Anyone who has sneezed their way through a pollen-filled spring or thought twice about putting peanuts in an elementary school lunchbox has at least a basic understanding of allergies. Ragweed pollen, shellfish and pet dander are common allergens that can trigger reactions ranging from itchy eyes to anaphylactic shock. Eosinophilic gastrointestinal disorders (EGID) are a rare group of allergies that cause inflammation in the gastrointestinal tract. For patients with an EGID, their allergic reaction may cause difficulty swallowing or chronic vomiting instead of sneezing or itchiness.  

For over a decade, a team of pediatric allergy and gastroenterology researchers and specialists at Arkansas Children's has been one of the few sites in the country treating EGID in pediatric patients. The EGID team is celebrating a procedure now available at Arkansas Children's - transnasal endoscopies.  

 

Allergies and Endoscopies 

Approximately 30-50 out of every 100,000 people are diagnosed with EGID. The number has nearly doubled in the last decade, according to Robert Pesek, M.D., the medical director for the allergy, severe asthma and EGID clinics at Arkansas Children’s Hospital (ACH) and associate professor of allergy and immunology and pediatrics at the University of Arkansas for Medical Sciences. Interestingly, EGID diagnosis requires an endoscopy rather than a typical skin test. “There's no blood test,” Dr. Pesek said. “There's no other test besides an endoscopy that will make the diagnosis. The only way to be certain is to physically look inside the esophagus [or other affected area of the GI tract].” 

An EGID allergy can cause inflammation anywhere in the gastrointestinal tract, but most occur in the esophagus. To diagnose EGID, a pediatric gastroenterologist inserts an endoscope - a thin tube with a camera and other miniaturized tools at the end - into the esophagus, looking for signs of inflammation and collecting a tiny amount of tissue, a process called taking a biopsy. Typically, the endoscope is inserted through the mouth and requires sedation with a general anesthetic. For years, EGID patients required multiple sedations, first during their diagnostic endoscopy and again each year, to monitor treatment.  Dr. Pesek said some parents wished for alternatives to anesthesia and sedation. 

"Listening to parent perspective and always trying to push the envelope to provide better care options" motivated Arkansas Children's team members to pursue training and certification in transnasal endoscopies, which don't require sedation. During a transnasal endoscopy, the endoscope is inserted into the nose. A mild topical medication numbs the nasal passage. "You can feel something moving through your nose but no pain," Dr. Pesek said. He and many other EGID team members underwent the procedure, which takes less than 15 minutes, to understand what their young patients would experience. 

Elaine Odiase, M.D., the director of advanced and general endoscopy at Arkansas Children’s Hospital (ACH) and an assistant professor of pediatric gastroenterology, hepatology and nutrition at the University of Arkansas for Medical Sciences (UAMS), was the first pediatric gastroenterologist in Arkansas certified to perform pediatric transnasal endoscopies. 

"A sedation-free transnasal endoscopy allows patients to return to their regular activities immediately following the clinic visit," Dr. Odiase said. "Truly, this is a huge improvement in care for our eosinophilic esophagitis patients." 


EGID Treatments 

Treatment begins after an endoscopy confirms an EGID diagnosis. Milk, dairy, eggs, wheat, soy, nuts, fish and shellfish are the most common triggers for EGID allergies. One treatment option is a food elimination diet, which requires identifying which food triggers the allergy and developing a strict diet that avoids the specific food. An Arkansas Children's nutritionist helps families and caregivers who choose this option by educating them on reading food labels, suggesting alternatives to common foods and designing menus to ensure a balanced diet. Treating EGID with a food-elimination diet can be challenging. Caregivers and children must constantly monitor the ingredients of their food. 

Fortunately, in 2022, the U.S. Food and Drug Administration (FDA) approved two medications for treating EGID in some pediatric patients. 

  • Dupixent treats various allergic diseases, including asthma, eczema and EGID. In 2022, the FDA approved Dupixent for children 12 and older. In early 2024, the FDA approved Dupixent for use in children ages 1 to 11 weighing at least 33 pounds. 

  • Eohilia is an FDA-approved corticosteroid for treating EGID impacting the esophagus in patients 11 years and older. 

The EGID team at ACH is one of 16 members of the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR), a group of health care organizations dedicated to improving the lives of individuals with eosinophilic gastrointestinal disorders. Members of CEGIR directly contributed to researching the FDA-approved medications. Dr. Pesek said, "Being a member of the consortium has helped us stay on the cutting edge of what the field is doing. We learn from others, they learn from us, and we can all take better care of our patients." 

Dr. Pesek said the success of the EGID clinic and its benefits for patients directly reflect the emphasis on teamwork at Arkansas Children's. The collaborative effort includes allergists, nutritionists, gastroenterologists and otolaryngologists. 

Patient Spotlight: Transnasal Endoscopy

Elaine Odiase, M.D., asks 14-year-old Joshua "JD" Clark about sports he plays while he sits in an exam chair in Arkansas Children's Hospital. It's early August. Even though he's not in school, he and his teammates are already attending daily football practices. As he talks about the heat and the positions he plays (fullback and middle linebacker), Dr. Odiase says, "We're already in the esophagus."  

JD is receiving his first transnasal endoscopy. Unlike previous endoscopies he's gotten since being diagnosed with a rare allergy that affects his esophagus and gastrointestinal (GI) tract, JD is awake for the procedure. Transnasal endoscopies only require a local anesthetic - lidocaine in this case - to numb the nose and throat before inserting an endoscope through the nostril. JD and Dr. Odiase carry on a casual conversation while she navigates the camera through his GI tract, taking pictures and tissue samples that will provide insights into the effectiveness of the treatment for his allergy, an eosinophilic gastrointestinal disorder. The samples will be tested for eosinophils - white blood cells that support the immune system and are part of the body's defense against allergens. 

"We're getting good pictures, too," Dr. Odiase said as JD talked about his favorite basketball team (the Golden State Warriors). Nurses and a child life specialist were on hand to check on JD's comfort. A green lollipop offsets the taste of the lidocaine.  

After around 20 minutes, the endoscopy is complete. If this had been a traditional endoscopy, the process would have taken over an hour. JD said he would have had to miss school the next day because of the lingering effects of anesthesia needed to completely sedate him. After his first transnasal endoscopy, JD was mostly hungry and ready to get back to his day without grogginess.  

*This article was written by the Arkansas Children’s content team and medically reviewed by Robbie Pesek, M.D.