Right Lower Quadrant Pain due to Eosinophilc Eosophagitis

Author: V. Dimov, M.D., Fellow, Creighton University Division of Allergy & Immunology
Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology

An 8-year-old boy is seen by his pediatrician for follow-up of abdominal pain. He had already visited the ER last week for RLQ abdominal pain and acute appendicitis had been ruled out. He complained of abdominal pain radiating to RLQ, nausea, vomiting, lack of appetite and weight loss for 6 months.

PMH:
Allergic rhinitis and conjunctivitis for 3 years, skin prick testing positive for house dust mite (2 years ago)

FMH:
Mother with allergic rhinitis

Medications:
Prevacid daily

Pets:
Outdoor hunting dogs

Physical examination:
Diffuse abdominal tenderness, no rebound, normal BS, otherwise normal.

What would you do?
The patient was referred to a gastroenterologist who performed an EGD which showed 19 eosinophils per HPF.


"Multi-ring esophagus" in eosinophilic esophagitis (left), infiltration of eosinophils (right). Source: Wikipedia.

What is the most likely diagnosis?
Eosinophilic esophagitis.

How would you treat this patient?
Fluticasone (Flovent) PO was started with rapid resolution of symptoms within 2-3 weeks. The patient's appetite improved greatly and he gained 10 pounds during a 6-month period.

What is the correct way to use fluticasone PO in eosinophilic esophagitis?
Fluticasone is used twice daily -- after breakfast and after dinner. After the puff, the patient should attempt to swallow. The same is repeated with the second puff. The mouth is rinsed with water and the water is swallowed. No food should be eaten for 2 hours.

The sequence is:
Spray, swallow.
Spray, swallow.
Rinse the mouth, swallow.

Does he need a biopsy in the future?
Yes, a repeat biopsy should be done to verify the effect of the treatment.

What else would you do for this patient?
He was prescribed Prevacid SoluTab 30 mg po qpm. PPI augments the therapeutic effect of inhaled fluticasone and a combination therapy (ICS plus PPI) should be used in all patients.

Veramyst nasal spry daily and Pataday eye drops daily were prescribed.

What are the typical symptoms of eosinophilic esophagitis in different age groups?
Infants present with vomiting.
Children present with abdominal pain and vomiting.
Older children present with the feeling that the "food is stuck."

What is the prognosis for resolution of eosinophilic esophagitis?
Uncertain.

85% of children with atopic dermatitis eventually become asymptomatic.
85% of children with asthma eventually become asymptomatic.
50% of children with allergic rhinitis eventually become asymptomatic.

There is a paucity of data to predict outcomes in eosinophilic esophagitis.

Final diagnosis:
Eosinophilic esophagitis.

References:
Eosinophilic Esophagitis. NEJM, 2007.
Eosinophilic Esophagitis: A Short Review. V. Dimov, 2008.
Esophagus - Eosinophilic Esophagitis. The DAVE Project - Gastroenterology.
Eosinophilic microabscess in eosinophilic esophagitis. JACI, Volume 119, Issue 6, Page A6 (June 2007)
Eosinophilic disorders. Current reviews of allergy and clinical immunology/Series. JACI, Volume 119, Issue 6, Pages 1291-1300 (June 2007).
Eosinophilic esophagitis, from Wikipedia, the free encyclopedia. Images under the terms of the GNU Free Documentation License.

Published: 07/16/2008
Updated: 08/22/2008