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Ishimura N, Shimura S, Jiao D, Mikami H, Okimoto E, Uno G, Aimi M, Oshima N, Ishihara S, Kinoshita Y. Clinical features of eosinophilic esophagitis: differences between Asian and Western populations. J Gastroenterol Hepatol 2015; 30 Suppl 1:71-7. [PMID: 25827808 DOI: 10.1111/jgh.12746] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The prevalence and incidence of eosinophilic esophagitis (EoE) have been rapidly increasing in Western countries. It is thought to be more common among Caucasians than other racial or ethnic groups, but epidemiological studies have not been fully evaluated in Asian populations, and its clinical manifestation is rarely documented. In this review, recent reports regarding EoE in Asian countries have been collected, and differences in the clinical features, including symptoms and endoscopic findings, between Asian and Western populations have been evaluated. In Asia, EoE is still much less prevalent than in Western countries. Baseline values for average age, male/female ratio, and personal history of allergic disease were comparable to those in Western populations. Predominant symptoms were dysphagia, and food impaction was extremely rare among Asian patients. Although the frequency of abnormal endoscopic findings varies among studies, over 90% of patients with EoE have shown abnormal findings such as linear furrow, which is the most common findings, in recent prospective studies in Asia. There are few reports regarding the treatment of EoE and no prospective studies evaluating drugs or elimination diet in patient with EoE have been reported in Asia. Overall, EoE had similar clinical characteristics in Asian populations. Because the incidence of EoE could increase in the future with the increase in allergic disorders in Asian countries, large-scale, nationwide prospective studies should be performed to more fully understand the epidemiology and pathophysiology of EoE in Asian populations.
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Affiliation(s)
- Norihisa Ishimura
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
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Wolf WA, Cotton CC, Green DJ, Hughes JT, Woosley JT, Shaheen NJ, Dellon ES. Predictors of response to steroid therapy for eosinophilic esophagitis and treatment of steroid-refractory patients. Clin Gastroenterol Hepatol 2015; 13:452-8. [PMID: 25086190 PMCID: PMC4312270 DOI: 10.1016/j.cgh.2014.07.034] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 07/13/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) is commonly treated with swallowed (topical) corticosteroids (tCS). However, few factors have been described that predict outcomes of steroid therapy. We aimed to identify factors associated with nonresponse to tCS and report outcomes of second-line treatment for patients with steroid-refractory EoE. METHODS We performed a retrospective cohort study by using the University of North Carolina EoE Clinicopathologic Database to identify patients who received tCS for EoE from 2006 through 2013. Demographic, symptom, endoscopic, and histologic data were extracted from medical records. Immunohistochemistry was performed on archived biopsies. Responders and nonresponders to tCS were compared. RESULTS Of 221 patients with EoE who received tCS, 71% had endoscopic improvement, 79% had symptomatic improvement, and 57% had histologic response (<15 eosinophils/high-power field). After multivariate logistic regression, esophageal dilation at the baseline examination predicted nonresponse (odds ratio, 2.9; 95% confidence interval, 1.4-6.3), and abdominal pain predicted response (odds ratio for nonresponse, 0.31; 95% confidence interval, 0.12-0.83); no other clinical features were predictive. On the basis of immunohistochemical analysis, higher baseline levels of tryptase (244 vs 157 mast cells/mm(2), P = .04) and eotaxin-3 (2425 vs 239 cells/mm(2), P = .02) were associated with steroid response, but levels of major basic protein were not. Among 27 steroid-refractory patients, a mean of 2 additional therapies were tried; only 48% of the patients eventually responded to any second-line therapy. CONCLUSIONS On the basis of a retrospective analysis of a large group of patients with EoE, only 57% have a histologic response to steroid therapy. Baseline esophageal dilation and decreased levels of mast cells and eotaxin-3 predicted which patients would not respond to therapy. Combining clinical factors and immunohistochemistry might therefore be used to direct therapy.
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Affiliation(s)
- W. Asher Wolf
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Cary C. Cotton
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Daniel J. Green
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Julia T. Hughes
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - John T. Woosley
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nicholas J. Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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53
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Katzka DA. Eosinophilic esophagitis and proton pump-responsive esophageal eosinophilia: what is in a name? Clin Gastroenterol Hepatol 2014; 12:2023-5. [PMID: 25086198 DOI: 10.1016/j.cgh.2014.07.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 07/22/2014] [Indexed: 02/07/2023]
Affiliation(s)
- David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
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55
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Park H. An overview of eosinophilic esophagitis. Gut Liver 2014; 8:590-7. [PMID: 25368745 PMCID: PMC4215443 DOI: 10.5009/gnl14081] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/12/2014] [Accepted: 07/10/2014] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease affecting both children and adults. The condition is characterized by an eosinophilic infiltration of the esophageal epithelium. Symptoms of esophageal dysfunction include dysphagia, food impaction and symptoms mimicking gastroesophageal reflux disease. Endoscopic examination typically reveals mucosal fragility, ring or corrugated mucosa, longitudinal furrows, whitish plaques or a small caliber esophagus. Histologic findings of >15 eosinophils per high-power field is the diagnostic hallmark of EoE. An elimination diet, topical corticosteroids or endoscopic dilation for fibrostenotic disease serve as effective therapeutic option.
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Affiliation(s)
- Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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56
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Kelly EA, Linn D, Keppel KL, Noel RJ, Chun RH. Otolaryngologic surgeries are frequent in children with eosinophilic esophagitis. Ann Otol Rhinol Laryngol 2014; 124:355-60. [PMID: 25385840 DOI: 10.1177/0003489414558108] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim was to study the prevalence of otolaryngologic surgeries in pediatric patients with eosinophilic esophagitis (EoE). METHODS Retrospective cohort study at a tertiary care center. The type of otolaryngologic surgeries performed in patients with diagnosis of EoE was recorded during a 5-year period. RESULTS Seventy-five percent of patients were male, with average age of EoE diagnosis at 7.5 years with an 83% incidence of atopy. Cohort analysis revealed that 33% (119/362) had a total of 275 otolaryngologic surgeries. Surgeries performed on 119 patients are as follows: 20% bilateral myringotomy with tubes, 14% tonsillectomy, 18.5% adenoidectomy, 1.4% sinus irrigation, 3.3% bronchoscopy, and 1.4% laryngotracheoplasty (LTP); 63% of patients underwent multiple procedures. Thirty percent of patients undergoing bilateral myringotomy with tube placement (BMT) needed additional tubes. Four of 5 LTP patients had successful operations. Twelve percent of patients had EoE diagnosis prior to an otolaryngologic surgery. CONCLUSION Thirty-three percent of children with EoE required otolaryngologic surgical intervention and nearly one-third who underwent BMT required additional ear tubes. A large fraction of children with EoE will undergo an otolaryngologic surgery, only a minority with a preoperative EoE diagnosis. Until the nature of this relationship is clarified, the high coincidence with otolaryngologic surgeries dictates that otolaryngologists should be familiar with diagnosis of EoE in patients.
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Affiliation(s)
- Elizabeth A Kelly
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David Linn
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kristina L Keppel
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Richard J Noel
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Robert H Chun
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Molina-Infante J, Lucendo AJ. Eosinophilic esophagitis: a practical approach to diagnosis and management. Expert Rev Gastroenterol Hepatol 2014; 8:925-34. [PMID: 24830679 DOI: 10.1586/17474124.2014.919851] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) has emerged as a common cause of dysphagia and food impaction in children and adults. A trial of proton pump inhibitor (PPI) therapy is a mandatory diagnostic first step, given that at least one third of patients with suspected EoE will have PPI-responsive esophageal eosinophilia. Once EoE is diagnosed, short-and long-term therapeutic decision making may rely on patient symptoms, phenotype (inflammatory vs fibrostenotic) and preferences. Currently, the most reliable therapeutic targets are mucosal healing and caliber abnormalities resolution. Topical steroids followed by endoscopic dilation are recommended in symptomatic narrow caliber esophagus/strictures, whereas either topical steroids or dietary therapy are good short-term options for mucosal inflammation. Maintenance anti-inflammatory therapy is necessary to prevent esophageal fibrotic remodeling and stricture formation.
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Affiliation(s)
- Javier Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, C/ Pablo Naranjo s/n 10003, Caceres, Spain
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58
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Restoring mucosal integrity: "closing the gap" in the treatment of esophageal eosinophilia. Clin Gastroenterol Hepatol 2014; 12:1830-1. [PMID: 25086196 DOI: 10.1016/j.cgh.2014.07.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 07/25/2014] [Accepted: 07/28/2014] [Indexed: 02/07/2023]
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Molina-Infante J, Rivas MD, Hernandez-Alonso M, Vinagre-Rodríguez G, Mateos-Rodríguez JM, Dueñas-Sadornil C, Perez-Gallardo B, Ferrando-Lamana L, Fernandez-Gonzalez N, Bañares R, Zamorano J. Proton pump inhibitor-responsive oesophageal eosinophilia correlates with downregulation of eotaxin-3 and Th2 cytokines overexpression. Aliment Pharmacol Ther 2014; 40:955-65. [PMID: 25112708 DOI: 10.1111/apt.12914] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 07/09/2014] [Accepted: 07/22/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND The molecular basis and effects of proton pump inhibitor (PPI) therapy on PPI-responsive oesophageal eosinophilia (PPI-REE) and eosinophilic oesophagitis (EoE) remain unknown. AIM To compare symptom-histological and cytokine gene expression in PPI-REE and EoE patients, at baseline and after specific treatment. METHODS In consecutive adult patients with an EoE phenotype (dysphagia/food impaction, typical endoscopic findings and > 15 eos/HPF), gene expression of eotaxin-3, IL-13, and IL-5 were determined in distal and proximal oesophagus, at baseline and after omeprazole 40 mg b.d. for 8 weeks. PPI-REE was defined by clinicohistological response. PPI nonresponders (EoE) were offered treatment with topical steroids. RESULTS Fifty three patients were re-evaluated on PPI therapy. 23 patients (43%) had PPI-REE and 30 patients (57%) had EoE. At baseline, eotaxin-3/IL-13/IL-5 gene expression was indistinguishable between EoE and PPI-REE, excepting increased IL-5 expression in proximal oesophagus (12.54 vs. 57, P = 0.029). PPI therapy significantly decreased eotaxin-3/IL-13 in PPI-REE, at both oesophageal sites (P ≤ 0.008), and IL-5 in distal (P = 0.016), but not in proximal oesophagus. Patients with steroid-responsive EoE also showed a significant decrease in eotaxin-3/IL-5 expression at both oesophageal sites. In EoE patients, initial PPI trial significantly decreased distal oesophageal eosinophilia (63.78 to 41.79 eos/HPF, P = 0.025) and led to symptom remission in 16%, but did not influence Th2 markers. CONCLUSIONS Baseline cytokine gene expression in PPI-REE was nearly indistinguishable from EoE. PPI therapy significantly downregulated oesophageal eotaxin-3/Th2-cytokine gene expression in PPI-REE, similarly to that seen in steroid-responsive EoE. A subset of EoE patients showed clinicohistological improvement on PPI therapy.
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Affiliation(s)
- J Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, Caceres, Spain
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60
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Aceves SS. Food allergy testing in eosinophilic esophagitis: what the gastroenterologist needs to know. Clin Gastroenterol Hepatol 2014; 12:1216-23. [PMID: 24035776 PMCID: PMC4048803 DOI: 10.1016/j.cgh.2013.09.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 09/04/2013] [Accepted: 09/04/2013] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is a clinicopathologic disease of increasing prevalence in children and adults. The triggering antigen in EoE is often a food that initiates a cascade of Th2-associated interleukins such as interleukin-5 and interleukin-13 and chemokines such as eotaxin-3 as well as esophageal eosinophilia and mastocytosis. Amino acid-based formulas have high efficacy rates in EoE and constitute the first evidence for food-triggered esophageal eosinophilia. Animal models have demonstrated the sufficiency of food antigens in triggering both the inflammatory and remodeling complications of EoE. Food elimination diets that are followed by single food introduction with repeat biopsy have proven the efficacy of empiric and allergy testing based elimination diets in children and adults. Although the ideal allergy test for identifying food antigens in EoE remains to be elucidated, the utility of food skin prick combined with atopy patch testing has been shown in large pediatric cohorts. By comparison, smaller, non-U.S. adult cohorts have not had similar results. Currently, a positive test on food allergy evaluation suggests a food trigger for EoE but does not substitute for biopsy-based tissue evaluation after food removal and reintroduction. The higher rates of food anaphylaxis in children with EoE, potential loss of tolerance to immunoglobulin E-positive foods that can occur with food avoidance, and the high rates of other atopic diatheses in EoE subjects all support the evaluation of EoE subject by an allergist, consideration for allergy testing, and an integrated approach by allergists, gastroenterologists, and pathologists in EoE management.
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Affiliation(s)
- Seema S. Aceves
- Division of Allergy, Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, Rady Children’s Hospital, San Diego, 9500 Gilman Drive, MC-0635, La Jolla, CA 92093, Phone: 858-966-5961, Fax: 858-966-6791,
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61
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Romano C, Chiaro A, Lucarelli S, Santarelli C, Cucchiara S, Guadagnini T, Miele E, Di Nardo G. Mucosal cytokine profiles in paediatric eosinophilic oesophagitis: a case-control study. Dig Liver Dis 2014; 46:590-5. [PMID: 24704289 DOI: 10.1016/j.dld.2014.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 03/02/2014] [Accepted: 03/10/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis is an inflammatory condition characterized by a dense eosinophilic infiltrate. The migration of eosinophils into the oesophagus is influenced by cytokines such as IL-5, IL-13 and eotaxin-3. The aim of this study was to evaluate changes in the cytokine expression profiles (IL-5, IL-13 and eotaxin-3/CCL26) in children after topical steroid treatment. METHODS a prospective case-control study was performed in 23 paediatric patients (age 5-16 years) with a histological diagnosis of eosinophilic oesophagitis. Histological evaluation and cytokine levels assay (IL-5, IL-13 and eotaxin-3/CCL26) in the proximal and distal oesophagus were performed before, and after 8 weeks of topical budesonide. Data were compared with a matched healthy control group. RESULTS quantitative expression levels of IL-5, IL-13 and eotaxin-3 were significantly higher in the eosinophilic oesophagitis group both compared to healthy subjects (p<0.0001). A significant reduction of the eosinophil infiltrate as well as of IL-5, IL-13 and eotaxin-3 mucosal profiles was observed after steroid treatment both at the proximal and distal oesophagus (p<0.0001). CONCLUSIONS IL-5, IL-13 and eotaxin-3/CCL26 are significantly over-expressed in the oesophageal epithelium of children with eosinophilic oesophagitis. Topical steroid treatment (inhaled and swallowed budesonide) can induce clinical response with partial mucosal remission.
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Affiliation(s)
- Claudio Romano
- Department of Pediatrics, Paediatric Endoscopy Unit, University of Messina, Italy
| | - Andrea Chiaro
- Department of Pediatrics, Paediatric Endoscopy Unit, University of Messina, Italy
| | - Sandra Lucarelli
- Department of Pediatrics, Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy
| | - Cinzia Santarelli
- Department of Pediatrics, Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy
| | - Salvatore Cucchiara
- Department of Pediatrics, Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy
| | | | - Erasmo Miele
- Department of Pediatrics, University Federico II, Naples, Italy
| | - Giovanni Di Nardo
- Department of Pediatrics, Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy.
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Abstract
Eosinophilic esophagitis (EoE) is an increasingly recognized immune antigen-mediated esophageal disease found in both children and adults. It is defined as a clinicopathologic disease characterized by symptoms of esophageal dysfunction accompanied by an eosinophil-predominant esophageal inflammation that occurs in the absence of other causes of esophageal eosinophilia. Classic symptoms in adults include dysphagia to solids and food bolus impaction but a variety of other symptoms are also encountered. Despite the increasing awareness of EoE among practicing physicians, a long delay from onset of symptoms to diagnosis remains a problem in this disease.
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63
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Thakkar K, Chen L, Tessier ME, Gilger MA. Outcomes of children after esophagogastroduodenoscopy for chronic abdominal pain. Clin Gastroenterol Hepatol 2014; 12:963-9. [PMID: 24016631 PMCID: PMC4412350 DOI: 10.1016/j.cgh.2013.08.041] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 08/10/2013] [Accepted: 08/16/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic abdominal pain is the most common indication for esophagogastroduodenoscopy (EGD) in children. However, little is known about the accuracy of EGD-based diagnosis or the outcomes of the patients who undergo this procedure. We examined the diagnostic yield of EGD and short-term outcomes of children who underwent this procedure for chronic abdominal pain. METHODS We conducted a prospective study of 290 children (4-18 years old; mean age, 11.9 ± 3.5 years; 93 girls) who underwent EGD for the primary indication of chronic abdominal pain (216 with at least 1 alarm feature) at a US pediatric gastroenterology referral center. We collected data on demographic features (age, sex), clinical characteristics (alarm features, Rome III criteria), and EGD results for each patient. All subjects with diagnostic lesions were followed for at least 1 year after EGD to determine short-term outcomes. RESULTS Overall, EGD provided an accurate diagnosis for 109 children (38%). Diagnoses included esophagitis (21.0%), eosinophilic gastroenteritis (4.1%), eosinophilic esophagitis (3.8%), Helicobacter pylori infection (2.0%), celiac disease (0.6%), and Crohn's disease (0.4%). Short-term outcomes were available for 81% of patients with diagnostic findings, and medical therapy was effective in approximately 67% of these children. CONCLUSIONS EGD is valuable for the diagnosis of children with abdominal pain, with a 38% diagnostic yield. EGD identified disorders for which medical therapy was effective in 67% of children during the year after diagnosis.
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Affiliation(s)
- Kalpesh Thakkar
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, Texas.
| | - Leon Chen
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, Texas
| | - Mary E Tessier
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, Texas
| | - Mark A Gilger
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, Texas
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64
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Epstein J, Warner JO. Recent advances in the pathophysiology and management of eosinophilic oesophagitis. Clin Exp Allergy 2014; 44:802-12. [DOI: 10.1111/cea.12316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- J. Epstein
- Department of Paediatric Gastroenterology; Chelsea and Westminster Hospital; London UK
| | - J. O. Warner
- Paediatric Section; Faculty of Medicine; Imperial College; Wright Fleming Institute; London UK
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65
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Martin K, Emil S, Bernard C, Gaied F, Blumenkrantz M, Laberge JM, Morinville V, Nguyen VH. Dextranomer hyaluronic acid copolymer effects on gastroesophageal junction. J Pediatr Gastroenterol Nutr 2014; 58:593-7. [PMID: 24345840 DOI: 10.1097/mpg.0000000000000259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The outcomes of fundoplication for gastroesophageal reflux disease are suboptimal in many children, and alternatives are clearly needed. Dextranomer hyaluronic acid (DxHA) copolymer, an agent with proven efficacy in vesicoureteral reflux, was studied with respect to its effects on the gastroesophageal junction (GEJ). METHODS Twelve New Zealand white rabbits underwent measurement of lower esophageal sphincter pressure followed by laparotomy and injection into the muscular layer of the GEJ (controls, 1.0 mL saline; low-dose DxHA [0.5 mL]; high-dose DxHA [1.0 mL]). After a 12-week survival period, the animals underwent manometry, sacrifice, and necropsy. Organs were examined histologically by pathologists blinded to the injection delivered. RESULTS All animals survived. Weight gain was equal in the 3 groups. There was no significant difference in mean lower esophageal sphincter pressure from baseline in any group (control 2.3 mmHg [95% confidence interval, CI -3.3 to 7.9]; low-dose group 3.2 mmHg [95% CI -0.8 to 7.2]; high-dose group -4.0 mmHg [95% CI -18.95 to 10.95]). Histologically, DxHA injection produced an intramural implant, with a foreign body giant cell reaction, and fibroblastic infiltration with collagen deposition. High-dose injection did not consistently result in a qualitative increase in the magnitude of the reaction. There was no mucosal injury or luminal stenosis. CONCLUSIONS In this first study evaluating the effects of DxHA injection at the GEJ, a histologic bulking effect was observed without obvious functional complications. The agent may have a role in the treatment of gastroesophageal reflux disease.
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Affiliation(s)
- Kathryn Martin
- *Division of Pediatric General and Thoracic Surgery †Division of Pediatric Pathology ‡Division of Pediatric Gastroenterology, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Dellon ES, Jensen ET, Martin CF, Shaheen NJ, Kappelman MD. Prevalence of eosinophilic esophagitis in the United States. Clin Gastroenterol Hepatol 2014; 12:589-96.e1. [PMID: 24035773 PMCID: PMC3952040 DOI: 10.1016/j.cgh.2013.09.008] [Citation(s) in RCA: 315] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/03/2013] [Accepted: 09/03/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) has become a major cause of upper gastrointestinal morbidity in children and adults. However, there are few data on the nationwide prevalence of EoE. We aimed to estimate the prevalence of EoE in the United States. METHODS We collected health insurance claims from a large database that represented the U.S. commercially insured population. We analyzed data from 2008 to 2011, identifying cases of EoE by using a previously validated definition, and calculated a period prevalence by using data from 2009 to 2011. EoE was defined as any instance of the International Classification of Diseases, 9th revision code 530.13. We calculated the prevalence of the code in the database and standardized the estimate to the U.S. population. RESULTS Of 35,575,388 individuals in this database, 16,405 had at least 1 code for EoE. The mean age was 33.5 years, 65% were male, 55.8% had dysphagia, and 52.8% had a diagnostic code for at least 1 allergic condition. Among 11,569,217 individuals with continuous insurance coverage between mid-2009 and mid-2011, 6513 had at least 1 code for EoE. When standardized to the U.S. population, the estimated period prevalence of EoE was 56.7/100,000 persons, translating to approximately 152,152 cases in the U.S. Prevalence peaked in men 35-39 years old, with a rate of 114.6/100,000 persons. CONCLUSIONS Despite its relatively recent description, EoE is frequently diagnosed in the United States, with an estimated prevalence of 56.7/100,000 persons. This estimate depends on the accuracy of the International Classification of Diseases, 9th revision code, but it could be an underestimate, because knowledge of the code and recognition of EoE are increasing.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Elizabeth T Jensen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Christopher F Martin
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael D Kappelman
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Loughrey MB, Johnston BT. Guidance on the effective use of upper gastrointestinal histopathology. Frontline Gastroenterol 2014; 5:88-95. [PMID: 28840905 PMCID: PMC5369723 DOI: 10.1136/flgastro-2013-100414] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/17/2013] [Accepted: 12/24/2013] [Indexed: 02/06/2023] Open
Abstract
Given the ever-increasing demand for upper gastrointestinal endoscopy, for diagnosis and surveillance, there is a need to consider when it is appropriate, and when it is not appropriate, to take an endoscopic biopsy for histological evaluation. In this article, we consider this in relation to each of the anatomical compartments encountered during oesophagogastroduodenoscopy, and in relation to the common clinical scenarios and endoscopic abnormalities encountered. There are clear indications to biopsy suspicious ulceration or mass lesions and for investigation of some inflammatory conditions, such as eosinophilic oesophagitis and coeliac disease. Increasing guidance is available on optimal biopsy sites and biopsy numbers to maximise yield from histology. Outside these areas, the endoscopist should consider whether biopsy of normal or abnormal appearing mucosa is likely to contribute to patient management, to ensure effective use of limited healthcare resources.
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Affiliation(s)
- Maurice B Loughrey
- Department of Histopathology, Royal Victoria Hospital, Belfast Trust, Belfast, UK
| | - Brian T Johnston
- Department of Gastroenterology, Royal Victoria Hospital, Belfast Trust, Belfast, UK
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Dellon ES, Kim HP, Sperry SL, Rybnicek DA, Woosley JT, Shaheen NJ. A phenotypic analysis shows that eosinophilic esophagitis is a progressive fibrostenotic disease. Gastrointest Endosc 2014; 79:577-85.e4. [PMID: 24275329 PMCID: PMC4599711 DOI: 10.1016/j.gie.2013.10.027] [Citation(s) in RCA: 348] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/14/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Phenotypes of eosinophilic esophagitis (EoE) are not well-characterized. OBJECTIVE To describe clinical features of patients with EoE with predefined phenotypes, determine predictors of these phenotypes, and make inferences about the natural history of EoE. DESIGN Retrospective study. SETTING Tertiary-care center. PATIENTS Incident EoE cases from 2001 to 2011 that met consensus diagnostic guidelines. INTERVENTION Review of records. MAIN OUTCOME MEASUREMENTS Endoscopic phenotypes, including fibrostenotic, inflammatory, or mixed. Other groups of clinical characteristics examined included atopy, level of esophageal eosinophilia, and age of symptom onset. Multinomial logistic regression assessed predictors of phenotype status. RESULTS Of 379 cases of EoE identified, there were no significant phenotypic differences by atopic status or level of eosinophilia. Those with the inflammatory phenotype were more likely to be younger than those with mixed or fibrostenotic (13 vs 29 vs 39 years, respectively; P < .001) and less likely to have dysphagia, food impaction, and esophageal dilation (P < .001 for all). The mean symptom length before diagnosis was shorter for inflammatory (5 vs 8 vs 8 years; P = .02). After multivariate analysis, age and dysphagia independently predicted phenotype. The odds ratio (OR) for fibrostenosis for each 10-year increase in age was 2.1 (95% CI, 1.7-2.7). The OR for dysphagia was 7.0 (95% CI, 2.6-18.6). LIMITATIONS Retrospective, single-center study. CONCLUSION In this large EoE cohort, the likelihood of fibrostenotic disease increased markedly with age. For every 10-year increase in age, the odds of having a fibrostenotic EoE phenotype more than doubled. This association suggests that the natural history of EoE is a progression from an inflammatory to a fibrostenotic disease.
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Affiliation(s)
- Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Hannah P. Kim
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Sarah L.W. Sperry
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - David A. Rybnicek
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - John T. Woosley
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nicholas J. Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Moawad FJ, Schoepfer AM, Safroneeva E, Ally MR, Chen YJ, Maydonovitch CL, Wong RKH. Eosinophilic oesophagitis and proton pump inhibitor-responsive oesophageal eosinophilia have similar clinical, endoscopic and histological findings. Aliment Pharmacol Ther 2014; 39:603-8. [PMID: 24461332 DOI: 10.1111/apt.12636] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 12/27/2013] [Accepted: 01/06/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Some patients with a phenotypic appearance of eosinophilic oesophagitis (EoE) respond histologically to PPI, and are described as having PPI-responsive oesophageal eosinophilia (PPI-REE). It is unclear if PPI-REE is a GERD-related phenomenon, a subtype of EoE, or a completely unique entity. AIM To compare demographic, clinical and histological features of EoE and PPI-REE. METHODS Two databases were reviewed from the Walter Reed and Swiss EoE databases. Patients were stratified into two groups, EoE and PPI-REE, based on recent EoE consensus guidelines. Response to PPI was defined as achieving less than 15 eos/hpf and a 50% decrease from baseline following at least a 6-week course of treatment. RESULTS One hundred and three patients were identified (63 EoE and 40 PPI-REE; mean age 40.2 years, 75% male and 89% Caucasian). The two cohorts had similar dysphagia (97% vs. 100%, P = 0.520), food impaction (43% vs. 35%, P = 0.536), and heartburn (33% vs. 32%, P = 1.000) and a similar duration of symptoms (6.0 years vs. 5.8 years, P = 0.850). Endoscopic features were also similar between EoE and PPI-REE; rings (68% vs. 68%, P = 1.000), furrows (70% vs. 70%, P = 1.000), plaques (19% vs. 10%, P = 0.272), strictures (49% vs. 30%, P = 0.066). EoE and PPI-REE were similar in the number of proximal (39 eos/hpf vs. 38 eos/hpf, P = 0.919) and distal eosinophils (50 vs. 43 eos/hpf, P = 0.285). CONCLUSIONS EoE and PPI-responsive oesophageal eosinophilia are similar in clinical, histological and endoscopic features and therefore are indistinguishable without a PPI trial. Further studies are needed to determine why a subset of patients with oesophageal eosinophilia respond to PPI.
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Affiliation(s)
- F J Moawad
- Gastroenterology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Abstract
Eosinophilic esophagitis (EoE) is currently defined as an immune-mediated chronic esophageal disorder that is diagnosed using both clinical and pathologic information. A series of consensus diagnostic guidelines for EoE have brought a measure of consistency to the field, but in practice the diagnosis of EoE can be challenging. Typical clinical symptoms of EoE, including dysphagia, heartburn, and chest pain, can overlap with gastroesophageal reflux disease, which itself is a common indication for performing endoscopic evaluation. The endoscopic findings of EoE, such as esophageal rings, strictures, linear furrows, and white exudates, are not specific. Esophageal eosinophilia, the histologic hallmark of EoE, is also not pathognomonic and can be seen in a range of conditions. Further complicating the diagnosis of EoE is the newly recognized entity of proton pump inhibitor-responsive esophageal eosinophilia, a condition that must be excluded prior to confirming a diagnosis of EoE. This paper will review the current diagnostic criteria for EoE and discuss multiple clinical, endoscopic, and histologic pitfalls in making the diagnosis of EoE.
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Affiliation(s)
- Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Alex A, Noti M, Wojno EDT, Artis D, Zhou C. Characterization of eosinophilic esophagitis murine models using optical coherence tomography. BIOMEDICAL OPTICS EXPRESS 2014; 5:609-620. [PMID: 24575353 PMCID: PMC3920889 DOI: 10.1364/boe.5.000609] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/17/2014] [Accepted: 01/18/2014] [Indexed: 05/29/2023]
Abstract
Pre-clinical studies using murine models are critical for understanding the pathophysiological mechanisms underlying immune-mediated disorders such as Eosinophilic esophagitis (EoE). In this study, an optical coherence tomography (OCT) system capable of providing three-dimensional images with axial and transverse resolutions of 5 µm and 10 µm, respectively, was utilized to obtain esophageal images from a murine model of EoE-like disease ex vivo. Structural changes in the esophagus of wild-type (Tslpr(+/+) ) and mutant (Tslpr(-/-) ) mice with EoE-like disease were quantitatively evaluated and food impaction sites in the esophagus of diseased mice were monitored using OCT. Here, the capability of OCT as a label-free imaging tool devoid of tissue-processing artifacts to effectively characterize murine EoE-like disease models has been demonstrated.
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Affiliation(s)
- Aneesh Alex
- Department of Electrical and Computer Engineering, Lehigh University, Bethlehem, PA-18015, USA
- Center for Photonics and Nanoelectronics, Lehigh University, Bethlehem, PA-18015, USA
| | - Mario Noti
- Department of Microbiology University of Pennsylvania, Philadelphia, PA 19104, USA
- Institute for Immunology, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Elia D. Tait Wojno
- Department of Microbiology University of Pennsylvania, Philadelphia, PA 19104, USA
- Institute for Immunology, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David Artis
- Department of Microbiology University of Pennsylvania, Philadelphia, PA 19104, USA
- Institute for Immunology, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Chao Zhou
- Department of Electrical and Computer Engineering, Lehigh University, Bethlehem, PA-18015, USA
- Center for Photonics and Nanoelectronics, Lehigh University, Bethlehem, PA-18015, USA
- Bioengineering Program, Lehigh University, Bethlehem, PA-18015, USA
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Abstract
BACKGROUND/AIMS Monitoring inflammation associated with eosinophilic esophagitis (EoE) relies on the identification of biomarkers that provide an objective measure of disease activity. To date, this metric has been the number of eosinophils in the squamous epithelial tissue. The search for alternative biomarkers as well as alternative methods to capture them has been the topic of much research. METHODS Based on clinical experience and a review of the literature, the aim of this chapter is to identify potential EoE biomarkers and methods to assess them. RESULTS With respect to the biomarkers, a number of candidates have arisen, including peripheral blood eosinophils, eosinophil granule proteins, Th2-related cytokines and exhaled nitric oxide. Methods to assess these biomarkers have included peripheral blood, luminal lavages and breath collections. CONCLUSIONS Future research will identify the best clinical outcome measure for EoE. While mucosal eosinophilia currently serves as a well-defined metric of inflammation, newer research studies will continue to address whether this number correlates reliably with other patient-reported outcomes, endoscopic findings, molecular analyses or other yet to be defined biomarkers.
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Affiliation(s)
- Calies Menard-Katcher
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, CO, USA,Gastrointestinal Eosinophilic Diseases Program, Aurora, CO, USA,Department of Pediatrics, Aurora, CO, USA,University of Colorado School of Medicine, Aurora, CO, USA
| | - Glenn T. Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, CO, USA,Gastrointestinal Eosinophilic Diseases Program, Aurora, CO, USA,Department of Pediatrics, Aurora, CO, USA,Mucosal Inflammation Program, Aurora, CO, USA,University of Colorado School of Medicine, Aurora, CO, USA,National Jewish Health, Denver, CO
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Vazquez-Elizondo G, Ngamruengphong S, Khrisna M, Devault KR, Talley NJ, Achem SR. The outcome of patients with oesophageal eosinophilic infiltration after an eight-week trial of a proton pump inhibitor. Aliment Pharmacol Ther 2013; 38:1312-9. [PMID: 24117619 DOI: 10.1111/apt.12513] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 08/25/2013] [Accepted: 09/10/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Current diagnostic guidelines recommend that eosinophilic oesophagitis (EoE) should be diagnosed only after GERD is excluded by a lack of response to a trial of acid suppression. There is limited information available providing outcome data about the effectiveness of this approach. AIM To examine the impact of double-dose proton pump inhibitor (PPI) therapy on symptoms, endoscopic and histological features in patients with documented oesophageal eosinophilia consistent with EoE (≥15 eosinophils/high-power field). METHODS Sixty consecutive symptomatic patients with documented oesophageal eosinophilia received open-label omeprazole 20 mg orally twice daily before meals for 8 weeks. Clinical, endoscopic and histological (resolution: 0-5 eosinophils/HPF, partial improvement: 5-14 eosinophils/HPF), or no improvement: (≥15 eosinophils/HPF) evaluation was repeated at the end of this period. An expert GI pathologist, unaware of the study aims, reviewed all slides. RESULTS Clinical improvement occurred in 43 (71.6%), endoscopic signs were reduced in 34 (61.8%) and normalised in 12 (21.8%), and histologically, 34 (56.6%) improved, while 15 (25%) obtained complete resolution. Overall, 22 patients (36.7%) obtained both complete clinical and histological remission. CONCLUSIONS More than 50% of patients with documented oesophageal eosinophilic infiltration in the EoE range improved when treated with a double-dose PPI trial for 8 weeks. These findings support the published guidelines recommending a PPI trial prior to diagnosing EoE, and confirm the existence of an eosinophilic oesophageal infiltrationPPI-responsive population.
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Abstract
Eosinophilic oesophagitis is a chronic inflammatory disease characterized by eosinophilic infiltration of the oesophageal mucosa. Food and aero-allergens are involved in its pathogenesis. Dysphagia and food impaction are the dominant symptoms in adult with eosinophilic oesophagitis. However, a wide range of symptoms has been noticed such as chest pain or gastro-oesophageal reflux disease-like symptoms. Upper gastro-intestinal endoscopy and oesophageal biopsies are crucial for the diagnosis of eosinophilic oesophagitis. Endoscopy might be normal or reveal typical patterns such as rings, furrows, exudates, oedema, and stricture. Two to four biopsies should be performed both in the distal and in the proximal oesophagus, and 15 eosinophils per high power field within the oesophageal epithelium are the minimal threshold to diagnose eosinophilic oesophagitis. Allergy testing is recommended, although its impact to orient treatment remains to be demonstrated. Eosinophilic oesophagitis treatment includes medical treatment, diet and endoscopic dilation. Proton pump inhibitors are the first-line therapy as some eosinophilic oesophagitis phenotypes respond well to proton pump inhibitors. Topical viscous corticosteroids or diet elimination are the treatment of choice. There is no clear evidence in the literature to prefer one to the other. Finally endoscopic dilation should be considered in case of persistent symptomatic stenosis despite medical therapy.
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76
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Abstract
Management of eosinophilic esophagitis (EoE) centers around the 3 Ds: diet, drug therapy, and dilation. Unfortunately, there is not a consistent relationship between symptom relief and resolution of mucosal eosinophilia. Elemental diets are very successful in children, but poorly tolerated by adults. The 6-food elimination diet is more attractive to adults, especially for those individuals with multiple food allergies. Steroids are the preferred anti-eosinophil drug for EoE. Oral prednisone is infrequently used because of side effects. Topical swallowed preparations (fluticasone, budesonide) are preferred for acute and possibly maintenance therapy. Relapses off steroids are frequent and dysphagia does not predictably improve. Esophageal dilation is key treatment for patients with the fibrostenotic phenotype of EoE. Long-term symptom relief for 1-2 years is common. Post-procedure chest pain is to be expected but perforation is very rare. A suggested algorithm for the treatment of EoE based on endoscopic phenotypes is outlined.
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Affiliation(s)
- Ricardo Prieto
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., MDC 72, Tampa, FL 33612, USA
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Tanaka K, Rubio CA, Dlugosz A, Truskaite K, Befrits R, Lindberg G, Schmidt PT. Narrow-band imaging magnifying endoscopy in adult patients with eosinophilic esophagitis/esophageal eosinophilia and lymphocytic esophagitis. Gastrointest Endosc 2013; 78:659-64. [PMID: 23827349 DOI: 10.1016/j.gie.2013.05.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 05/17/2013] [Indexed: 12/13/2022]
Affiliation(s)
- Kyosuke Tanaka
- Department of Gastroenterology and Hepatology, Karolinska University Hospital, Stockholm, Sweden
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Dellon ES, Irani AM, Hill MR, Hirano I. Development and field testing of a novel patient-reported outcome measure of dysphagia in patients with eosinophilic esophagitis. Aliment Pharmacol Ther 2013; 38:634-42. [PMID: 23837796 DOI: 10.1111/apt.12413] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 05/12/2013] [Accepted: 06/23/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Dysphagia is the hallmark of eosinophilic esophagitis (EoE), but no validated dysphagia instruments in this population exist. AIM To develop and field test a patient-reported outcome (PRO) for dysphagia in subjects with EoE. METHODS This was a multi-centre/multi-phase prospective study. The first phase developed a dysphagia questionnaire using qualitative methods. The second phase was a 30-day field trial to test the instrument and assess content validity. Adolescents and adults with EoE, active symptoms of dysphagia and oesophageal eosinophilia (≥15 eosinophils per high-power field) were enrolled. Solid-food-avoidance days, dysphagia days and actions taken to get relief were recorded. A dysphagia score was calculated and compared to the Straumann Dysphagia Instrument (SDI). RESULTS Ten adolescents and 10 adults were included in the first phase and the Dysphagia Symptom Questionnaire (DSQ), a three-item daily electronic diary, was developed. In the second phase, 35 subjects finished the field trial (18 adults, 17 adolescents, mean age 24, 54% male, 95% white, 54% currently on topical corticosteroids). The median number of dysphagia days per week was 2 for adolescents vs. 4 for adults (P < 0.001), and 2 for those on topical steroids vs. 4 for those not on topical steroids (P < 0.001). The DSQ score strongly correlated with the number of dysphagia days (R = 0.96; P < 0.001) and the SDI (R = 0.77; P < 0.001). CONCLUSIONS The DSQ, a three-question patient-reported outcome, was successfully developed and field tested. The DSQ had content validity and the score accurately measured dysphagia frequency and intensity. The Dysphagia Symptom Questionnaire is suitable for use in clinical trials of EoE patients with dysphagia.
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Affiliation(s)
- E S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7080, USA.
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Gawron AJ, Pandolfino JE. Ambulatory reflux monitoring in GERD--which test should be performed and should therapy be stopped? Curr Gastroenterol Rep 2013; 15:316. [PMID: 23475599 DOI: 10.1007/s11894-013-0316-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Diagnosing gastroesophageal reflux disease (GERD) often entails using a combination of patient symptoms, response to proton pump inhibitors (PPI), upper endoscopy, and ambulatory reflux testing. Each of these has limitations of which the clinician must be aware when managing patients with reflux symptoms. Ambulatory reflux monitoring, in particular, can potentially document the true presence of pathologic GERD. Consequently, reflux testing is often necessary in our evaluation of patients with reflux symptoms, and can be useful in distinguishing etiologies driving a lack of response to PPI therapy. Reflux testing results can be also used to guide appropriate PPI prescribing and clinical decision making for appropriate or unnecessary therapy. This review focuses on the limitations of our current diagnostic paradigm and highlights how reflux testing can be helpful in the diagnosis and management of patients with poor response to PPI therapy.
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Affiliation(s)
- Andrew J Gawron
- Department of Medicine, The Feinberg School of Medicine, Northwestern University, 676 St Clair St, Suite 1400, Chicago, IL 60611-2951, USA
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80
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McLaren A. Case 1: A 12-year-old boy with difficulty swallowing. Paediatr Child Health 2013; 18:353-355. [PMID: 24421707 PMCID: PMC3804633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2013] [Indexed: 06/03/2023] Open
Affiliation(s)
- Anya McLaren
- Correspondence (Case 1): Dr Anya McLaren, The Hospital for Sick Children, Mailbox # 104, Division of Pediatric Medicine, 555 University Avenue, Toronto, Ontario M5G 1X8. E-mail
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Dellon ES. The pathogenesis of eosinophilic esophagitis: beyond the eosinophil. Dig Dis Sci 2013; 58:1445-8. [PMID: 23625288 PMCID: PMC3696481 DOI: 10.1007/s10620-013-2679-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 03/27/2013] [Indexed: 01/07/2023]
Affiliation(s)
- Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Molina-Infante J, Katzka DA, Gisbert JP. Review article: proton pump inhibitor therapy for suspected eosinophilic oesophagitis. Aliment Pharmacol Ther 2013; 37:1157-64. [PMID: 23656497 DOI: 10.1111/apt.12332] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 03/26/2013] [Accepted: 04/23/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent advances in eosinophilic oesophagitis (EoE) have confirmed the existence of a new disease phenotype, proton pump inhibitor (PPI)-responsive oesophageal eosinophilia (PPI-REE). AIM To summarise evidence supporting the use of PPI therapy in patients with suspected EoE (oesophageal dysfunction plus >15 eos/HPF in oesophageal biopsies). METHODS A literature search was conducted through MEDLINE, using the MeSH search terms 'eosinophilic oesophagitis', 'proton pump inhibitors' and 'oesophageal eosinophilia'. Relevant articles and their reference lists were identified through manual review. RESULTS Ten articles, including 258 patients with suspected EoE (152 children, 106 adults) undergoing clinico-histological re-evaluation after PPI therapy, were identified. In children, clinical response ranged from 78% to 86% and histological remission from 23% to 40%. In adults, symptom response ranged from 25% to 80% and histological remission from 33% to 61%. Among PPI-REE patients with oesophageal pH-monitoring, 35 showed pathological and 10 normal studies. PPI-REE was significantly commoner with documented gastro-oesophageal reflux disease (GERD) when compared to patients with negative pH monitoring (70% vs. 29%, P < 0.001). Symptom improvement/resolution occurred in 50-85% of patients without histological remission on PPI therapy. Six PPI-REE patients demonstrated clinico-histological relapse on PPI therapy. CONCLUSIONS At least one third of patients with suspected EoE achieve clinico-histological remission on PPI therapy. Response is more limited in children compared with that in adults. pH monitoring does not accurately predict response to PPI therapy, albeit histological remission is significantly higher, up to 70%, upon documented GERD. Symptom improvement is common with PPI therapy despite persistent eosinophilic infiltration.
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Affiliation(s)
- J Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, 10001 Caceres, Spain.
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Sealock RJ, Kramer JR, Verstovsek G, Richardson P, Rugge M, Parente P, Vela M, El-Serag HB. The prevalence of oesophageal eosinophilia and eosinophilic oesophagitis: a prospective study in unselected patients presenting to endoscopy. Aliment Pharmacol Ther 2013; 37:825-32. [PMID: 23441936 PMCID: PMC3602156 DOI: 10.1111/apt.12268] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 10/09/2012] [Accepted: 02/06/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Oesophageal eosinophilia (EE) is encountered in clinical practice as oesophageal biopsies are being obtained in patients with GI symptoms other than classical symptoms of eosinophilic oesophagitis (EoE). The prevalence, determinants and clinical relevance of EE identified irrespective of symptoms are unclear. AIM To determine the prevalence and risk factors of EE with or without EoE in a nonselected group of patients undergoing endoscopy and in primary care patients. METHODS A cross-sectional study in a single VA centre in which we obtained at least one oesophageal biopsy from patients presenting to elective endoscopy, as well as a sample of patients eligible for screening colonoscopy recruited from primary care clinics. EE was defined by >15 eosinophils in a single HPF; and EoE was defined as definite, probable or none depending on the presence of EE, acid-suppressive therapy and oesophageal symptoms. RESULTS EE was identified in 33 of 1357 patients (2.4%, 95% CI: 1.7-3.4); of whom 9 had definite EoE (0.66%, 95% CI: 0.23-1.10), 17 had probable EoE (1.25%), and the only 7 patients had EE without EoE. The prevalence of EE was 2.3% among patients undergoing elective endoscopy and 0.1% among patients eligible for screening colonoscopy. Seasonal allergies (adjusted OR: 2.78; 95% CI: 1.26-6.11) and oesophageal strictures (4.50; 0.90-22.40) were associated with EE. CONCLUSIONS The prevalence of EE was 2.3% among unselected patients presenting to endoscopy most of whom have EoE. EE was present in 0.1% in primary care patients none of whom had EoE.
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Affiliation(s)
- Robert J. Sealock
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer R. Kramer
- Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,the Sections of Health Services Research, Baylor College of Medicine, Houston, Texas
| | | | - Peter Richardson
- Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,the Sections of Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Massimo Rugge
- Surgical Pathology & Cytopathology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Paola Parente
- Casa Sollievo della Sofferenza, Department of Pathology, San Giovanni Rotondo, Italy
| | - Marcelo Vela
- Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Hashem B. El-Serag
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Straumann A, Hoesli S, Bussmann C, Stuck M, Perkins M, Collins LP, Payton M, Pettipher R, Hunter M, Steiner J, Simon HU. Anti-eosinophil activity and clinical efficacy of the CRTH2 antagonist OC000459 in eosinophilic esophagitis. Allergy 2013; 68:375-85. [PMID: 23379537 DOI: 10.1111/all.12096] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic, Th2-type inflammatory disease. Chemoattractant receptor-homologous molecule on Th2 cells (CRTH2) is a prostaglandin D(2) (PGD(2)) receptor, expressed by Th2 cells and other inflammatory cells, including eosinophils and basophils, that mediates chemotaxis and activation. OC000459 is a selective CRTH2 antagonist and would be expected to suppress eosinophilic tissue inflammation. The purpose of this study was to evaluate the efficacy and safety of an OC000459 monotherapy in adult patients with active, corticosteroid-dependent or corticosteroid-refractory EoE. METHODS In this randomized, double-blind, placebo-controlled trial, 26 adult patients (m/f = 22/4; mean age 41 years, range 22-69 years) with active EoE, dependent or resistant to corticosteroids, were treated either with 100 mg OC000459 (n = 14) or placebo (n = 12) twice daily. Pre- and post-treatment disease activity was assessed clinically, endoscopically, histologically, and via biomarkers. The primary end point was the reduction in esophageal eosinophil infiltration. RESULTS After an 8-week OC000459 treatment, the esophageal eosinophil load decreased significantly, from 114.83 to 73.26 eosinophils per high-power field [(eos/hpf), P = 0.0256], whereas no reduction was observed with placebo (102.80-99.47 eos/hpf, P = 0.870). With OC000459, the physician's global assessment of disease activity improved from 7.13 to 5.18 (P = 0.035). OC000459 likewise reduced extracellular deposits of eosinophil peroxidase and tenascin C, the effects not seen with placebo. No serious adverse events were observed. CONCLUSIONS An 8-week treatment with the CRTH2-antagonist, OC000459, exerts modest, but significant, anti-eosinophil and beneficial clinical effects in adult patients with active, corticosteroid-dependent or corticosteroid-refractory EoE and is well tolerated.
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Affiliation(s)
- A. Straumann
- Swiss EoE Clinic and EoE Research Network; Olten
| | - S. Hoesli
- Institute of Pharmacology; University of Bern; Bern
| | - Ch. Bussmann
- Institute of Pathology; General Hospital Lucerne; Lucerne; Switzerland
| | - M. Stuck
- Institute of Pharmacology; University of Bern; Bern
| | | | | | | | | | | | - J. Steiner
- Oxford Therapeutics Consulting Ltd; Brightwell cum Sotwell; Oxon; UK
| | - H.-U. Simon
- Institute of Pharmacology; University of Bern; Bern
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85
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Eosinophilic esophagitis--recognition, diet and drugs. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:510-1. [PMID: 22891174 DOI: 10.1155/2012/984260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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