Researchers Try to Settle Question About Possible EoE, Celiac Link

A recent study examined a possible association in children diagnosed with celiac disease and eosinophilic gastrointestinal disorders.

Is there a connection between celiac disease (CD) and eosinophilic gastrointestinal disorders? Some case reports and observational studies have suggested a possible link, but population-based studies have not borne this out.

To probe this further, researchers investigated the prevalence of eosinophilic esophagitis (EoE) at the time of CD diagnosis.

CD is an autoimmune T-cell disorder triggered by the ingestion of gluten in genetically predisposed individuals, leading to gut inflammation and other symptoms. Avoiding gluten is the only known treatment. EoE is an inflammatory disorder marked by symptoms of esophageal dysfunction and histological evidence of eosinophil-predominant inflammation in esophageal biopsies; it is also triggered by certain food proteins, depending on the individual. A diagnosis requires persistent symptoms after excluding other causes.

However, the genetic underpinnings of each disease are different, as is the underlying mechanism of the disease process.

The authors, from 2 hospitals in Italy, aimed to investigate the prevalence of esophageal eosinophilia and EoE in a large group of children with CD, prospectively followed over 11 years. The observational study took place at the Giovanni XXII Children’s Hospital of Bari and San Paolo Hospital of Bari. The children’s hospital is the tertiary referral center for patients with pediatric CD and EoE, in an area with an estimated population of 107,000 children. The pediatric unit at San Paolo Hospital also performs pediatric endoscopies.

In 2008, a protocol was adopted where children diagnosed with CD underwent routine esophageal biopsies. For this study, eligible patients were those referred to the units from January 2008 to January 2019 who were diagnosed with CD. All patients were followed for least 1 year.

The diagnosis of CD was based on guidelines from the European Society of Gastroenterology, Hepatology and Nutrition.

At least 4 esophageal biopsies were sampled in patients who underwent endoscopy. Finding at least 15 eosinophils per high-power field (Eos/HPF) on esophageal biopsies was considered suggestive of esophageal eosinophilia, and EoE was diagnosed according to the International Consensus Diagnostic Criteria for Eosinophilic Esophagitis

A total of 465 children (male, 42%; mean [SD] age, 7.1 years [6.2]) were diagnosed with CD. Of those, 370 patients underwent endoscopy, and esophageal biopsies were available in 313.

Of the 313, 290 esophageal biopsies (93%) showed no eosinophils, 18 (5.4%) had mild eosinophilic infiltration (<14 Eos/HPF), and 5 (1.6%) had esophageal eosinophilia (≥15 Eos/HPF).

The prevalence of esophageal eosinophilia in children with CD was 1.6% (95% CI, 0.54%-2.9%), which the researchers called “an incidental finding.”

Only 1 child with CD was diagnosed with EoE, for a prevalence of 0.3% (95% CI, 0.2%-0.5).

In the general population at around the same time, the authors said they diagnosed EoE in 33 children, leading to a prevalence of EoE of 0.031% (95% CI, 0.02%-0.04%). They wrote that the odds ratio for an association between EoE and CD was at least 6.5 times higher in their study (95% CI, 0.89–47.7; P = .06) than in the general population.

Children with eosinophilic inflammation and CD were more atopic than those with CD alone, they said.

Although there were findings of an increased number of eosinophils (>15/HPF) in patients with CD, it "does not have a clinical implication or warrant intervention, and therefore we do not recommend routine esophageal biopsies unless clinically indicated," the authors concluded.


Cristofori F, D’Abramo FS, Rutigliano V, et al. Esophageal eosinophilia and eosinophilic esophagitis in celiac children: a ten year prospective observational study. Nutrients. Published online October 24, 2021. doi:10.3390/nu13113755

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