title: Age-based differences in the diagnosis and management of esophageal eosinophilia.
abstract: BACKGROUND
  Eosinophilic esophagitis (EoE) is hallmarked by esophageal eosinophilia, >15 eosinophils(eos)/high-powered field (hpf), unresponsive to acid inhibition, and varied symptomatology. EoE consensus guidelines do not discriminate based on age for initiating treatment.
  
  
  OBJECTIVE
  To evaluate if age-related differences exist in managing esophageal eosinophilia and EoE within a university population.
  
  
  METHODS
  In a retrospective cohort study from a referral center, the medical records of 426 pediatric and adult patients with at least 1 presenting symptom of esophagitis, reflux, or upper gastrointestinal dysfunction, who underwent esophageal biopsy between 2009 and 2011 were analyzed for age-based differences in care in diagnosing and managing esophageal eosinophilia.
  
  
  RESULTS
  For these patients, 79.6% (336/426) had ≥15 eos/hpf in biopsy specimens, which was not associated with age. Significantly fewer adults than children with ≥15 eos/hpf were diagnosed with EoE (P < .001), referred for allergy evaluation (P < .001), started on swallowed steroid therapy (P < .001), or underwent repeated biopsy (P < .001). Increasing age, atopy, and increasing biopsy peak eos count moderated these effects, but the adjusted predicted probabilities for these outcomes were significantly lower among adults. Restriction for an 8-week prebiopsy proton-pump inhibitor trial did not alter the age-based relationships for an allergy referral or repeated biopsy.
  
  
  CONCLUSIONS
  Numerous age-based differences in the management of symptomatic patients with esophageal eosinophilia existed in this cohort. Adults were significantly less likely than children to receive a clinical diagnosis of EoE, allergy referral, or steroid treatment, or to have a repeated biopsy. Even when stratified for an 8-week prebiopsy proton-pump inhibitor trial, advancing age was associated with lower odds of referral or repeated biopsy. Further study is necessary to better understand why discrepancies exist and their potential ramifications.
authors.affiliation: Division of Allergy and Clinical Immunology, The Ichan School of Medicine at Mount Sinai, New York, NY; Department of Medicine and Pediatrics, The University of Michigan Health System, Ann Arbor, Mich.
authors.forename: Whitney
authors.initials: W
authors.lastname: Rassbach
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Mich.
authors.forename: Joel H
authors.initials: JH
authors.lastname: Rubenstein
authors.affiliation: Department of Pathology, SUNY Upstate Medical University, Syracuse, NY; Department of Pathology, The University of Michigan Medical School, Ann Arbor, Mich.
authors.forename: Matthew
authors.initials: M
authors.lastname: Elkins
authors.affiliation: Division of Gastroenterology, Department of Pediatrics, The University of Michigan Medical School, Ann Arbor, Mich.
authors.forename: Vera
authors.initials: V
authors.lastname: DeMatos
authors.affiliation: Department of Pathology, The University of Michigan Medical School, Ann Arbor, Mich.
authors.forename: Joel K
authors.initials: JK
authors.lastname: Greenson
authors.affiliation: The University of Michigan Food Allergy Center; Ann Arbor, Mich; Division of Allergy and Clinical Immunology, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Mich; Department of Pediatrics, Child Health Evaluation and Research Unit, The University of Michigan Medical School, Ann Arbor, Mich. Electronic address: mgreenha@med.umich.edu.
authors.forename: Matthew
authors.initials: M
authors.lastname: Greenhawt
mesh_terms: D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000367:Age Factors; D001706:Biopsy; D015331:Cohort Studies; D057765:Eosinophilic Esophagitis / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D054328:Proton Pump Inhibitors
keywords: Adults; Age; Allergy; Biopsy; Care pathways; Children; Dietary therapy; Dilation; Dysphagia; Eosinophil; Eosinophilic esophagitis; Esophageal biopsy; Esophagogastroduodenoscopy; GERD; Health disparities; Swallowed steroid therapy; TIGER