Clinical Implications of Pediatric Colonic Eosinophilia

Abstract

Objective: Pediatric colonic eosinophilia represents a confounding finding with a wide differential. It is often difficult to determine which children may progress to inflammatory bowel disease (IBD), which have an eosinophilic colitis (EC), and which may have no underlying pathology. There is little guidance for the practitioner on the approach to these patients. To define the clinical presentations of colonic eosinophilia and identify factors which may aid in diagnosis we reviewed patients with colonic eosinophilia and the clinicopathologic factors associated with their diagnoses.

Methods: An 8-year retrospective chart review of children whose histopathology identified colonic eosinophilia (N = 72) compared to controls with normal biopsies (N = 35).

Results: Patients with colonic eosinophilia had increased eosinophils/high-power field compared to controls (P < 0.001) and had 3 clinical phenotypes. Thirty-six percent had an inflammatory phenotype with elevated erythrocyte sedimentation rate (P < .0001), chronic inflammation on colonic biopsies (P < 0.001), and were diagnosed as having IBD. Thirty-seven percent were diagnosed as having EC, associated with male sex (P < 0.005) and peripheral eosinophilia (P = 0.041). Twenty-one percent had no significant colonic pathology. Forty-three percent of patients had >1 colonoscopy and 68% of these had change from initial diagnoses.

Conclusions: There are 3 main phenotypes of children with colonic eosinophilia. Signs of chronic systemic inflammation raise suspicion for IBD. Peripheral eosinophilia and male sex are associated with EC. A significant percent of children with colonic eosinophilia do not have colonic disease. Eosinophils/high-power field is not reliable to differentiate etiologies. Repeat colonoscopies may be required to reach final diagnoses.

Figure 1

Black error bar identifies Mean peak eosinophils/HPF (eos/HPF) in control colonic (gray square) biopsies vs. patients with colonic eosinophilia (black circle). **** p<.0001

Figure 2. A) Presenting symptoms of patients with colonic eosinophilia (percent). B) Final diagnoses of patients noted to have colonic eosinophilia (percent). Other includes

irritable bowel syndrome, EoE, lymphocytic colitis, constipation, toddler’s diarrhea (some patients received more than one final diagnosis such as EoE and EC).

Figure 3

Peak eos/HPF by location in the colon in patients with colonic eosinophilia with diagnosis of inflammatory bowel disease (IBD) and without IBD (Non-IBD). Differences in peak mean eos/HPF were significantly different in the rectosigmoid (p = 0.008)

Figure 4

A) Patient data for patients undergoing at least 2 colonoscopies B) Percent of patients with a clinically relevant change in diagnosis after repeat endoscopies. C) Diagnoses of patients after the first endoscopy and after 2 or greater endoscopies. Patients who had more than one possible diagnosis considered were labeled as Undecided. Several patients had multiple diagnoses that were not mutually exclusive and included in other.