Research Article

Risk factors for esophageal strictures in children and adolescents with eosinophilic esophagitis

Vijayalakshmi Kory*, Thirumazhisai S Gunasekaran, Kumail Hussain, Tiffany Patton, Yi Li, Cheryl LeFaiver and James Berman

Published: 27 October, 2022 | Volume 5 - Issue 1 | Pages: 033-038

Studies in children with eosinophilic esophagitis (EoE) have reported esophageal strictures but none have examined risk factors associated with strictures. 
Aim: To assess risk factors associated with strictures in children with EoE. 
Methods: In this retrospective study, children with EoE seen over 20 years were separated into two groups; with and without strictures. Physical features, CBC, endoscopic findings, and biopsy of the distal and mid-esophagus were captured. Statistical significance with p - value and multivariate logistic regression was done. 
Results: Total patients 222 and 20 (9.1%) had strictures. Mean age of stricture patients 12.7 years (range 7-18) and non-stricture 9.3 years (range 1-17) (p = 0.006). Among stricture patients following were prevalent and significant; dysphagia (stricture 100% vs. non-stricture 41.6%, 
p = 0.0005) and food impaction (70.04% vs. 4%, p = 0.0005); EGD: rings and exudates were strongly associated with stricture, 45.0% vs. 4.5%, p = 0.0005 and 60% vs. 30.7%, p = 0.008, respectively. Abdominal pain was lower in the stricture group (5% vs. 31.2%, p = 0.017). Eosinophil counts were numerically more in the stricture group but not significant. Multivariate logistic regression confirmed that strictures are likely to 
occur among patients with dysphagia (p = 0.02, OR = 11.7, 95% LCL 2.0) and food impaction (p = 0.0001, OR = 80.9, 95% LCL 15.4), respectively, adjusted for age and gender. 
Conclusion: EoE children with dysphagia or food impaction have a higher chance of having an esophageal stricture. These EoE children 12 years or over with exudates or rings on endoscopy, should be treated and carefully monitored, to reduce the risk of stricture formation.

Read Full Article HTML DOI: 10.29328/journal.japch.1001050 Cite this Article Read Full Article PDF


Eosinophilic esophagitis; Risk factors; Dysphagia; Strictures; Food impaction


  1. Dellon ES, Liacouras CA, Molina-Infante J, Furuta GT, Spergel JM, Zevit N, Spechler SJ, Attwood SE, Straumann A, Aceves SS, Alexander JA, Atkins D, Arva NC, Blanchard C, Bonis PA, Book WM, Capocelli KE, Chehade M, Cheng E, Collins MH, Davis CM, Dias JA, Di Lorenzo C, Dohil R, Dupont C, Falk GW, Ferreira CT, Fox A, Gonsalves NP, Gupta SK, Katzka DA, Kinoshita Y, Menard-Katcher C, Kodroff E, Metz DC, Miehlke S, Muir AB, Mukkada VA, Murch S, Nurko S, Ohtsuka Y, Orel R, Papadopoulou A, Peterson KA, Philpott H, Putnam PE, Richter JE, Rosen R, Rothenberg ME, Schoepfer A, Scott MM, Shah N, Sheikh J, Souza RF, Strobel MJ, Talley NJ, Vaezi MF, Vandenplas Y, Vieira MC, Walker MM, Wechsler JB, Wershil BK, Wen T, Yang GY, Hirano I, Bredenoord AJ. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology. 2018 Oct;155(4):1022-1033.e10. doi: 10.1053/j.gastro.2018.07.009. Epub 2018 Sep 6. PMID: 30009819; PMCID: PMC6174113.
  2. Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, Burks AW, Chehade M, Collins MH, Dellon ES, Dohil R, Falk GW, Gonsalves N, Gupta SK, Katzka DA, Lucendo AJ, Markowitz JE, Noel RJ, Odze RD, Putnam PE, Richter JE, Romero Y, Ruchelli E, Sampson HA, Schoepfer A, Shaheen NJ, Sicherer SH, Spechler S, Spergel JM, Straumann A, Wershil BK, Rothenberg ME, Aceves SS. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011 Jul;128(1):3-20.e6; quiz 21-2. doi: 10.1016/j.jaci.2011.02.040. Epub 2011 Apr 7. PMID: 21477849.
  3. Furuta GT, Liacouras CA, Collins MH, Gupta SK, Justinich C, Putnam PE, Bonis P, Hassall E, Straumann A, Rothenberg ME; First International Gastrointestinal Eosinophil Research Symposium (FIGERS) Subcommittees. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007 Oct;133(4):1342-63. doi: 10.1053/j.gastro.2007.08.017. Epub 2007 Aug 8. PMID: 17919504.
  4. Baker RD, Baker SS. Towards Better Diagnosis and Monitoring of Eosinophilic Esophagitis: Are We There Yet? J Pediatr Gastroenterol Nutr. 2020 Apr;70(4):410. doi: 10.1097/MPG.0000000000002603. PMID: 31880661.
  5. Dellon ES, Jensen ET, Martin CF, Shaheen NJ, Kappelman MD. Prevalence of eosinophilic esophagitis in the United States. Clin Gastroenterol Hepatol. 2014 Apr;12(4):589-96.e1. doi: 10.1016/j.cgh.2013.09.008. Epub 2013 Sep 11. PMID: 24035773; PMCID: PMC3952040.
  6. Soon IS, Butzner JD, Kaplan GG, deBruyn JC. Incidence and prevalence of eosinophilic esophagitis in children. J Pediatr Gastroenterol Nutr. 2013 Jul;57(1):72-80. doi: 10.1097/MPG.0b013e318291fee2. PMID: 23539047..
  7. Odze RD. Pathology of eosinophilic esophagitis: what the clinician needs to know. Am J Gastroenterol. 2009 Feb;104(2):485-90. doi: 10.1038/ajg.2008.40. Epub 2009 Jan 13. PMID: 19174804.
  8. Straumann A, Bauer M, Fischer B, Blaser K, Simon HU. Idiopathic eosinophilic esophagitis is associated with a T(H)2-type allergic inflammatory response. J Allergy Clin Immunol. 2001 Dec;108(6):954-61. doi: 10.1067/mai.2001.119917. PMID: 11742273.
  9. Rawson R, Yang T, Newbury RO, Aquino M, Doshi A, Bell B, Broide DH, Dohil R, Kurten R, Aceves SS. TGF-β1-induced PAI-1 contributes to a profibrotic network in patients with eosinophilic esophagitis. J Allergy Clin Immunol. 2016 Sep;138(3):791-800.e4. doi: 10.1016/j.jaci.2016.02.028. Epub 2016 Apr 8. PMID: 27212082; PMCID: PMC5014565.
  10. Yang ZC, Yi MJ, Ran N, Wang C, Fu P, Feng XY, Xu L, Qu ZH. Transforming growth factor-β1 induces bronchial epithelial cells to mesenchymal transition by activating the Snail pathway and promotes airway remodeling in asthma. Mol Med Rep. 2013 Dec;8(6):1663-8. doi: 10.3892/mmr.2013.1728. Epub 2013 Oct 14. PMID: 24126595.
  11. Kagalwalla AF, Akhtar N, Woodruff SA, Rea BA, Masterson JC, Mukkada V, Parashette KR, Du J, Fillon S, Protheroe CA, Lee JJ, Amsden K, Melin-Aldana H, Capocelli KE, Furuta GT, Ackerman SJ. Eosinophilic esophagitis: epithelial mesenchymal transition contributes to esophageal remodeling and reverses with treatment. J Allergy Clin Immunol. 2012 May;129(5):1387-1396.e7. doi: 10.1016/j.jaci.2012.03.005. Epub 2012 Apr 1. PMID: 22465212; PMCID: PMC3340537.
  12. Aceves SS. Remodeling and fibrosis in chronic eosinophil inflammation. Dig Dis. 2014;32(1-2):15-21. doi: 10.1159/000357004. Epub 2014 Feb 28. PMID: 24603375; PMCID: PMC4037288.
  13. Hirano I, Pandolfino JE, Boeckxstaens GE. Functional lumen imaging probe for the management of esophageal disorders: expert review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017; 15: 325-334.
  14. Dellon ES, Kim HP, Sperry SL, Rybnicek DA, Woosley JT, Shaheen NJ. A phenotypic analysis shows that eosinophilic esophagitis is a progressive fibrostenotic disease. Gastrointest Endosc. 2014 Apr;79(4):577-85.e4. doi: 10.1016/j.gie.2013.10.027. Epub 2013 Nov 23. PMID: 24275329; PMCID: PMC4599711.
  15. Kim JP, Weingart G, Hiramoto B, Gregory DL, Gonsalves N, Hirano I. Clinical outcomes of adults with eosinophilic esophagitis with severe stricture. Gastrointest Endosc. 2020 Jul;92(1):44-53. doi: 10.1016/j.gie.2020.01.015. Epub 2020 Jan 16. PMID: 31954704.
  16. Al-Hussaini A. Savary Dilation Is Safe and Effective Treatment for Esophageal Narrowing Related to Pediatric Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr. 2016 Nov;63(5):474-480. doi: 10.1097/MPG.0000000000001247. PMID: 27111342; PMCID: PMC5084639.
  17. Gunasekaran T, Kory V, Li Y.Esophageal Strictures in Pediatric Patients with Eosinophilic Esophagitis; Short Segment Stricture Vs. Narrow Caliber Esophagus. SF Hepatology Gastroenterology 2020; 1(1):1003. https://scienceforecastoa.com/Articles/HG-V1-E1-1003.pdf
  18. Gunasekaran T, Kory V, Sonawane SS.Comprehensive Comparison of Dysphagia Predominant Eosinophilic Esophagitis, with and without Food Impaction: 101 Children and Adolescents. SN Compr. Clin. Med. 2021;3: 2134-2140. https://doi.org/10.1007/s42399-02100889-1
  19. Franciosi JP, Hommel KA, DeBrosse CW, Greenberg AB, Greenler AJ, Abonia JP, Rothenberg ME, Varni JW. Development of a validated patient-reported symptom metric for pediatric eosinophilic esophagitis: qualitative methods. BMC Gastroenterol. 2011 Nov 18;11:126. doi: 10.1186/1471-230X-11-126. PMID: 22099448; PMCID: PMC3228698.
  20. Dohil R, Newbury R, Fox L, Bastian J, Aceves S. Oral viscous budesonide is effective in children with eosinophilic esophagitis in a randomized, placebo-controlled trial. Gastroenterology. 2010 Aug;139(2):418-29. doi: 10.1053/j.gastro.2010.05.001. Epub 2010 May 7. PMID: 20457157.
  21. Gunasekaran T, Prabhakar G, Schwartz A, Gorla K, Gupta S, Berman J. Eosinophilic Esophagitis in Children and Adolescents with Abdominal Pain: Comparison with EoE-Dysphagia and Functional Abdominal Pain. Can J Gastroenterol Hepatol. 2016;2016:4123692. doi: 10.1155/2016/4123692. Epub 2016 Aug 16. PMID: 27610357; PMCID: PMC5004036.
  22. Gunasekaran TS, Chu C, Ronquillo N Jr, Chennuri R, Adley B, Borgen K, Schwartz A, Newberry R, Berman J. Detailed Histologic Evaluation of Eosinophilic Esophagitis in Pediatric Patients Presenting with Dysphagia or Abdominal Pain and Comparison of the Histology between the Two Groups. Can J Gastroenterol Hepatol. 2017;2017:3709254. doi: 10.1155/2017/3709254. Epub 2017 Dec 17. PMID: 29392125; PMCID: PMC5748089. 
  23. Arias Á, Lucendo AJ. Epidemiology and risk factors for eosinophilic esophagitis: lessons for clinicians. Expert Rev Gastroenterol Hepatol. 2020 Nov;14(11):1069-1082. doi: 10.1080/17474124.2020.1806054. Epub 2020 Aug 24. PMID: 32749898.
  24. Ferguson AE, Fulkerson PC. Eosinophilic esophagitis: Time to classify into endotypes? J Allergy Clin Immunol. 2018 Jul;142(1):71-72. doi: 10.1016/j.jaci.2018.04.025. Epub 2018 May 8. PMID: 29751005; PMCID: PMC8034426.
  25. Schoepfer AM, Safroneeva E, Bussmann C, Kuchen T, Portmann S, Simon HU, Straumann A. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology. 2013 Dec;145(6):1230-6.e1-2. doi: 10.1053/j.gastro.2013.08.015. Epub 2013 Aug 13. PMID: 23954315.
  26. Lipka S, Kumar A, Richter JE. Impact of Diagnostic Delay and Other Risk Factors on Eosinophilic Esophagitis Phenotype and Esophageal Diameter. J Clin Gastroenterol. 2016 Feb;50(2):134-40. doi: 10.1097/MCG.0000000000000297. PMID: 25710524.
  27. Kim JP, Weingart G, Hiramoto B, Gregory DL, Gonsalves N, Hirano I. Clinical outcomes of adults with eosinophilic esophagitis with severe stricture. Gastrointest Endosc. 2020 Jul;92(1):44-53. doi: 10.1016/j.gie.2020.01.015. Epub 2020 Jan 16. PMID: 31954704.
  28. Eluri S, Tappata M, Huang KZ, Koutlas NT, Robey BS, Fan C, Reed CC, Shaheen NJ, Dellon ES. Distal esophagus is the most commonly involved site for strictures in patients with eosinophilic esophagitis. Dis Esophagus. 2020 Mar 5;33(2):doz088. doi: 10.1093/dote/doz088. PMID: 31778150 .
  29. Warners MJ, Oude Nijhuis RAB, de Wijkerslooth LRH, Smout AJPM, Bredenoord AJ. The natural course of eosinophilic esophagitis and long-term consequences of undiagnosed disease in a large cohort. Am J Gastroenterol. 2018 Jun;113(6):836-844. doi: 10.1038/s41395-018-0052-5. Epub 2018 Apr 27. PMID: 29700481.
  30. Gunasekaran TS, Chu C, Ronquillo N Jr, Chennuri R, Adley B, Borgen K, Schwartz A, Newberry R, Berman J. Detailed Histologic Evaluation of Eosinophilic Esophagitis in Pediatric Patients Presenting with Dysphagia or Abdominal Pain and Comparison of the Histology between the Two Groups. Can J Gastroenterol Hepatol. 2017;2017:3709254. doi: 10.1155/2017/3709254. Epub 2017 Dec 17. PMID: 29392125; PMCID: PMC5748089.
  31. Liacouras CA, Spergel JM, Ruchelli E, Verma R, Mascarenhas M, Semeao E, Flick J, Kelly J, Brown-Whitehorn T, Mamula P, Markowitz JE. Eosinophilic esophagitis: a 10-year experience in 381 children. Clin Gastroenterol Hepatol. 2005 Dec;3(12):1198-206. doi: 10.1016/s1542-3565(05)00885-2. PMID: 16361045.
  32. Hoofien A, Dias JA, Malamisura M, Rea F, Chong S, Oudshoorn J, Nijenhuis-Hendriks D, Otte S, Papadopoulou A, Romano C, Gottrand F, Miravet VV, Orel R, Oliva S, Junquera CG, Załęski A, Urbonas V, Garcia-Puig R, Gomez MJM, Dominguez-Ortega G, Auth MK, Kori M, Ben Tov A, Kalach N, Velde SV, Furman M, Miele E, Marderfeld L, Roma E, Zevit N. Pediatric Eosinophilic Esophagitis: Results of the European Retrospective Pediatric Eosinophilic Esophagitis Registry (RetroPEER). J Pediatr Gastroenterol Nutr. 2019 Apr;68(4):552-558. doi: 10.1097/MPG.0000000000002215. PMID: 30540712.
  33. Hoofien A, Rea F, Espinheira MDC, Amil Dias J, Romano C, Oliva S, Auth MK, Zangen T, Kalach N, Domínguez-Ortega G, De Angelis P, Zevit N; ESPGHAN EGID Working Group. Systemic steroids have a role in treating esophageal strictures in pediatric eosinophilic esophagitis. Dig Liver Dis. 2021 Mar;53(3):324-328. doi: 10.1016/j.dld.2020.11.025. Epub 2020 Dec 15. PMID: 33334703.
  34. Menard KC, Benitez A, Pan Z, Faria A .Influence of age and esosinophilic esophagitis in esophageal distensibility in pediatric cohort. Am J Gastroenterol 2017; 112:1466-1473.


Similar Articles

Recently Viewed

Read More

Most Viewed

Read More

Help ?