Date Published: March 24, 2016
Publisher: Springer US
Author(s): Abdulrahman Al-Hussaini, Amany AboZeid, Abdul Hai.
The clinical, endoscopic, and histologic findings of eosinophilic esophagitis (EoE) are well characterized; however, there have been very limited data regarding the radiologic findings of pediatric EoE. We report on the radiologic findings of pediatric EoE observed on barium esophagram and correlate them with the endoscopic findings.
We identified children diagnosed with EoE in our center from 2004 to 2015. Two pediatric radiologists met after their independent evaluations of each fluoroscopic study to reach a consensus on each case. Clinical and endoscopic data were collected by retrospective chart review.
Twenty-six pediatric EoE cases (age range 2–13 years; median 7.5 years) had barium esophagram done as part of the diagnostic approach for dysphagia. Thirteen children had abnormal radiologic findings of esophagus (50%): rings formation (n = 4), diffuse irregularity of mucosa (n = 8), fixed stricture formation (n = 3), and narrow-caliber esophagus (n = 10). Barium esophagram failed to show one of 10 cases of narrow-caliber esophagus and 10 of 14 cases of rings formation visualized endoscopically. The mean duration of symptoms prior to diagnosis of EoE was longer (3.7 vs. 1.7 year; p value 0.019), and the presentation with intermittent food impaction was commoner in the group with abnormal barium esophagram as compared to the group with normal barium esophagram (69% vs. 8%; p value 0.04).
Barium swallow study is frequently normal in pediatric EoE. With the exception of narrow-caliber esophagus, our data show poor correlation between radiologic and endoscopic findings.
We identified children diagnosed with EoE in our center from April 2004 to December 2015. EoE was defined as esophageal mucosal infiltration with a peak eosinophil count ≥15 eosinophils/high-powered field in biopsies obtained from multiple levels of esophagus. The hospital PACS was then used to locate barium esophagram performed in these patients. EoE cases who underwent barium esophagram within 1 week prior to upper endoscopy, were included in the study. Clinical records, laboratory data, and pathology reports were reviewed. Endoscopy reports were also reviewed for the presence or absence of a small-caliber esophagus, ringed esophagus, mucosal furrowing, white exudates, or strictures and compared with the radiological findings.
During the study period, 50 pediatric EoE cases were diagnosed (age range 1–14 years, median 8 years; 36 males). Twenty-six cases (age range 2–13 years, median 7.5 years; 19 males) had barium swallow study done within 1 week prior to upper endoscopy, as part of the diagnostic approach. The details of clinical, radiologic, and endoscopic findings of the 26 patients are shown in Table 1. The main indication for the barium studies were dysphagia and vomiting. Thirteen patients had normal barium esophagram (50%); the remaining 13 patients had abnormal fluoroscopic findings: rings formation in 4 (15%), narrow-caliber esophagus in 10 (38.5%), esophageal stricture in 3 (11.5%), and irregularity of esophageal contour in 8 patients (31%).Table 1Summary of the clinical, radiologic, and endoscopic findings of the 26 pediatric patients with EoEPatientAge (years)SexSymptomsDuration of symptoms (years)Barium swallow findingsEndoscopic findings18MaleDysphagia, weight loss1Rings in UERings, mucosal furrowing29FemaleDysphagia, intermittent food impaction3Normal“Low-grade” short narrow caliber in ME (4 cm), rings, mucosal furrowing32FemaleFFeeding difficulty vomiting, FTT1NormalMucosal furrowing44FemaleFeeding difficulty vomiting, FTT0.6Stricture at cervical region of esophagus, short narrow caliber in UE, mucosal irregularityStricture at 2 cm below UES, “intermediate-grade” short narrow caliber in UE (3 cm), white exudates, mucosal furrowing56MaleDysphagia2Rings in ME, mucosal irregularity in ME and LERings, mucosal furrowing64MaleDysphagia1Short-segment narrow caliber in LE, mucosal irregularity“intermediate-grade” short-segment narrow caliber in LE (3 cm), mucosal furrowing710MaleDysphagia, weight loss3Stricture at cervical region of esophagus, long-segment narrow caliber in UE and ME, rings in UE, mucosal irregularity in UE“High-grade” long-segment narrow caliber in UE and ME (8 cm), rings, white exudates, mucosal furrowing88MaleDysphagia, weight loss1NormalRings, white exudates, mucosal furrowing95MaleDysphagia0.8NormalMucosal furrowing104MaleDysphagia, vomiting2NormalMucosal furrowing115FDysphagia0.4NormalMucosal furrowing124MaleDysphagia2NormalMucosal furrowing, rings, white exudates1311FemaleDysphagia, intermittent food impaction3NormalMucosal furrowing, rings, white exudates145FemaleDysphagia, vomiting2NormalMucosal furrowing, white exudates1510MaleDysphagia, intermittent food impaction2Stricture at 3 cm from UES, long-segment narrow caliber in ME and LEStricture at 3 cm from UES, “high-grade” long-segment narrow caliber at UE and ME (14 cm), rings, white exudates, mucosal furrowing1612FemaleDysphagia2RingsRings, mucosal furrowing178MaleDysphagia, intermittent food impaction7Short-segment narrow caliber in ME“Intermediate-grade” short-segment narrow caliber (3 cm) in ME, rings, white exudates, mucosal furrowing1813MaleDysphagia, heart burn2NormalNormal1912MaleDysphagia, intermittent food impaction7Long-segment narrow caliber in ME and LE, Rings“Intermediate-grade” long-segment narrow caliber (8 cm), rings, white exudates, mucosal furrowing207MaleDysphagia, intermittent food impaction, weight loss2Long-segment narrow caliber in UE and ME, mucosal irregularity“Intermediate-grade” long-segment narrow caliber in UE and ME (14 cm), rings, white exudates, mucosal furrowing219MaleDysphagia, food impaction, weight loss5Narrow caliber at UE, mucosal irregularity“Intermediate-grade” short narrow caliber at UE (4 cm), white exudates, rings, mucosal furrowing2210MaleDysphagia, food impaction7Narrow short-segment caliber in ME, mucosal irregularity“High-grade” short narrow caliber at ME (4 cm), white exudates, rings, mucosal furrowing233.5MaleVomiting3NormalMucosal furrowing242.2MaleVomiting dysphagia1.5NormalMucosal furrowing258.5MaleDysphagia, food impaction1NormalWhite exudates, mucosal furrowing267MaleDysphagia, food impaction, weight loss6Long-segment narrow caliber throughout the entire course of esophagus“Low-grade” long narrow caliber (20 cm), white exudates, mucosal furrowing, mucosal ulcerF, female; FTT, failure to thrive; LE, lower esophagus; M, male; MU, mid-esophagus; UE, upper esophagus; UES, upper-esophageal sphincter
The most important finding of our study is the poor sensitivity of barium esophagram to diagnose EoE as 50% of our patients had normal fluoroscopic findings. Therefore, in order to be diagnosed with EoE, patient must undergo upper endoscopy and multiple level biopsies from esophagus to fulfill histopathological criterion (≥15 eosinophil/HPF). Another important finding is the lack of good correlation between radiologic and endoscopic findings, with the exception for esophageal stricture and narrow-caliber esophagus. These two findings speak against the routine use of esophageal fluoroscopy as a routine diagnostic test for EoE, but it can be helpful in selected cases to characterize anatomic abnormalities that can be difficult to define endoscopically and to provide information on the length and diameter of esophageal narrowing.