What is the treatment plan for a 9-year-old female patient with newly diagnosed coeliac disease and eosinophilic esophagitis, with elevated calprotectin levels and eosinophil count, and a history of food allergies?

Treatment Plan for 9-Year-Old with Newly Diagnosed Coeliac Disease and Eosinophilic Esophagitis

Primary Treatment Approach

This patient requires simultaneous management of both conditions: a strict gluten-free diet for coeliac disease and PPI therapy (lansoprazole 15mg daily) for eosinophilic esophagitis, with mandatory dietitian involvement given the complexity of multiple dietary restrictions. 1

Immediate Management Steps

For Coeliac Disease

• Initiate strict gluten-free diet immediately - this is the only effective therapy for coeliac disease and must be maintained indefinitely 2
• The elevated tTG (>128) and positive AEM with DQ8 positivity confirm the diagnosis, and the OGD findings are consistent with both conditions 2

For Eosinophilic Esophagitis

• Continue lansoprazole 15mg once daily for 8-12 weeks as planned - PPI therapy is first-line treatment for EoE with strong evidence for inducing histological and clinical remission 1, 3
• The finding of up to 36 eosinophils/hpf on OGD confirms active EoE requiring treatment 1
• Do NOT add empiric food elimination beyond what is already restricted - the patient already excludes multiple foods for IgE-mediated allergies (lentils, chickpeas, peanuts, sesame, tree nuts), and adding further restrictions without dietitian guidance risks severe nutritional deficiency 1

Critical Dietitian Involvement

Mandatory referral to experienced dietitian is essential - this patient faces triple dietary complexity: 1

• Gluten-free diet for coeliac disease
• Multiple food allergen avoidances (milk, egg, wheat, soy, nuts, grass, silver birch per RAST)
• Potential future EoE-directed elimination if PPI fails

The dietitian must ensure:

• Adequate calcium, vitamin D, B12, iron, and fiber replacement given wheat/dairy restrictions 1
• Monitoring for nutritional deficiencies common in children with multiple food restrictions 1
• Assessment of feeding behaviors, as children with EoE often develop abnormal feeding patterns 1

Follow-Up and Monitoring Strategy

At 3 Weeks (As Planned)

• Assess symptom response to PPI therapy 3
• Review dietitian assessment and nutritional adequacy 1
• Monitor adherence to gluten-free diet 2

At 8-12 Weeks

• Repeat OGD with biopsies is mandatory - symptoms do not correlate with histological activity in EoE, so endoscopic assessment while on treatment is essential to determine PPI response 1, 3
• Take at least 6 biopsies from different esophageal sites 1
• Histological remission is defined as <15 eosinophils per 0.3mm² 1
• Repeat coeliac serology (tTG) to assess dietary adherence 2

At 6 Months

• Repeat coeliac serology to confirm downtrending antibodies on gluten-free diet 2

If PPI Therapy Fails (>15 eosinophils/0.3mm² at 8-12 weeks)

Second-line options in order of preference: 1, 3

1. Topical corticosteroids (swallowed fluticasone or budesonide) - high-grade evidence for inducing remission and preventing stricture formation 1, 3

2. Empiric dietary elimination - only if family is highly motivated and with intensive dietitian support 1

   • Start with 2-food elimination (milk and wheat already restricted for allergies) 4, 5
   • Do NOT use allergy testing to guide elimination - skin prick, specific IgE, and patch testing have poor predictive value for EoE triggers 1
   • Each food reintroduction requires 8-12 weeks and repeat endoscopy 1

3. Combination therapy (PPI + topical steroids or PPI + diet) - reserved for refractory cases only 1

Important Clinical Pitfalls to Avoid

• Do NOT assume symptom improvement means histological remission - endoscopy with biopsy is mandatory to assess EoE response 1, 3
• Do NOT add empiric food elimination without dietitian involvement - risk of severe nutritional deficiency in a growing child with multiple existing restrictions 1
• Do NOT use allergy testing to guide EoE dietary therapy - the positive RAST results are relevant for IgE-mediated allergies (hence the EpiPen) but not for directing EoE elimination diet 1
• Do NOT discontinue PPI if histological remission achieved - maintenance therapy is essential as relapse rates are high after withdrawal 1, 3
• Do NOT ignore the mildly elevated calprotectin (59) - while colon was normal on OGD, this warrants monitoring as it may indicate subclinical inflammation 1

Multidisciplinary Management

This patient requires joint management by: 1

• Pediatric gastroenterologist (primary coordinator)
• Specialist dietitian experienced in both coeliac disease and EoE
• Allergist for optimization of concomitant atopic disease management (given multiple IgE-mediated allergies, asthma requiring salbutamol)

The combination of coeliac disease, EoE, and multiple IgE-mediated food allergies represents a complex phenotype requiring coordinated care to balance disease control with nutritional adequacy and quality of life 1

Long-Term Considerations

• Maintenance therapy will likely be needed indefinitely - both conditions are chronic 1, 3, 2
• Early effective treatment of EoE may prevent fibrostenotic complications requiring future endoscopic dilation 1
• Transition planning to adult services should begin in adolescence to ensure continuity of care 1