Incidental finding of esophageal eosinophilia in patients investigated for suspected celiac disease: results from a pediatric retrospective study.

Incidental esophageal eosinophilia (EE) can be detected in children investigated for suspected celiac disease (CD), but the relationship between CD and eosinophilic esophagitis (EoE) remains unclear. This study describes the characteristics of these patients and evaluates whether EE resolves on a gluten-free diet (GFD). This retrospective study included all patients < 18 years biopsied for suspected CD (2018-2025). When esophageal abnormalities were observed, additional biopsies were taken. Cases (CD + EE) had positive antitransglutaminase antibodies-classified as active CD (ACD) or potential CD (PCD) if presented or not intestinal damage- and biopsy-proven EE (≥ 15 eos/HPF). Comparators were randomly selected among CD-diagnosed patients without macroscopical esophageal abnormalities (CD + EE -). Clinical, immunological, and histological features were compared. EE remission (< 15 eos/HPF) was assessed in cases after treatment. PCD patients received proton pump inhibitors (PPIs) for 8 weeks, with GFD prescribed only if PPIs failed. ACD patients received a 6-month GFD first, with PPIs added if esophageal remission was not achieved. 14/520 children (2.7%) had confirmed EE (9 ACD, 5 PCD). Only 2/14 (14%) were symptomatic. Compared to 100 CD + EE - subjects, cases were significantly more likely to be male (86% vs. 34%; p = 0.0003), atopic (57% vs. 22%; p = 0.009), and having peripheral eosinophilia (86% vs. 12%; p < 0.0001). Overall, GFD induced EE remission in 5/11 (45%) of cases. Most ACD patients required additional PPI therapy after GFD failure.

conclusionIncidental EE affects ~ 3% of pediatric CD evaluations. These patients typically fulfill histological EoE criteria and are often asymptomatic. Male sex, atopy, and peripheral eosinophilia are strongly associated to this condition. While GFD resolves EE in nearly half of cases, the persistence in others suggests EE is frequently an independent comorbidity. Nonetheless, a GFD is a viable first-line approach in dual-diagnosis patients. WHAT IS KNOWN: • Incidental esophageal eosinophilia (EE) is sometimes found in children being evaluated for celiac disease (CD). • The precise clinical relationship and overlap between celiac disease and eosinophilic esophagitis (EoE) remain unclear. WHAT IS NEW: • Incidental EE affects ~3% of pediatric CD cases; patients are often asymptomatic but strongly linked to male sex, atopy, and peripheral eosinophilia. • A gluten-free diet solves EE in aroung 45% of cases, making it a viable first-line approach in dual diagnosis of EE and celiac disease, though others additional, EE specific therapies.