Background: The presence of an increased eosinophil count in the esophageal mucosa is most commonly a result of gastroesophageal reflux and eosinophilic esophagitis (EoE). The latter is an uncommon problem that has been increasingly reported in the general population over the past 3 decades. The prevalence of EoE has also been shown to have increased during this time and it is estimated to occur in up to 0.1% of the pediatric population. In a proportion of children EoE may be related to food allergies. Food allergy is reported after solid organ transplantation.  Here we examined the nature of esophageal eosinophilia in our pediatric patients who have undergone intestinal transplantation.

Method: We reviewed patient charts and databases of the Transplant Institute at the MedStar Georgetown University Hospital. Data on pediatric patients transplanted between 2004 and 2012 was examined. As part of the institute protocol upper endoscopy is performed annually in pediatric patients from the first year after intestinal transplantation.

Results: Of 79 patients that had undergone intestinal transplantation 19 (24%) were found to have eosinophilia on mucosal biopsy of the esophagus. Of these 13 (68%) were male. The age at transplantation was, mean 2.7 + 2.3 years, median 2.1, range 0.6-9.3. Indications for transplantation were, gastroschesis (n= 5), necrotizing enterocolitis (n= 4), malrotation/volvulus (n= 4), pseudoobstruction (n= 4), intestinal atresia (n= 2). Then majority of transplanted grafts were liver and small bowel (n=11, 2 included a colon). The remaining grafts were, isolated small bowel (n=3), small bowel with colon (n=2) and multivisceral transplants (n=2). The time from transplantation to maximal eosinophilia was, mean 4.1 + 2.0 years, median 3.7, range 0.7-7.6. Endoscopic and pathologic reports available in 17/19. In 11/17 (65%) the endoscopic appearance of the esophagus was typical of EoE (characterized by linear furrows or trachealization), in 2/17 (12%) the visual features favored reflux esophagitis and in 4/17 (24%) the esophagus appeared normal. Histological evidence of EoE (>15 eosinophils/high power field) was present 12/17 (71%) and 9 of these 12 (75%) had the typical endoscopic and histologic findings of EoE indicating 9/79 (11%) prevalence of EoE in our patients. Regression showed a strong inverse correlation between the year of transplantation and the time to development of esophageal eosinophilia (Figure), R sq. = 72.3, p=0.00.

Conclusion: Eosinophilic esophagitis occurs in patients who have undergone intestinal transplantation. Patients should be screened routinely.