Celiac disease and eosinophilic esophagitis (EoE) are both immune-mediated disorders, commonly diagnosed in pediatric gastroenterology. But Arielle Bergman, MD, a pediatric gastroenterologist at NewYork-Presbyterian and Weill Cornell Medicine, says she has seen an increase in patients being diagnosed with both diseases. Below, Dr. Bergman discusses the findings from her recent study looking at the prevalence of concurrent celiac disease and EoE, and the implications this overlap has on patient care.
The Intersection of the Two Diseases
Celiac disease is an autoimmune disease that occurs in genetically susceptible individuals whereby gluten ingestion leads to an inflammatory enteropathy and a variety of potential symptoms, including abdominal pain, diarrhea, and poor growth. EoE is an atopic condition in which the esophagus develops eosinophilic inflammation in the setting of one or more food antigens. This leads to symptoms such as difficulty eating, dysphagia, abdominal pain, food impaction, and poor growth.
We know there are food triggers for both conditions. Gluten is the culprit in celiac disease. In EoE, the trigger could be any food. The most common is dairy, but wheat is among the potential etiologies for EoE. Previous studies have conflicted over the potential overlap between the two conditions.
Research Methods
We wanted to get a better understanding of the prevalence of EoE in pediatric patients with celiac disease. We conducted a retrospective study that compared characteristics of patients who have both diseases to patients with celiac disease only. Patients included in the study had to meet the definition of celiac disease based on guidelines from the North American Society for Gastroenterology, Hepatology, and Nutrition (NASPGHAN), which meant they needed to have duodenal biopsies consistent with celiac disease. For EoE, we defined those patients based on guidelines as well, which were more than 15 eosinophils per high power field on esophageal biopsies.
Key Findings
Our study demonstrated a higher proportion of EoE in pediatric patients with celiac disease than would be expected for EoE in the general pediatric population, suggesting a potential pathophysiological overlap between the two disorders.
We included 148 patients with celiac disease in our study and of those, 11 patients had both celiac and EoE (7.4%). Among the patients with both celiac and EoE:
- 27.2% reported upper gastrointestinal symptoms
- 63.4% reported abdominal pain and/or bloating
- 27.2% reported constipation
- 9.1% reported diarrhea
- 27.2% reported growth/endocrine problems
We looked at albumin, hemoglobin, and absolute eosinophil count on complete blood count as well as their tissue transglutaminase level. We found that patients with both celiac and EoE had a higher absolute eosinophil count than patients with only celiac disease — the median was 326 compared to 200.
Future Implications
The main takeaway is that we need larger prospective studies to better understand the overlap between EoE and celiac disease, to establish best practices in esophageal biopsies for patients undergoing endoscopy for celiac disease, and best treatments.
We know how many biopsies we should take for celiac disease. We have guidance for how many biopsies we need to make a diagnosis of EoE. It’s common for pediatric gastroenterologists to take at least one set of biopsies from the esophagus when performing a diagnostic endoscopy for celiac disease, often in the distal esophagus. However, I suggest that we should obtain biopsies from multiple levels in the esophagus for all patients with celiac disease, particularly if they have a higher absolute eosinophil count. This is particularly important as EoE symptoms can be very subtle.
In addition, future studies should evaluate best treatment practices for patients diagnosed with the two conditions concurrently. This study did not evaluate follow-up on these patients as there was insufficient data. However, it would be interesting to understand how effective a gluten free diet would be to treat the patient’s EoE, given that this is required to treat for celiac disease.
