A 6-month-old boy presents with a history of gagging and emesis shortly after formula feedings. During these episodes, the child arches his back and becomes fussy according to his worried parents. His mother relates that the emesis is mostly partially-digested formula, and is non-bloody and non-bilious. These episodes occur 2 to 3 times per day, and the parents are very concerned because their child looks very uncomfortable during these episodes. His vital signs are stable. On physical exam, the pediatrician notes a well-nourished baby who is growing appropriately along the 50th percentile for all parameters, is happy and playful. The pediatrician diagnoses gastroesophageal reflux (Figure 54-1) and prescribes acid-suppression with an H2-blocker at a weight-appropriate dosing. His episodes of emesis, arching, and discomfort improve significantly.

A 12-year-old boy presents with a chief complaint of “food sticking in his throat.” He feels that it happens with several foods, and his mother states that his diet mostly consists of peanut butter sandwiches and steak. His past history is only significant for seasonal allergies. He feels that he has heartburn constantly. Trials of H2-blockers and proton pump inhibitors in the past resulted in little improvement of his symptoms. An endoscopy is performed and demonstrates white patches and concentric rings in the esophagus, with pathology results confirming a diagnosis of eosinophilic esophagitis (Figures 54-2 and 54-3).

Gastroesophageal reflux disease (GERD) is a common pediatric problem in general practice. The manifestations and mechanisms of reflux vary between infants, children, and adolescents, and is brought to attention due to the discomfort it causes in all three age ranges. GERD is defined as the passage of gastric contents into the esophagus due to relaxation of the lower esophageal sphincter.

Eosinophilic esophagitis (EoE) is a Th-2 cell mediated immune disease which causes epithelial eosinophilia in the esophagus, leading to symptoms of dysphagia and reflux symptoms refractory to acid suppression.

Reflux, gastroesophageal reflux, acid reflux, heartburn.

Eosinophilic gastroenteritis.

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  Approximately 50 to 67 percent of infants aged 3 to 4 months have reflux as reported by parents.¹

  
  
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  Prevalence decreases to 5 percent at 12 months.¹

  
  
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  Approximately 7 to 8 percent of older children and adolescents experience reflux symptoms.²

  
  
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  GERD is more common in children with neurologic impairment and has been reported in up to 77 percent in this population.³

  
  
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  The estimated prevalence of EoE is reported in children to be around 1 in 10,000.⁴

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  Reflux results from inappropriate relaxation of the lower esophageal sphincter, allowing gastric juices and contents to reflux back into the esophagus.

  
  
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  EoE is a chronic immune/antigen mediated disease which causes the build-up of eosinophils in the esophageal mucosa, leading to dysphagia, foreign body impaction, and refractory reflux symptoms.

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  Reflux risk factors include age, genetic predisposition, spicy foods, caffeine consumption, cigarette smoking, neurologic conditions such as cerebral palsy or seizure disorders, and Down Syndrome.

  
  
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  EoE risk factors include other atopic diseases (asthma, eczema, or allergic rhinitis) as well as allergies to food antigens. Genetics also play a role in EoE; in 6.8 percent of cases, there is a family member with similar symptoms.⁵