LETTERS TO THE EDITOR
Role of Endoscopic Ultrasound acute episode may consist in the use of b2 adrenergic agonists to
in Children
T o the Editor: Gordon et al (1) report on endoscopic ultrasound
(EUS) as an emerging tool for pediatric pancreatobiliary
disorders, reaffirming a prior report from Scheers et al (2). Some
content of the newer study, however, needs clarification. Foremost
is disagreement regarding the terminology ‘‘EUS-fine needle
aspiration,’’ used by the authors for all the EUS-guided interven-
tional procedures such as celiac plexus block or pancreatic fluid
collection drainage (3,4). If fine needle aspiration alone was done
for pancreatic fluid collection or pseudocyst without any EUS-
guided drainage, then its clear indication should be specified, as
aspiration alone is usually inappropriate. The new finding that the
present study adds according to the authors is the role of EUS in
delineating mucosal gastrointestinal disease. I found only 1 case of
gastrointestinal stromal tumors of the 43 cases that could support
their statement. Utility of EUS in diagnosis of pyloric stenosis in
infants is questionable compared with high-resolution ultrasound
alone except in rare cases (5). Considering the thin abdominal wall
of infants, EUS seems to have no advantage over conventional
ultrasound, which is less invasive. It is unlikely in the present study
that an infant with suspected pyloric stenosis was taken directly to
endoscopy and then EUS without an abdominal ultrasound, a detail
that was not specified. On careful analysis of the Table 1, the
statement ‘‘EUS led to new diagnosis in 34 of the 43 patients’’
appears to be exaggerated. Moreover authors do not discuss how
EUS may affect outcomes including any changes in management.
Jaya Agarwal
Regency Health Care
Kanpur, India
REFERENCES
1. Gordon K, Conway J, Evans J, et al. EUS and EUS-guided interventions
alter clinical management in children with digestive diseases. J Pediatr
Gastroenterol Nutr 2016;63:242–6.
2. Scheers I, Ergun M, Aouattah T, et al. Diagnostic and therapeutic roles of
endoscopic ultrasound in pediatric pancreaticobiliary disorders. J Pediatr
Gastroenterol Nutr 2015;61:238–47.
3. Ramesh J, Bang JY, Trevino J, et al. Endoscopic ultrasound-guided
drainage of pancreatic fluid collections in children. J Pediatr Gastro-
enterol Nutr 2013;56:30–5.
4. Jazrawi SF, Barth BA, Sreenarasimhaiah J. Efficacy of endoscopic
ultrasound-guided drainage of pancreatic pseudocysts in a pediatric
population. Dig Dis Sci 2011;56:902–8.
5. Khan K. High-resolution EUS to differentiate hypertrophic pyloric
stenosis. Gastrointest Endosc 2008;67:375–6.
Salbutamol Therapy for Food
Impaction in Eosinophilic Oesophagitis
T o the Editor: Food impaction is a common presentation of
eosinophilic esophagitis. Inflammation leads to reduction of
esophageal distensibility through subepithelial fibrosis with dysfunc-
tion of the longitudinal muscle layer (1). Impaction is treated by
endoscopic retrieval of bolus. The intermittent nature of impaction
and muscular spasm has, however, led to the concept that treatment of
JPGN  Volume 65, Number 4, October 2017
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
promote oesophageal relaxation (2). Seven adolescent boys
(mean age 13 years; range 11–17 years) were admitted with food
impaction. Before disimpact were treated with oral salbutamol
(100 mg  kg1  dose1, maximum 5 mg, in 1 mL saline—dosage
equivalent to the usual nebulisation). In 5 patients, there was complete
resolution of symptoms within 30 minutes as the food migrated
spontaneously to the stomach. The sixth patient showed improvement
of chest pain but endoscopy was still needed, revealing a large piece
of meat, removed in fragments. The seventh improved drooling, but
an impacted medication pill was still retained in a stenosis. Suspected
eosinophilic esophagitis was confirmed in all patients by endoscopy
and multiple biopsies. Proton pump inhibitors were not used before
endoscopy. Informed consent was obtained from the parents and
ethics committee. The recognised effects of b2 adrenergic agonists
upon pressure and peristalsis in the lower two-thirds of the oesopha-
gus make them logical for treating reversible muscle spasm of acute
bolus impaction, similar to patients with asthma (3–5). If there is
fibrotic stricture (as in patient no. 7) such therapy is unlikely to be
effective. Animal studies suggest that oesophageal muscle relaxation
is mediated by b3 and b2 adrenergic agonists (3). In humans, there is
evidence of response to b2 agonists (4,5), and the contribution of b3
agonists has yet to be established. Nebulised albuterol reduced
amplitude of lower and mid-oesophageal contractions in healthy
volunteers (4). Swallowed salbutamol sulphate (4 mg in 4 mL water)
relieved diffuse oesophageal spasm in a 58-year-old patient (5).
It is known that occasionally food impaction can resolve
spontaneously. Most of our patients had prior minor episodes, but
the ones reported here were more severe and prolonged.
Patient selection and monitoring will be important, as sub-
epithelial fibrosis and ischaemic heart disease are more frequent in
adult patients, in whom a high dose of b2 agonist could be
hazardous. Although encouraging, these results are from a small
group of patients without control group as spontaneous remission is
seen with bolus impaction, a controlled study is needed to examine
these issues.

Jorge Amil Dias, Sofia Fernandes, Susana Corujeira

Eunice Trindade, Marta Tavares, and ySimon Murch

Centro Hospitalar de São João, Serviço de Pediatria
Unidade de Gastroenterologia Pediátrica,
Porto, Portugal
y
University Hospital Coventry & Warwickshire
Coventry, UK
REFERENCES
1. Korsapati H, Babaei A, Bhargava V, et al. Dysfunction of the longitudinal
muscles of the oesophagus in eosinophilic oesophagitis. Gut
2009;58:1056–62.
2. Murch S, Allen KJ, Chong SKF, et al. Potential for improving therapy and
defining new research targets in eosinophilic oesophagitis based on
understanding of immunopathogenesis. J Pediatr Gastroenterol Nutr
2013;57:529–34.
3. de Boer RE, Brouwer F, Zaagsma J. The beta-adrenoceptors mediating
relaxation of rat oesophageal muscularis mucosae are predominantly of
the beta 3-, but also of the beta 2-subtype. Br J Pharmacol
1993;110:442–6.
4. Crowell MD, Zayat EN, Lacy BE, et al. The effects of an inhaled beta(2)-
adrenergic agonist on lower esophageal function: a dose-response study.
Chest 2001;120:1184–9.
5. Okamura S, Oshimoto H, Sakamoto T, et al. Beta-adrenoreceptor agonists
for diffuse esophageal spasm. J Gastroenterol 2002;37:229–30.
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