of the adult GI cases overall.
The investigators divided the peak eosinophil counts into tertiles of 20–59, 60–100, and more than 100 per high-powered field. Almost half of the cases (46%) had a peak mucosal eosinophil count exceeding 100 per field. Neither age nor gender was significantly associated with the distribution of the peak counts. Patients whose primary indication for endoscopy was dysphagia were slightly more likely to have higher peak mucosal eosinophil counts than those who did not report dysphagia.
Among adults, dysphagia was the most common indication for endoscopy (70%), followed by gastroesophageal reflux disease/heartburn (27%) and abdominal pain/dyspepsia (31%). Among children, however, the indications for endoscopy were more varied: 38% had GERD/heartburn, 31% had abdominal pain/dyspepsia, 26% had dysphagia, and 14% had nausea/vomiting.
“Adults reported dysphagia more than all other indications combined, whereas in children, it was only the third most common indication, suggesting that these groups differ in their clinical presentations,” the investigators said (Gastroenterology 2008;134:1316–21).
The authors also noted that the prevalence of EE increased significantly over the study period among patients who had dysphagia as the primary indication for endoscopy. These prevalence figures were 0.1% in 2002, 0.9% in 2003, 1.2% in 2004, and 1.9% in 2005.
“There are two possible explanations for this trend. The first is that the prevalence truly is increasing, representing an epidemic of sorts. The second is that gastroenterologists have become knowledgeable about the disease, and their choice of whom to biopsy has become more targeted,” the authors said.