Influence of race and gender on the presentation of eosinophilic esophagitis

Association of Clinical Reactivity with Sensitization to Allergen Components in Multifood-Allergic Children

BACKGROUND

Thirty percent of children with food allergies have multiple simultaneous allergies; however, the features of these multiple allergies are not well characterized serologically or clinically.

OBJECTIVE

We comprehensively evaluated 60 multifood-allergic patients by measuring serum IgE to key allergen components, evaluating clinical histories and medication use, performing skin tests, and conducting double-blind, placebo-controlled food challenges (DBPCFCs).

METHODS

Sixty participants with multiple food allergies were characterized by clinical history, DBPCFCs, total IgE, specific IgE, and component-resolved diagnostics (IgE and IgG4) data. The food allergens tested were almond, egg, milk, sesame, peanut, pecan, walnut, hazelnut, cashew, pistachio, soy, and wheat.

RESULTS

Our data demonstrate that of the reactions observed during a graded DBPCFC, gastrointestinal reactions occurred more often in boys than in girls, as well as in individuals with high levels of IgE to 2S albumins from cashew, walnut, and hazelnut. Certain food allergies often occurred concomitantly in individuals (ie, cashew/pistachio and walnut/pecan/hazelnut). IgE testing to components further corroborated serological relationships between and among these clustered food allergies.

CONCLUSIONS

Associations of certain food allergies were shown by DBPCFC outcomes as well as by correlations in IgE reactivity to structurally related food allergen components. Each of these criteria independently demonstrated a significant association between allergies to cashew and pistachio, as well as among allergies to walnut, pecan, and hazelnut.

An Overview of the Diagnosis and Management of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by symptoms of esophageal dysfunction and eosinophilic infiltration of the esophageal mucosa. The diagnosis requires esophageal biopsies demonstrating at least 15 eosinophils per high-powered field following a course of high-dose proton pump inhibitors. Management of EoE consists of the three Ds: drugs, dietary therapy, and esophageal dilation. In this review, we discuss the epidemiology, pathogenesis, diagnosis, and treatment of EoE to include the role of emerging therapies.

Eosinophilic Esophagitis in Children and Its Relationship with Parental Allergies: Texas Children's Hospital Experience

BACKGROUND

Eosinophilic esophagitis (EoE) is an allergen-mediated, clinicopathological condition affecting all ages. The characteristics of children with EoE in the southwestern USA have not been fully described. Furthermore, very little is known about the relationship between parental allergies and risk of EoE in their offspring in this patient population.

AIMS

To characterize children with EoE and to examine the relationship between prevalence of parental allergies and occurrence of EoE in their offspring at a single referral pediatric center in the southwestern USA.

METHODS

Demographic and clinical information of 126 children (≤18 years of age) with EoE was abstracted in a pre-determined data extraction form and analyzed. The allergy history was collected from biological parents of 61 children (parent-child cluster) with EoE in a standardized questionnaire and analyzed.

RESULTS

The median age at presentation was 8 years (interquartile range 4-13). The majority of our patients were male (71 %) and Caucasian (59 %). Overall, 84 % of children reported allergies. Prevalence of food allergy was significantly higher compared to environmental allergies (P = 0.001). At least 46 % of parents reported allergies. A significantly higher proportion of fathers had developed allergies during their childhood compared to adulthood (P = 0.03).

CONCLUSIONS

The characteristics of EoE in our patients were similar to those reported from other parts of the country. Childhood onset of paternal allergies appears to be a risk factor for occurrence of EoE in their offspring. Additional research to elucidate the relationship between parental allergies and occurrence of EoE in their offspring is warranted.

Effects of Race and Sex on Features of Eosinophilic Esophagitis

BACKGROUND & AIMS

Clinical and endoscopic features of eosinophilic esophagitis (EoE) differ between children and adults and among racial backgrounds. We investigated whether there were any associations between race or sex and clinical presentation, endoscopic features, and histologic findings from patients with EoE of various racial backgrounds.

METHODS

We performed a retrospective, multicenter, cross-sectional analysis of 793 patients with EoE (476 adults and 317 children; mean age, 26 years; range, 0.1-84 years; 72% male) from clinical registries at 5 tertiary care centers in the United States. EoE was defined per consensus guidelines. Data with predetermined variables were extracted from clinical registries at each participating institution.

RESULTS

Of the study cohort, 660 patients were white (83%), 77 were African American (10%), and 56 were of other races (7%). A significantly larger proportion of white persons than African Americans or other races had dysphagia (74%, 56%, and 53%, respectively; P < .001), food impaction (35%, 13%, and 13%, respectively; P < .001), and features of EoE that included rings (46%, 25%, and 18%, respectively; P < .001) or furrows (70%, 58%, and 55%, respectively; P = .012). Males and females had similar clinical presentations, histories of atopy, findings from endoscopy, and histologic characteristics. A higher proportion of males than females had strictures (17% vs 11%; P = .038).

CONCLUSIONS

Race, and to a smaller degree sex, are associated with features of EoE. African Americans have different clinical symptoms and fewer endoscopic features of EoE than white persons. EoE should be considered in African Americans even without typical findings.

Insights into the emerging epidemic of eosinophilic oesophagitis

Eosinophilic oesophagitis (EOE) is a relatively recently recognised condition characterised by an increase in oesophageal eosinophils. EOE occurs in children and adults with a strong male preponderance. There has been a sharp increase in EOE in North America, Europe and Australia. The reasons for this increase remain unclear but are likely to be influenced by genetic and environmental factors, as well as early-life exposures. Based on recent population-based data, the estimated EOE prevalence in the USA is 56.7 per 100,000 persons. The peak prevalence was observed in patients between 35 and 39 years of age. Prevalence figures in Asia and the Middle East generally appear to be lower than in Western countries, but population-based studies are not available. A causal association between coeliac disease and EOE appears unlikely. Data on the seasonal variation of EOE remain inconclusive. Further population-based studies are needed to define the epidemiology of EOE.

Do We Know What Causes Eosinophilic Esophagitis? A Mechanistic Update

The mechanisms underlying eosinophilic esophagitis (EoE) have been intensely investigated, and significant advances have been made in understanding the pathogenesis of EoE. EoE is defined as a chronic immune/antigen-mediated disease, characterized clinically by symptoms of esophageal dysfunction and histologically by an esophageal eosinophilic infiltrate. In this paper, we will review the current knowledge of EoE pathophysiology based on both animal and human data and discuss possible etiologic mechanisms from the genetic and environmental perspectives. EoE is a Th2-predominant inflammatory process triggered by allergens. Proinflammatory cytokines and chemokines recruit eosinophils and other effector cells, such as mast cells, into the esophageal epithelium, where they cause direct damage and promote esophageal remodeling. The genetic expression profile of EoE has been described, and several single nucleotide polymorphisms have been identified and associated with EoE. While this genetic contribution is important, it is difficult to postulate that EoE is primarily a genetic disease. Given the rapid epidemiologic changes in the incidence and prevalence of EoE over the past two decades, environmental factors may be the driving force. While it is not known what causes EoE in an individual patient at a specific time, the current hypothesis is that there is a complex interaction between genetic factors and environmental exposures that remains to be elucidated.

Racial differences in eosinophilic gastrointestinal disorders among Caucasian and Asian

BACKGROUND

Although there is an increasing number of eosinophilic gastrointestinal disorders (EGID) cases including eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE), being reported globally, no systematic reviews have been conducted to elucidate the racial differences in these disorders. We aimed to show the racial differences, especially among Caucasians and Asians, in the risk of EoE and EGE.

METHODS

We conducted a systematic review using PubMed in September 2012. All case reports and case series on EGID that involved human subjects and described race or ethnicity, as well as pathological findings, were included. For the comparison of reported cases between Caucasians and Asians, a chi-squared test was used.

RESULTS

Among the 687 studies found in PubMed, 121 studies fulfilled the eligibility criteria. In total, 2621 patients were reviewed. Among Caucasian EGID patients, 94% had EoE; while among Asian EGID patients, 72% had EGE (p < 0.001). Among EoE, Asians were significantly less likely to have dysphagia and heartburn, but more likely to have vomit and abdominal pain, compared to Caucasians (p < 0.001). Further, among EGE, Asians were significantly more likely to have eosinophil-infiltrated colon than Caucasians (OR: 3.22, 95% confidence interval [CI]: 1.60-7.04), but were less likely to have eosinophil-infiltrated stomach (OR: 0.29, 95% CI: 0.17-0.49).

CONCLUSIONS

We found that EoE occurs more frequently in Caucasian EGID patients than Asian EGID patients, while the reverse is true for EGE. Also, racial disparities in symptoms and eosinophil-infiltrated tissues were observed. Our findings suggest further genetic and environmental studies to elucidate the etiology of EGID.

Reliability of symptoms and endoscopic findings for diagnosis of esophageal eosinophilia in a Japanese population

BACKGROUND/AIMS

The clinical characteristics of esophageal eosinophilia (EE), which is essential for diagnosis of eosinophilic esophagitis (EoE), have not been fully clarified in a Japanese population. The aim of this study was to analyze the reliability of symptoms and endoscopic findings for diagnosing EE in Japanese individuals.

METHODS

We prospectively enrolled subjects who complained of esophageal symptoms suggesting EoE and/or those with endoscopic findings of suspected EoE at the outpatient clinics of 12 hospitals. Diagnostic utility was compared between the EE and non-EE groups using logistic regression analysis.

RESULTS

A total of 349 patients, including 319 with symptoms and 30 with no symptoms but endoscopic findings suggesting EoE were enrolled. Of those with symptoms, 8 (2.5%) had EE, and 3 were finally diagnosed with EoE. Of those without symptoms but endoscopic findings, 4 had EE. Among 8 symptomatic patients, 7 had abnormal endoscopic findings suspicious of EoE. Although dysphagia was a major symptom in EE, none of the presenting symptoms was useful for diagnosis of EE. Among the endoscopic findings, linear furrow was the most reliable (OR = 41.583).

CONCLUSION

EE is uncommon among patients with esophageal symptoms in Japanese individuals. The most useful endoscopic finding for diagnosis of EE was linear furrow, whereas subjective symptoms were not supportive.

Clinical features of eosinophilic esophagitis: differences between Asian and Western populations

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.

Gender is a determinative factor in the initial clinical presentation of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease resulting in symptoms of esophageal dysmotility. Abnormalities include dysphagia, food impaction and reflux. Although men appear to comprise a majority of the EoE population, few studies have directly assessed gender-associated clinical differences. The aim of this study is to identify the effect of gender on the initial clinical presentation of adult-onset EoE patients. We reviewed our electronic medical record database from January 2008 to December 2011 for adults diagnosed with EoE per the 2011 updated consensus guidelines. Patient demographics, presenting symptoms, endoscopy findings and complications were recorded. Proportions were compared using chi-squared analysis, and means were compared using the Student's t-test. A total of 162 patients met the inclusion criteria and 71 (44%) were women. Women were more likely to report chest pain (P = 0.03) and heartburn (P = 0.06), whereas men more commonly reported dysphagia (P = 0.04) and a history of food impaction (P = 0.05). Endoscopic findings were similar between groups. No patients suffered esophageal perforations. These data suggest that men report more fibrostenotic symptoms and women report more inflammatory symptoms at the time of diagnosis. There was no difference in endoscopic findings between genders. This is one of the only reviews comparing differences in clinical presentation, endoscopic findings and complications between gender for EoE. The current recommended guidelines state that any patient with symptoms of esophageal dysfunction should be biopsied for EoE. Our findings support biopsying patients with typical and atypical symptoms of dysmotility including heartburn and chest pain.

Advances in clinical management of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated clinicopathologic condition that has become an increasingly important cause of upper gastrointestinal morbidity in adults and children over the past 2 decades. It is diagnosed based on symptoms of esophageal dysfunction, the presence of at least 15 eosinophils/high-power field in esophageal biopsy specimens, and exclusion of competing causes of esophageal eosinophilia, including proton pump inhibitor-responsive esophageal eosinophilia. We review what we have recently learned about the clinical aspects of EoE, discussing the clinical, endoscopic, and histological features of EoE in adults and children. We explain the current diagnostic criteria and challenges to diagnosis, including the role of gastroesophageal reflux disease and proton pump inhibitor-responsive esophageal eosinophilia. It is also important to consider the epidemiology of EoE (with a current incidence of 1 new case per 10,000 per year and prevalence of 0.5 to 1 case per 1000 per year) and disease progression. We review the main treatment approaches and new treatment options; EoE can be treated with topical corticosteroids, such as fluticasone and budesonide, or dietary strategies, such as amino acid-based formulas, allergy test-directed elimination diets, and nondirected empiric elimination diets. Endoscopic dilation has also become an important tool for treatment of fibrostenotic complications of EoE. There are a number of unresolved issues in EoE, including phenotypes, optimal treatment end points, the role of maintenance therapy, and treatment of refractory EoE. The care of patients with EoE and the study of the disease span many disciplines; EoE is ideally managed by a multidisciplinary team of gastroenterologists, allergists, pathologists, and dieticians.

Eosinophilic gastritis in children: clinicopathological correlation, disease course, and response to therapy

OBJECTIVES

Eosinophilic gastritis (EG), defined by histological criteria as marked eosinophilia in the stomach, is rare, and large studies in children are lacking. We sought to describe the clinical, endoscopic, and histopathological features of EG, assess for any concurrent eosinophilia at other sites of the gastrointestinal (GI) tract, and evaluate response to dietary and pharmacological therapies.

METHODS

Pathology files at our medical center were searched for histological eosinophilic gastritis (HEG) with ≥70 gastric eosinophils per high-power field in children from 2005 to 2011. Pathology slides were evaluated for concurrent eosinophilia in the esophagus, duodenum, and colon. Medical records were reviewed for demographic characteristics, symptoms, endoscopic findings, comorbidities, and response to therapy.

RESULTS

Thirty children with severe gastric eosinophilia were identified, median age 7.5 years, 14 of whom had both eosinophilia limited to the stomach and clinical symptoms, fulfilling the clinicopathological definition of EG. Symptoms and endoscopic features were highly variable. History of atopy and food allergies was common. A total of 22% had protein-losing enteropathy (PLE). Gastric eosinophilia was limited to the fundus in two patients. Many patients had associated eosinophilic esophagitis (EoE, 43%) and 21% had eosinophilic enteritis. Response to dietary restriction therapy was high (82% clinical response and 78% histological response). Six out of sixteen patients had persistent EoE despite resolution of their gastric eosinophilia; two children with persistent HEG post therapy developed de novo concurrent EoE.

CONCLUSIONS

HEG in children can be present in the antrum and/or fundus. Symptoms and endoscopic findings vary, highlighting the importance of biopsies for diagnosis. HEG is associated with PLE, and with eosinophilia elsewhere in the GI tract including the esophagus. The disease is highly responsive to dietary restriction therapies in children, implicating an allergic etiology. Associated EoE is more resistant to therapy.

Lack of seasonal variation in the incidence of eosinophilic oesophagitis in adolescent and adult non-PPI-responsive oesophageal eosinophilia midwestern US populations

BACKGROUND

Eosinophilic oesophagitis (EoO) has been associated with allergic disorders as well as aeroallergens. The current literature has shown a possible association between seasonal variation, mainly in the spring, and the incidence of EoO. However, this data was based on small population studies that did not exclude proton-pump inhibitor (PPI)-responsive oesophageal eosinophilia (PPI-ROE) in their cohort.

AIM

The aim of this study was to determine if there is a seasonal variation associated with the diagnosis of EoO in patients that had been treated with high-dose PPI prior to diagnosis.

METHODS

Oesophageal biopsies were obtained from a cohort of patients who presented with symptoms of dysphagia, odynophagia, and heartburn during a 10-year period. Symptomatic patients who had biopsies from the mid and distal oesophagus with ≥20 eosinophils per high-power field (hpf) while on high-dose PPI treatment for at least 5 weeks were diagnosed as having EoO. The monthly and seasonal incidences were determined (winter, January-March; spring, April-June; summer, July-September; Autumn, October-December).

RESULTS

A total of 20,718 patients were identified and their records evaluated. From this cohort, 193 (0.93%) symptomatic patients had biopsy-proven oesophageal eosinophilia (≥20 eosinophils/hpf) and no seasonal variation was seen in this group. However, only 57 (0.28%) had been adequately treated with PPI prior to diagnosis (i.e. non-PPI-ROE biopsy-proven EoO; ≥20 eosinophils/hpf: 39 males, 18 females; age 29.5 years). The most common medical history components included asthma (12.3%) and food allergies (3.5%), and the most common presenting symptoms included dysphagia (50.9%) and heartburn (26.3%). The monthly and seasonal incidences in our cohort were with no apparent trend (p = 0.713 and 0.703, respectively).

CONCLUSIONS

The incidence of EoO was consistent across all 12 months as well as during the four seasons. Our data does not support a seasonal variation in relation to the incidence of EoO in the US midwestern non-PPI-ROE population.

Epidemiology of eosinophilic esophagitis

In this article, the epidemiology of eosinophilic esophagitis (EoE) is reviewed. Demographic features and natural history are described, the prevalence and incidence of EoE are highlighted, and risk factors for EoE are discussed. EoE can occur at any age, there is a male predominance, it is more common in whites, and there is a strong association with atopic diseases. EoE is chronic, relapses are frequent, and persistent inflammation increases the risk of fibrostenotic complications. The prevalence is currently estimated at 0.5-1 in 1000, and EoE is now the most common cause of food impaction. The incidence of EoE is approximately 1/10,000 new cases per year, and the increase in incidence is outpacing increases in recognition and endoscopy volume, but the reasons for this evolving epidemiology are not yet fully delineated.

The pathophysiology of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is an emerging disease characterized by esophageal eosinophilia (>15eos/hpf), lack of responsiveness to acid-suppressive medication and is managed by allergen elimination and anti-allergy therapy. Although the pathophysiology of EoE is currently unsubstantiated, evidence implicates food and aeroallergen hypersensitivity in genetically predisposed individuals as contributory factors. Genome-wide expression analyses have isolated a remarkably conserved gene-expression profile irrespective of age and gender, suggesting a genetic contribution. EoE has characteristics of mainly TH2 type immune responses but also some TH1 cytokines, which appear to strongly contribute to tissue fibrosis, with esophageal epithelial cells providing a hospitable environment for this inflammatory process. Eosinophil-degranulation products appear to play a central role in tissue remodeling in EoE. This remodeling and dysregulation predisposes to fibrosis. Mast-cell-derived molecules such as histamine may have an effect on enteric nerves and may also act in concert with transforming growth factor-β to interfere with esophageal musculature. Additionally, the esophageal epithelium may facilitate the inflammatory process under pathogenic contexts such as in EoE. This article aims to discuss the contributory factors in the pathophysiology of EoE.

Prevalence of eosinophilic esophagitis in a United States military health-care population

Eosinophilic esophagitis (EoE) is a rapidly emerging chronic immune-mediated condition affecting children and adults, both genders, and all races. A large variation in the prevalence of EoE exists in the literature. The aim of this study is to establish the prevalence of EoE in a military health-care population in the United States using a comprehensive electronic medical record search. Using the International Classification for Diseases-9 code for EoE (530.13), the total number of EoE patients enrolled in the military health-care system from October 1, 2008 to September 30, 2009 including active-duty military, dependents of military personnel, and retirees were identified. For each case of EoE identified, demographic data (age, gender, and race) and geographic location was obtained. The overall prevalence of EoE was calculated as well as the prevalence within subgroups. The geographic regional locations were reported per the U.S. Census Bureau regions (Northeast, South, Midwest, and West). A total of 987 EoE patients were identified from 10,180,515 military health-care beneficiaries, establishing an overall prevalence of 9.7 per 100,000 (95% confidence interval [CI] 9.1-10.3). Seven hundred twenty-eight out of 7,707,372 adult patients were identified, establishing a prevalence of 9.5 per 100,000 (95% CI 8.8-10.1). Two hundred fifty-nine out of 2,473,143 pediatric patients were identified, establishing a prevalence of 10.5/100,000 (95% CI 9.2-11.8). EoE was more prevalent in males (odds ratio [OR] 2.03 [95% CI 1.78-2.32]) and higher in Caucasian versus African Americans (18.1 vs. 5.2/100,000, OR 3.47 [95% CI 2.40-5.03]). EoE was more prevalent in the Western region of the United States compared with the Northeast, South, and Midwest regions, with a prevalence of 11.9 versuss 5.2, 9.6, and 9.2 per 100,000, respectively. When comparing Northern with Southern states, there was an increased prevalence in the North (10.9 vs. 7.2/100,000, P < 0.05). In this large nationwide study, increase in prevalence of EoE was seen in younger adults, with a higher prevalence in Caucasians. Geographically, the western United States had a significantly higher prevalence with a slightly higher prevalence in the Northern latitude.

A phenotypic analysis shows that eosinophilic esophagitis is a progressive fibrostenotic disease

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.

Racial differences in the clinical presentation of pediatric eosinophilic esophagitis

BACKGROUND

Analysis of current data suggests that 80% to 90% of children diagnosed with eosinophilic esophagitis are white. Little data exist regarding the presentation of eosinophilic esophagitis and potential clinical differences in minority children.

OBJECTIVE

This study compared the clinical presentation of eosinophilic esophagitis in African American children with white children treated at an urban allergy referral center.

METHODS

At an urban allergy clinic, a 2-year retrospective chart review was performed of 50 consecutive pediatric patients diagnosed with eosinophilic esophagitis. Presenting symptoms, age at diagnosis, coexisting atopic disease, and laboratory parameters were compared between races.

RESULTS

Most of the 50 children identified were boys (74%), as previously described. However, unlike prior literature, most were nonwhite (42% white, 42% African American, 4% Asian, and 12% other). African American children compared with white children had (1) a significantly higher frequency of failure to thrive (P < .01) and vomiting (P < .01) as presenting symptoms, (2) a higher frequency of comorbid atopic dermatitis (P < .01), (3) a younger mean age of symptom presentation and formal diagnosis (3.7 vs 9.1 years; P < .01), and (4) a trend toward a longer interval between symptom onset and formal diagnosis. However, after adjusting for confounding variables of age and insurance type, several of these racial differences were no longer significant.

CONCLUSION

African American children in this series had a larger burden of eosinophilic esophagitis than previously described as well as differences in clinical presentation compared with white patients. Analysis of these findings suggests that providers be aware of this potential diagnosis in young, atopic African American children with symptoms of esophageal dysfunction.

Eosinophilic oesophagitis: clinical presentation and pathogenesis

Eosinophilic oesophagitis (EoE) is an inflammatory disorder of the oesophagus which has become increasingly recognised over recent years, although it remains underdiagnosed in many centres. It is characterised histologically by a significant eosinophilic infiltration of the oesophageal mucosa (>15 eosinophils per high powered field), and clinically with features of oesophageal dysfunction such a dysphagia, food impaction, and proton pump inhibitor (PPI) resistant dyspepsia. Fibrosis and oesophageal remodelling may occur and lead to oesophageal strictures. An allergic predisposition is common in the EoE population, which appears to be primarily food antigen driven in children and aeroallergen driven in adults. Evidence suggests that the pathogenesis of EoE is due to a dysregulated immunological response to an environmental allergen, resulting in a T helper type 2 (Th2) inflammatory disease and remodelling of the oesophagus in genetically susceptible individuals. Allergen elimination and anti-inflammatory therapy with corticosteroids are currently the mainstay of treatment; however, an increasing number of studies are now focused on targeting different stages in the disease pathogenesis. A greater understanding of the underlying mechanisms resulting in EoE will allow us to improve the therapeutic options available.

Genetics of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a complex genetic disorder characterized by eosinophilic inflammation within the esophagus. Multiple epidemiological studies estimate the prevalence of EoE is 4 in 10,000, with a higher disease prevalence in individuals of European ancestry and in males, highlighting a genetic etiology of the disease. EoE has often been noted to occur in multiple family members, particularly siblings, in a non-Mendelian pattern, indicating the heritable component of EoE is likely complex in nature. Although EoE is a newly diagnosed disorder involving a complex polygenic etiology, much progress has been made towards identifying the molecular pathways contributing to the disease pathogenesis and the genetic variants associated with disease susceptibility using a variety of approaches (genome-wide and candidate gene) as well as study designs (case-control and family-based cohorts). Here, we discuss the major scientific findings that have shaped the current molecular and genetic landscape of EoE as well as the major obstacles in the discovery of disease causal variants in complex disorders.

Epidemiology of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is an allergy-associated disease defined clinically by esophagus-related symptoms in combination with a dense esophageal eosinophilia, both of which are unresponsive to prolonged acid suppression with proton pump inhibitors. Over the last two decades EoE has increasingly been recognized in various geographical areas (mostly industrialized countries) with high socioeconomic development. The prevalence rate is increasing and reaches up to 50 patients per 100,000 inhabitants in some indicator regions. Whether this increased prevalence is due to a real increase in incidence, a result of increased awareness by health care providers or because of the nonfatal nature of EoE adding more and more cases to the patient pool is still a matter of controversy. Several studies have consistently demonstrated a male predominance in EoE, with a male-to-female risk ratio of 3:1. The average age at diagnosis ranges between 30 and 50 years and suggests that EoE is a disease of the middle-aged man. It can affect patients of every race, but the disease is more common among Caucasians. In both children and adults, EoE has been clearly associated with allergies to food and aeroallergens, and most EoE patients present with a personal allergic background (e.g. asthma, rhinoconjunctivitis or oral allergy syndrome). In conclusion, knowledge of epidemiologic parameters of EoE is crucial for identifying risk factors as well as pathogenic mechanisms, planning preventive measures and determining optimal treatment strategies.

Development and field testing of a novel patient-reported outcome measure of dysphagia in patients with eosinophilic esophagitis

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.

ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE)

Esophageal eosinophilia and eosinophilic esophagitis (EoE) are increasingly recognized and prevalent conditions, which now represent common clinical problems encountered by gastroenterologists, pathologists, and allergists. The study of EoE has become a dynamic field with an evolving understanding of the pathogenesis, diagnosis, and treatment. Although there are limited data supporting management decisions, clinical parameters are needed to guide the care of patients with eosinophilic-esophageal disorders. In this evidence-based review, recommendations developed by adult and pediatric gastroenterologists are provided for the evaluation and management of these patients. New terminology is emphasized, particularly the concepts of esophageal eosinophilia and proton-pump inhibitor-responsive esophageal eosinophilia (PPI-REE) as entities distinct from EoE.

Adult versus pediatric eosinophilic esophagitis: important differences and similarities for the clinician to understand

Eosinophilic esophagitis (EoE) is recognized as a common, allergy-associated cause of chronic esophageal symptoms affecting both children and adults. Research has begun to shed light on its epidemiology with consistent results from various geographical areas. Differences in clinical presentation, endoscopic aspects and response to treatment have all been reported for patients of different ages, and the question as to whether adult and pediatric EoE are manifestations of a single entity or in fact two distinct disorders has been posed. The most relevant differences between pediatric and adult EoE come from evolutionary changes in the consequences of the disease, including fibrous remodeling, and the ability to express symptoms. However, most studies support a common pathogenesis and similar histopathological features for adult and pediatric patients, being the same diagnostic criteria applied to them. This article comprehensively reviews the most recently published information and addresses important questions about the natural history of EoE.

Eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition whereby infiltration of eosinophils into the esophageal mucosa leads to symptoms of esophageal dysfunction. EoE is encountered in a substantial proportion of patients undergoing diagnostic upper endoscopy. This review discusses the clinical, endoscopic, and histologic features of EoE and presents the most recent guidelines for its diagnosis. Selected diagnostic dilemmas are described, including distinguishing EoE from gastroesophageal reflux disease and addressing the newly recognized clinical entity of proton-pump inhibitor-responsive esophageal eosinophilia. Also highlighted is evidence to support both pharmacologic and nonpharmacologic treatments, including topical corticosteroids, dietary elimination therapy, and endoscopic dilation.

Food impaction in older age: Think about an eosinophilic esophagitis

Eosinophilic esophagitis is an inflammatory condition of esophagus. It is generally seen in childhood and young population. Men are more commonly affected than women. However, it is not common in an advanced age. Eosinophilic esophagitis decreases the ability of the esophagus to stretch and accommodation against foods. Therefore, the major symptom in adults with eosinophilic esophagitis is difficulty in swallowing solid food (dysphagia). Specifically, the food gets stuck in the esophagus after it is swallowed. Less common symptoms include heartburn and chest pain. Because of this, it may be incorrectly diagnosed as a gastroesophageal reflux disease. Here, we reported a case presented with food impaction at advanced age. As a conclusion, eosinophilic esophagitis is a rare entity that must be remembered in advance aged patients presenting with food impaction.

Rapidly increasing incidence of eosinophilic esophagitis in a large cohort

BACKGROUND

Recent literature has shown increasing incidence and prevalence rates of eosinophilic esophagitis (EoE). However, data are mainly based on small studies and come from centers dedicated to EoE. Aim of this study was to estimate the incidence rates of EoE by using a large database.

METHODS

We performed a cross-sectional study of the pathology reports describing esophageal eosinophilia from 1996 through 2010, using the nationwide network and registry of histo- and cytopathology in The Netherlands (PALGA). All histopathology reports nationwide enter this database. We classified cases according to the diagnosis made by the pathologist. Annual incidence rates of EoE were estimated.

KEY RESULTS

Our search criteria yielded 8838 positive pathology reports. Eosinophilic esophagitis was diagnosed in 674 patients, of which 74% were men. In another 174 patients, no distinction was made between eosinophilia caused by gastro-esophageal reflux disease or EoE. The incidence of EoE increased considerably over the years, being 0.01 in 1996, 0.01 in 2000, 0.14 in 2005, and 1.31 per 100,000 persons in 2010. Eosinophilic esophagitis was diagnosed in all age groups, but in 2010 the highest incidence was seen in 20-29 years old males, in whom it was estimated to be 3.23 per 100,000 persons. The incidence in children was 0.73 per 100,000 in 2010. No seasonal variation in diagnosis of EoE was observed.

CONCLUSIONS & INFERENCES

In this large study, we found robust data on increasing incidence rates of pediatric and adult EoE in the past 15 years. This rapidly increasing incidence has not reached a plateau yet.

Diagnosis and management of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by esophageal dysfunction and eosinophilic infiltrate in the esophageal epithelium in the absence of other potential causes of eosinophilia. EoE is increasing in incidence and prevalence, and is a major cause of gastrointestinal morbidity among children and adults. EoE is thought to be immune mediated, with food or environmental antigens stimulating a T-helper (Th)-2 inflammatory response. An increased understanding of the pathogenesis of EoE has led to the evolution of diagnostic and treatment paradigms. We review the latest approach to diagnosis of EoE and present consensus diagnostic guidelines. We also discuss the clinical, endoscopic, and histologic features of EoE and challenges to diagnosis. Finally, we present the 3 major treatment options for EoE: pharmacologic therapy, dietary modification, and endoscopic dilation.

Confounding factors affect the pathophysiology of eosinophilic esophagitis

Eosinophilic esophagitis is a newly diagnosed esophageal disease in adult and children. The clinical and pathological characteristics of this disease have been established and were recently summarized in the expert clinical guideline published in 2011. In spite of the wide knowledge accumulated on this disease, there are many areas where scientific data are missing, especially in regard to the disease's pathophysiology. Recent publications have suggested that other confounding factors modify the disease and may affect its clinical-phenotypic presentation. Those factors may include place of living, air pollution, race, genetic factors and other. In the present report we discussed and review those confounding factors, the new developments, and what direction we should go to further advance our knowledge of this disease.

Eosinophilic esophagitis: diagnostic tests and criteria

PURPOSE OF REVIEW

To present the clinical, endoscopic, and histologic features of eosinophilic esophagitis (EoE), review the current diagnostic guidelines for EoE, and present an approach for diagnosis of EoE. It will also highlight selected techniques that are under development that may be useful in the future for diagnosis of EoE.

RECENT FINDINGS

Recently updated guidelines emphasize that EoE is a clinicopathologic condition. Specifically, three criteria must be met to diagnose EoE: clinical symptoms of esophageal dysfunction; an esophageal biopsy with a maximum eosinophil count of at least 15 eosinophils per high-power microscopy field, with few exceptions; and exclusion of other possible causes of esophageal eosinophilia, including proton-pump inhibitor responsive esophageal eosinophilia (PPI-REE). A PPI trial is typically required both to assess for PPI-REE and to evaluate for the presence of concomitant gastroesophageal reflux disease.

SUMMARY

EoE is a chronic, immune-mediated disorder. Because no single symptom, endoscopic finding, or histopathologic feature is pathognomonic, diagnosis can be challenging. In the future, symptom scores, tissue or serum biomarkers, and genetic testing may play a role in diagnosis, but these methods have yet to be validated and are not yet recommended for routine clinical use.

Prevalence of esophageal eosinophilia varies by climate zone in the United States

OBJECTIVES

The epidemiology of eosinophilic esophagitis (EoE) is rapidly evolving, and differences in climate could impact the prevalence of EoE. We aimed to examine the association between esophageal eosinophilia and climate zones in the United States.

METHODS

This was a cross-sectional study of esophageal biopsies from 2008 to 2010 in a large US pathology database. Cases were patients with esophageal eosinophilia; controls had normal esophageal biopsies. A Köppen-Geiger (K-G) climate class was assigned to each patient, and the association between case-control status and the main K-G climate type (tropical, arid, temperate, or cold) was assessed.

RESULTS

A total of 233,649 patients were included, 71,948 (30.8%) with normal esophageal biopsies and 9,995 (4.3%) with esophageal eosinophilia. Using the temperate zone as the referent and after multivariable analysis, the odds of esophageal eosinophilia were highest in the cold climate zone (odds ratio (OR)=1.39, 95% confidence interval (CI): 1.34-1.47), compared with the tropical zone (OR=0.87; 95% CI: 0.71-10.8) and the arid zone (OR=1.27; 95% CI: 1.19-1.36). Increased likelihood of EoE was also associated with increasing odds of being in the cold climate zone. Compared with patients with normal esophageal biopsies, patients with dysphagia, a clinical suspicion of EoE, no reflux or Barrett's esophagus, esophageal eosinophilia, and eosinophilic microabscesses had the highest adjusted odds of being in a cold climate zone (OR 2.02; 1.78-2.28).

CONCLUSIONS

Esophageal eosinophilia differs significantly between K-G climate zones, with the highest prevalence in the cold and arid zones. Geographical and climate patterns may help identify candidate antigens characteristic to high-prevalence areas to be targeted for future investigation.