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Different facets of pediatric gastroenterology
What might a pediatrician encounter?
It has become customary for pediatricians to devote Saturdays and Sundays to improving their professional competencies. The Union of Pediatricians of Russia has for years practiced holding its congresses, conferences, and symposiums on weekends, so that more physicians have the opportunity to participate. These events also include webinars held on Saturdays.
The last Saturday before the summer break, a pediatric Saturday, was devoted to topical issues of pediatric gastroenterology. Dr. Andrei Surkov, M.D., a leading pediatric gastroenterologist, opened the event with the following topic: "Gastrointestinal tract disorders in children as a multifaceted problem.
Eosinophilic diseases are not a common pathology, but they are not casuistic either. Their prevalence is almost comparable to that of inflammatory bowel disease (IBD). Therefore, every pediatrician, pediatric gastroenterologist may encounter this pathology. They are essentially allergic diseases. The spectrum of allergens that cause them includes those found in common food allergies as well (cow's milk protein, eggs, soy, nuts, fish, wheat, etc.), but the most frequent triggers include foods that are less common in atopic dermatitis and other allergic classic diseases. These include not only wheat, but also rice, oats, and meat.
Not the carpet, but individual spots
Symptoms of eosinophilic diseases have quite a lot of overlap, especially when it comes to gastritis, enteritis, esophagitis. Nausea, vomiting, abdominal pain, diarrhea, can occur with each of them. At the same time, there are specific symptoms. For example, esophagitis is characterized by dysphagia, GERD-like symptoms, and stuck food in the esophagus, which are prevalent depending on age and on debut. Children at an early age are more likely to suffer from eating problems: difficulties in feeding, refusal to eat, and retching. A little later, vomiting comes to the fore. And in adolescence and adults, the most important symptoms are dysphagia and stuck food in the esophagus.
To diagnose eosinophilic esophagitis, as well as other eosinophilic diseases, an endoscopy and biopsy are necessary. In esophagitis, the most common endoscopic signs are white plaque (which may resemble candidiasis), longitudinal sulcus, rings, strictures, and reduced vascular pattern.
- But we should remember that the absence of endoscopic signs of eosinophilic esophagitis does not exclude the presence of this disease," M. Tkachenko emphasized. - Therefore, histological examination plays a key role. If eosinophilic esophagitis is suspected, it is necessary to take a biopsy - in children at least 6 biopsy specimens: 2 from the lower third of the esophagus, 2 from the middle and 2 from the upper one. With a smaller number of biopsy specimens, eosinophilic esophagitis can be missed, because eosinophils infiltrate the esophageal mucosa not in a carpet, but as if in spots. In addition, the number of eosinophils in a single biopsy may not reach the diagnostic limit (15 or more in the field of view).
Eosinophils may form microabscesses (it is clusters of eosinophils that appear endoscopically as white grits, white plaque). There are also other histological signs, such as degranulation of eosinophils, their location in the surface layer, as well as not very specific ones (since they also occur in reflux esophagitis): increase in basal layer thickness, papillae height and intercellular distances.
All these signs are taken into account in the diagnosis of eosinophilic esophagitis. In reality, the number of eosinophils in the field of view reaches an average of 60, so there is usually no difficulty in interpreting the histologic picture.
Elimination, and not only that.
This large number of eosinophils leads to esophageal remodeling, ring formation, and eosinophilic strictures, which are one of the causes of food getting stuck in the esophagus. Typically, pieces of meat, more often chicken, get stuck.
The remodeling process can be reversible, if anti-inflammatory therapy or nutritional therapy is intervened in time, and irreversible if conservative treatment does not help. Then it is necessary to resort to surgical methods, in particular balloon dilatation. It is therefore important to diagnose and treat eosinophilic esophagitis in a timely manner.
Why can dysphagia also occur in the absence of eosinophilic strictures? It is thought to be because of an immediate allergic reaction that occurs right at the time of feeding. It is not uncommon in patients with esophagitis, with about 40% of patients experiencing it.
Treatment of eosinophilic esophagitis includes primarily allergen elimination, as well as the use of proton pump inhibitors and inhaled steroids, and the use of monoclonal antibodies is now gaining momentum.