Reviewer: S. Randhawa, M.D., Allergist/Immunologist
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.
Past medical history (PMH)
Allergic rhinitis and conjunctivitis for 3 years, skin prick testing positive for house dust mite (2 years ago)
Fast medical history (FMH)
Fast medical history (FMH)
Mother with allergic rhinitis.
Medications
Medications
Prevacid (lansoprazole) daily.
Pets
Pets
Outdoor hunting dogs.
Physical examination
Physical examination
Diffuse abdominal tenderness, no rebound, normal BS, otherwise normal.
What would you do?
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?
"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?
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.
Pulmicort (budesonide) Respules, 0.5/2 mL PO bid may work better than fluticasone spray since the patients actually drinks the viscous liquid rather than using a spray.
What is the correct way to use fluticasone PO in eosinophilic esophagitis?
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?
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?
What else would you do for this patient?
He was prescribed Prevacid (lansoprazole) 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 (fluticasone) nasal spry daily and Pataday (olopatadine) eye drops daily were prescribed.
What are the typical symptoms of eosinophilic esophagitis in different age groups?
Veramyst (fluticasone) nasal spry daily and Pataday (olopatadine) 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?
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
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.
Eosinophilic Esophagitis, mind map diagram (click to enlarge the image).
References
Eosinophilic Esophagitis. NEJM, 2007.
Eosinophilic Esophagitis: Brief 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).
How to make budesonide viscous solution?
Pulmicort (budesonide) Respules, 0.5/2 mL PO bid may work better than fluticasone spray since the patients actually drinks the liquid rather than using a spray.
Mix Pulmicort Respules® (or generic budesonide) with sucralose. Each milligram of budesonide is mixed with 10 sucralose packets (Splenda®). In one pediatric study, if children's height was under 5 feet, they received 1 mg; if they were over five feet, they received 2 mg.
Summary
Eosinophilic Esophagitis, mind map diagram (click to enlarge the image).
Two inhaled corticosteroids have been used to treat eosinophilic esophagitis - fluticasone and budesonide.
The usual starting dose of budesonide in an adult is a 1 mg ampule mixed with a slurry of artificial sweetener (usually sucralose) using 10 packets, dependent upon taste, and swallowed b.i.d. In a child, 0.5 mg can be used in the same way, mixed with 5 packets.
Fluticasone is typically started at a dose of 440 mcg b.i.d. This can be lowered to 220 mcg b.i.d. subsequently.
References
Eosinophilic Esophagitis. NEJM, 2007.
Eosinophilic Esophagitis: Brief 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).
Dohil R, Newbury R, Fox L, Basian J, Aceves S. Oral viscous budesonide is effective in children with eosinophilic esophagitis in a randomized, placebo-controlled trial. Gastroenterology. 2010;139:418-429.
Eosinophilic esophagitis, from Wikipedia, the free encyclopedia. Images under the terms of the GNU Free Documentation License.
Related reading
Proton-Pump Inhibitors (PPIs) Are Associated With Increased Cardiovascular Risk Independent of Clopidogrel Use http://goo.gl/zANv
Eosinophilic esophagitis, from Wikipedia, the free encyclopedia. Images under the terms of the GNU Free Documentation License.
Related reading
Proton-Pump Inhibitors (PPIs) Are Associated With Increased Cardiovascular Risk Independent of Clopidogrel Use http://goo.gl/zANv
2 comments:
Rinse and spit. NOT rinse and swallow water. Will wash fluticasone out of the esophagus.
I don't think there is a firm recommendation whether to spit or swallow after the rinse with steroid. If you know of any studies, please post them in the comments section.
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