Eosinophilic esophagitis in children: immunopathological analysis and response to fluticasone propionate

The role of lymphocytes in eosinophilic gastrointestinal disorders

Eosinophilic gastrointestinal diseases (EGIDs) encompass a variety of disorders including eosinophilic esophagitis (EE), eosinophilic gastroenteritis (EG), and eosinophilic colitis. Although the pathogenesis of EGIDs is still poorly understood, dietary food antigens have been shown to cause EGIDs through several short-term clinical studies. The relationship of EGIDs with food allergy points to a potential breach of oral tolerance in EGIDs and to a potentially important role played by lymphocytes in responding to the oral food antigens. This article discusses the concept of oral tolerance, the available evidence for the role that lymphocytes play in the induction and pathogenesis of EGIDs, and the evidence for a potential breach in oral tolerance in EGIDs.

The role of the high-affinity IgE receptor, FcepsilonRI, in eosinophilic gastrointestinal diseases

Primary eosinophilic gastrointestinal diseases (EGIDs) are a heterogeneous group of diseases including eosinophilic esophagitis, eosinophilic gastritis, eosinophilic gastroenteritis, eosinophilic enteritis, and eosinophilic colitis. The unifying hallmark and diagnostic marker of EGIDs is an eosinophil-rich inflammatory infiltrate of the GI mucosa, in the absence of known causes for eosinophilia. The etiology of EGIDs is not yet fully understood. The pathogenesis however seems to involve a complex interplay of genetic predisposition, exposure to food- and environmental allergens and IgE-mediated activation of the immune system. Accumulating evidence relates EGIDs to the group of T-helper (Th) 2 mediated immune disorders, like IgE-mediated allergy. In this article we discuss a possible role of IgE-mediated immune-activation via the high affinity receptor for IgE, FcepsilonRI, in the pathogenesis of primary EGIDs. Beyond its defined role in type I allergic reactions, we here hypothesize that activation of tetrameric FcepsilonRI on mast cells and basophils as well as trimeric FcepsilonRI on human eosinophils and antigen presenting cells in the gastrointestinal mucosa is critically involved in the pathology of EGIDs. We also discuss how IgE-independent triggering of FcepsilonRI could be a mechanisms responsible for activation of the immune system in patients with EGID.

Biology and treatment of eosinophilic esophagitis

Eosinophilic esophagitis is a recently recognized but expanding disorder characterized by antigen-driven eosinophil accumulation in the esophagus. Symptoms frequently mimic those of gastroesophageal reflux disease, but the diseases are distinct in their histopathology, gene expression signature, response to therapy, hereditary risk, and association with allergies. The pathogenesis of eosinophilic esophagitis involves environmental and genetic factors, particularly food antigens and expression level of the eosinophil chemoattractant eotaxin-3, respectively. Analyses of gene expression signatures and animal models have indicated the importance of adaptive T-cell immunity that involves interleukin-5 and interleukin-13-induced esophageal epithelial cell responses. Symptoms, dysregulation of esophageal gene expression, and pathology are largely reversible following reduced exposure to specific food antigens as well as anti-inflammatory therapy, but chronic treatment is necessary to prevent relapse. Therefore, eosinophilic esophagitis is a disease with unique features that include chronic esophagitis, atopy, immune sensitization to oral antigens, reversibility, and familial association.

Epidemiology of eosinophilic esophagitis over three decades in Olmsted County, Minnesota

BACKGROUND & AIMS

Data on secular trends and outcomes of eosinophilic esophagitis (EE) are scarce. We performed a population-based study to assess the epidemiology and outcomes of EE in Olmsted County, Minnesota, over the last 3 decades.

METHODS

All cases of EE diagnosed between 1976 and 2005 were identified using the Rochester Epidemiology Project resources. Esophageal biopsies with any evidence of esophagitis and/or eosinophilic infiltration were reviewed by a single pathologist. Clinical course (treatment, response, and recurrence) was defined using information collected from medical records and prospectively via a telephone questionnaire. Incidence rates per 100,000 person years were directly adjusted for age and sex to the US 2000 population structure.

RESULTS

A total of 78 patients with EE were identified. The incidence of EE increased significantly over the last 3 of the 5-year intervals (from 0.35 [95% confidence interval (CI)], 0-0.87] per 100,000 person-years during 1991-1995 to 9.45 [95% CI, 7.13-11.77] per 100,000 person-years during 2001-2005). The prevalence of EE was 55.0 (95% CI, 42.7-67.2) per 100,000 persons as of January 1, 2006, in Olmsted County, Minnesota. EE was diagnosed more frequently in late summer/fall. The clinical course of patients with EE was characterized by recurrent symptoms (observed in 41% of patients).

CONCLUSIONS

The prevalence and incidence of EE is higher than previously reported. The incidence of clinically diagnosed EE increased significantly over the last 3 decades, in parallel with endoscopy volume. Seasonal incidence was greatest in late summer and fall. EE also appears to be a recurrent relapsing disease in a substantial proportion of patients.

Eosinophilic oesophagitis in adults

Previously considered a rare condition, eosinophilic oesophagitis (EoE) has become increasingly recognized as an important cause of dysphagia and food impactions in adults. This is likely attributable to a combination of an increasing incidence of EoE and a growing awareness of the condition. EoE may occur in isolation or in conjunction with eosinophilic gastroenteritis. However, the burgeoning field is likely attributable to the variant that uniquely affects the oesophagus. Adults classically present with symptoms of dysphagia, food impactions, and heartburn. Typical endoscopic features include concentric mucosal rings, linear furrowing, white plaques or exudates and a narrow caliber oesophagus. In some cases, the endoscopic features may appear normal. For years, EoE went unrecognized because eosinophilic infiltration was accepted as a manifestation of reflux, which continues to be a confounding factor in some patients. Current consensus is that the diagnosis of EoE is established by 1) the presence of symptoms, especially dysphagia and food impactions in adults, 2) > or =15 eosinophils per high power field in oesophageal tissue, and 3) exclusion of other disorders with similar presentations such as GERD. Current understanding of EoE pathophysiology and natural history are limited but the entity has been increasingly linked to food allergies and aeroallergens. The main treatment options for EoE are proton pump inhibitors, dietary manipulation, and topical or oral glucocorticoids. This review highlights recent insights into EoE in adults although, clearly, much of the available data overlap with pediatrics and, occasionally, with eosinophilic gastroenteritis.

The role of mast cells in eosinophilic esophagitis

Eosinophilic esophagitis (EE) is a chronic inflammatory disease of the esophagus which is characterized by the presence of dense infiltrate of eosinophilic leukocytes restricted to this organ mucosa. Accumulating published evidence suggests a strong role of mast cells in the inflammatory infiltrate in the physiopathology of EE. We have reviewed published articles with relevant information about the presence and possible role of mast cells in EE. Although mast cells have been studied indirectly in EE, reported data allow us to confirm that the number of mast cells infiltrating the esophageal epithelium in adult and child patients with EE is higher with respect to the normal state and in gastroesophageal reflux disease. Mast cells linked to IgE, which are not found in other conditions, have been identified in EE. Despite that fact, an anaphylactic reaction history after exposure to allergens is not common in these patients. Therefore, the mast cells' function in EE could be dependent on T lymphocytes, as suggested by a mast cell gene expression analysis. Bi-directional crosstalk is established between mast cells and eosinophils, hence establishing interesting hypotheses regarding their relationship to EE physiopathology. Mast cells' function as an immune response leader seems to substitute for their effector functions in EE, while at the same time opening new research pathways for consideration of these cells as a therapeutic target in EE. However, the inefficiency of therapies that inhibit mast cell functions while they are effective in other respiratory tract diseases results in the need for specific studies to identify the real function of such complex cells in the physiopathology of EE. There is indirect proof of the role of mast cells in EE, while many doubts exist about their activation mechanism, which does not seem to be IgE-mediated. Specific approach studies are needed to clarify the function of these cells in the physiopathology of EE, which could be a possible therapeutic target.

Eosinophilic esophagitis

Eosinophilic esophagitis is a chronic inflammatory disorder characterized by dense eosinophilic infiltration of the esophageal mucosa. The pathogenesis is incompletely understood and food allergies and aeroallergens have been implicated. The most common clinical presentation in adults is dysphagia to solids. Its associated endoscopic findings are distinct and include concentric rings and longitudinal furrows, although endoscopy may be unremarkable in a minority of patients. A number of management strategies exist; however, data are limited in adults, and only a few are based on randomized controlled trials. Management options include dietary modifications, pharmacological therapy, and endoscopic dilation.

Eosinophilic esophagitis: concepts, controversies, and evidence

Eosinophilic esophagitis has become a prominent chronic esophageal disorder in clinical pediatric and adult gastroenterology. Its manifestations are protean in childhood, but dysphagia predominates the clinical presentation in adults. Adverse immune responsiveness to dietary antigens underlies most cases, as is reflected in clinical and histologic remission with appropriate diet management in the majority, although an understanding of the mechanisms underlying the inflammatory process remains incomplete. Intense investigations to explain the underpinnings of the disorder and to discover effective therapy are ongoing.

Paediatric eosinophilic oesophagitis presenting to the otolaryngologist

Introduction:

The prevalence of eosinophilic oesophagitis is increasing. A Pubmed search for ‘eosinophilic oesophagitis’ and ‘eosinophilic esophagitis’ yielded 345 publications since 1976. Only seven were in otolaryngology journals.1–7Patients typically present with dysphagia, vomiting, dyspepsia or food impaction and are therefore usually referred to a paediatric gastroenterologist; otolaryngologists are not usually involved in management. A missed diagnosis may result in oesophageal stricture.

Methods:

Two patients, aged two and four years, were referred to the paediatric otolaryngology department with intermittent upper oesophageal food impaction. A paediatric gastroenterologist was involved in the investigation. Histological examination of oesophageal biopsies demonstrated changes consistent with eosinophilic oesophagitis.

Results:

Both patients were expediently diagnosed, investigated and managed.

Conclusion:

A diagnosis of eosinophilic oesophagitis must be considered in patients presenting with food bolus impaction. Early involvement of a paediatric gastroenterology team in the diagnosis is recommended in children presenting with oesophageal symptoms, in order to avoid delayed diagnosis.

What's new in the diagnosis and therapy of eosinophilic esophagitis?

PURPOSE OF REVIEW

Eosinophilic esophagitis (EoE) is a relatively new chronic inflammatory disease of the esophagus. Novel aspects in the diagnosis and treatment of EoE are discussed in this review.

RECENT FINDINGS

Development of diagnostic guidelines consisting of symptoms as well as endoscopic and histopathologic criteria has improved the awareness of clinicians and the diagnosing of EoE. The clinically challenging discrimination of EoE from gastroesophageal reflux disease has become more obvious and has evoked the need for more individualized therapy options. Today, most patients with EoE can be treated successfully with topical corticosteroids. However, no convincing alternative treatment strategies exist for corticosteroid-refractory or corticosteroid-dependent patients. Interestingly, a single-nucleotide polymorphism in the eotaxin-3 gene has been linked to increased disease susceptibility for EoE.

SUMMARY

EoE is an emerging esophageal disease. A better understanding of the pathogenesis of this disorder would improve the clinical recognition and diagnostic ability and ultimately provide patients with more optimal treatment options.

Esophageal trachealization: a feature of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is an inflammatory condition characterized by intense eosinophilic infiltration of the esophagus. EE is frequently misdiagnosed as gastroesophageal reflux disease. Here, we present a child with EE and a characteristic endoscopic finding, "ringed esophagus". An 11-year-old Saudi boy presented with dysphagia for 1 year. He had experienced an intermittent sensation of solid food sticking in his chest, which was relieved by drinking liquids. A barium swallow excluded anatomical causes of dysphagia, but revealed multiple-ringed esophagus. Endoscopy showed a furrowing and trachealizing appearance of the entire esophagus. Hisologically, extensive eosinophilic infiltration was a feature in biopsies obtained from the esophagus. The child responded well to a 2-month course of inhaled fluticasone. Symptoms recurred 3 months after discontinuation of therapy, which necessitated resumption of inhaled fluticasone. The endoscopic appearance of multiple esophageal rings should raise suspicion of EE and be confirmed by esophageal biopsies.

Eosinophilic esophagitis: the newest esophageal inflammatory disease

Eosinophilic esophagitis (EoE) is a chronic esophageal inflammatory disease of undetermined pathophysiology that results in dense mucosal eosinophilia and esophageal dysfunction. In childhood, vague symptoms associated with GERD and feeding difficulties are the first manifestations of EoE. Adults typically present with dysphagia and food impaction. No pathognomonic features have been identified for EoE and, therefore, its diagnosis must be made on both clinical and histological grounds. Effective treatments rely on steroids and dietary exclusions.

[Eosinophilic esophagitis in 29 pediatric patients]

BACKGROUND

Eosinophilic esophagitis is a recently described entity with esophageal symptoms like gastroesophageal reflux disease and significant esophageal eosinophilic infiltration.

AIM

To present our clinical series of 29 children with eosinophilic esophagitis, describing the clinical and diagnostic features, treatment and outcome.

METHODS

We describe 29 patients (22 boys), 1-18 years-old, with 20 eosinophils per high-power field in esophageal biopsy specimens and absence of eosinophilic inflammation in the stomach and duodenum. Evaluation of the clinical, endoscopic and histologic findings, treatment and outcome was undertaken.

RESULTS

The most common presenting symptoms included vomiting in 15 patients (52%) and abdominal pain in 11 patients (38%). Children under the age of 4 years presented with feeding disorder and failure to thrive. Patients between 5 and 8 years of age presented commonly with abdominal pain or symptoms that may be associated with reflux (heartburn and/or vomiting). Patients over the age of 8 presented most often with abdominal pain, dysphagia and occasional food impaction. Endoscopic features included vertical furrowing in 14 patients (48%), whitish papules in 12 (41%), corrugated rings in 2 patients (7%) and esophageal erosions in 3 patients (10%). In seven patients endoscopy was normal (24%). Treatment included swallowed fluticasone propionate in 19 patients and restriction diet in 7 patients. Patients who returned for follow-up had either improvement or remission of symptoms. After treatment, endoscopic biopsies were repeated in 11 patients, and a significant decrease in esophageal eosinophil counts was observed.

CONCLUSIONS

The diagnosis of eosinophilic esophagitis must be considered when symptoms of reflux do not respond to conventional treatment. Upper gastrointestinal endoscopy must be complemented by a detailed analysis of histologic findings and eosinophil counts.

Immunopathological mechanisms of eosinophilic oesophagitis

BACKGROUND

Eosinophilic oesophagitis (EO) is a chronic inflammatory disease of the oesophagus, with an emergent character, defined by the presence of a dense infiltrate by eosinophilic leukocytes restricted to the mucosa of this organ after excluding gastro-oesophageal acid reflux. It is manifested by chronic and/or recurrent dysphagia and episodes of oesophageal alimentary impaction, with great variation in terms of intensity, frequency, and duration of the attacks.

METHODS

An Internet-based search was performed for the most recent articles with relevant information concerning immunopathological mechanisms involved in EO.

RESULTS

Bibliographical data allow us to define that EO is related to an allergic or hypersensitivity-induced reaction after exposure to foods or inhalants, with increased prevalence of sensitisation to these allergens. Data published up to now suggest a cellular hypersensitivity reaction rather than a humoral one in the physiopathology of EO. In this disease, sensitised T-lymphocytes mediate a Th2 type response, releasing cytokines such as IL-5, with a possible Th1 component that requires further investigation. The function of the abundant CD8+ T-lymphocytes present in the oesophageal epithelium has yet to be explained. Mast cells also participate in epithelial inflammatory infiltrate in EO, and it is still unknown if its activation, mainly through IgE, contributes to the immunopathology of the disease even though EO rarely manifests immediate hypersensitivity reactions. IL-5 and different forms of eotaxins perform an important active role in the recruitment of eosinophils to the oesophagus.

CONCLUSIONS

EO is an immunologically complex and little studied entity that is associated with other allergic diseases and in which different effector cells participate, determining an immunological response of cellular rather than a humoral hypersensitivity reaction. The data available point out that EO is a disorder of the Th2 retarded immune response, in which the triggering factor might not be IgE. Although the final inflammatory phenomena observed in EO are common for the different patients, the cascade of inflammatory mediators that lead to them might not be identical in all cases, and the morphological and functional disorders observed in EO would represent the final convergence of different activation forms of the mechanisms of inflammation.

Immunomodulatory therapy of eosinophil-associated gastrointestinal diseases

Eosinophil-associated gastrointestinal disorders (EGIDs), including eosinophilic esophagitis (EE) and eosinophilic gastroenteritis (EG), are a spectrum of increasingly recognized inflammatory diseases characterized by gastrointestinal symptoms and eosinophilic infiltration of the gastrointestinal tract. Significant morbidity is associated with the development of esophageal strictures in some patients. Immune-mediated reactions to food allergens appear to drive the inflammation in a subset of patients, especially those with solitary EE, but dietary interventions remain difficult in EE and are less effective in EG. Despite the increasing incidence of these disorders and their increased recognition by physicians, there are currently no medications that either United States or European Union regulatory agencies have specifically approved for use in EGIDs. This lack of safe and effective therapies for EGIDs is a major obstacle in the care of these patients and underscores the need for new therapeutic approaches. This review briefly discusses the currently available 'off label' drug treatments for EGIDs, most notably topical and systemic corticosteroids. Pathogenesis studies of EGIDs suggest possible therapeutic targets, and conversely, clinical trials of mechanistically-targeted therapeutics give insight into disease pathogenesis. Thus, EGID pathogenesis is discussed as an introduction to mechanistically-targeted immunotherapeutics. The two biologic categories that have been used in EGIDs, anti-IgE (omalizumab) and anti-IL-5 (SCH55700/reslizumab and mepolizumab), are discussed. Because there are similarities in the pathogenesis of EGIDs with asthma and atopic dermatitis, biologic therapeutics currently in early trials for asthma management are also briefly discussed as potential therapeutic agents for EGIDs. Given the deficiencies of current therapeutics and the rapidly advancing knowledge of the pathogenesis of these disorders, EGIDs are an ideal model for translating recent advances in understanding immunopathogenesis into mechanistically-based therapeutics. Further understanding of the early events in pathogenesis is also needed to develop preventive and disease-modifying treatments.

Pathology of eosinophilic esophagitis: what the clinician needs to know

Eosinophilic esophagitis (EOE) is a clinical pathologic syndrome characterized by influx of numerous eosinophils into the esophageal epithelium. It is important for clinicians to be aware of the spectrum, as well as the characteristic location and distribution, of morphologic changes in EOE to maximize the diagnostic yield in mucosal biopsy specimens. The major pathologic features of EOE include eosinophilic microabscesses, surface layering of eosinophils often associated with surface sloughing of necrotic squamous cells, and peak eosinophil counts usually greater than 15 per high power field (hpf) within the squamous epithelium. Minor features, which are frequent but less specific, include marked basal cell hyperplasia, lengthening of lamina propria papillae, intercellular edema, and lamina propria fibrosis with chronic inflammation. The number, distribution, and location of intraepithelial eosinophils in EOE vary greatly between previously published studies. Thus, utilization of a diagnostic cutoff point for intraepithelial eosinophils in EOE, particularly in the absence of other major features of EOE, is currently considered unwise. In fact, some patients may show combined features of both gastroesophageal reflux disease (GERD) and EOE, which complicates the histologic analysis of these patients. In contrast to GERD, EOE typically involves longer lengths of the esophagus, affects the proximal equally, or even more, than the distal esophagus, and the pathologic findings are often patchy in distribution. As a result, it is highly recommended that clinicians obtain biopsies from patients suspected of have EOE only after treatment with high-dose proton pump inhibitor therapy, and that biopsies be obtained from both the proximal and distal esophagus in both normal and abnormal appearing areas.

Mechanisms of food allergy

Allergy type sensitization occurring in the gut results from a break in oral tolerance, mostly occurring in early childhood. In these patients, a minute amount of the large load of potential food allergens not only will result in immunoglobulin E (IgE) type sensitization mostly, but also in food allergies resulting from other mechanisms including eosinophil-driven disease or resulting from T-cell-mediated inflammation. Symptoms elicited by subsequent exposure to foods in these patients will be mostly in relation to the mechanism of the disease. In this educational review series, we described three cases of food allergy, first, a child with typical IgE-mediated food allergy, second, a child with eosinophilic proctocolitis and in the third patient, we will address tolerance acquisition mechanisms. These cases are discussed with regards to their specific immune events.

Dissociation between symptoms and histological severity in pediatric eosinophilic esophagitis

OBJECTIVES

The relation between patient symptoms and histological severity of eosinophilic esophagitis (EE) is not known. We created a pediatric EE symptom score (PEESS) and compared the results with histological findings in the esophagus.

PATIENTS AND METHODS

Subjects ages 3 to 18 years with a histological diagnosis of EE or their parent completed a survey rating the frequency and severity of their gastrointestinal symptoms. Scores ranged from 0 to 98. Eosinophil numbers in esophageal biopsy specimens were correlated with the PEESS.

RESULTS

A total of 49 subjects completed the PEESS. The symptom score did not correlate with the peak eosinophil count (r = 0.079). Newly diagnosed, untreated EE subjects (N = 15) had a mean score of 24.7 +/- 16.4 with a modest correlation between the PEESS and the number of eosinophils in the distal esophagus (r = 0.37). The mean PEESS score in the 34 treated patients was lower than in untreated patients (15.6 +/- 12.9; P = 0.046). The mean score for treated patients in histological remission was the same as for treated patients with active EE, regardless of treatment type. Abdominal pain was the most frequent and severe symptom reported. Among 20 of the 34 subjects (58.8%) in histological remission, 17 (85%) continued to report symptoms with a mean score of 17.4 +/- 9.9 (range 1-38). Three children with active histological EE (10%) reported no symptoms.

CONCLUSIONS

Children with untreated EE had a higher PEESS than treated subjects. Symptoms persisted in 85% of EE patients despite histological resolution and 10% with active EE reported no symptoms. Our data indicate a dissociation between symptoms and histology in pediatric EE.

Eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a disease based on a clinicopathologic diagnosis that involves a localized eosinophilic inflammation of the esophagus. A significant increase in the diagnosis of pediatric EoE has occurred over the past 10 years not only due to a greater recognition of the disease among gastroenterologists, allergists, and pathologists but also secondary to an increased incidence of the disease. EoE is defined by the presence of 15 or more esophageal eosinophils per high-power field isolated to the esophagus associated with clinical symptoms that do not respond to acid suppression therapy. Although the exact mechanism of EoE is unknown, food allergens are thought to have an important role. Effective treatment options include dietary restrictions and various steroid formulations.

Treatment of eosinophilic esophagitis: overview, current limitations, and future direction

Eosinophilic esophagitis (EE) is an increasingly recognized syndrome presenting with upper gastrointestinal (UGI) symptoms in association with hypereosinophilia (>15 eosinophils/HPF) on esophageal mucosal biopsies. The pathogenesis is unknown, but the candidate etiologies include food and aeroallergen hypersensitivity and an unusual presentation of gastroesophageal reflux disease. This review will highlight the treatments of EE in children and adults. Current treatments are controversial, few data are available in adults, and long-term studies are almost nonexistent. We outline the limitations in the current studies and suggest seven major issues in the study design that must be addressed in future drug trials.

3-yr-follow-up of topical corticosteroid treatment for eosinophilic esophagitis in adults

BACKGROUND

Eosinophilic esophagitis (EE) is a clinicopathologic syndrome comprising isolated eosinophilic inflammation of the esophagus, with symptoms of dysphagia, and possibly, reflux. It was initially described in children, and in recent years, there is a heightened awareness in adults. The etiology is not completely understood. The treatments include dietary manipulation, topical corticosteroids, systemic corticosteroids, Montelukast, and endoscopic dilation. In adults, there are no randomized trials demonstrating the efficacy of any particular treatment, and no prospective studies describing the natural history of the disease following treatment.

METHODS

We performed an interval follow-up of patients treated with a swallowed corticosteroid inhaler. We contacted 51 adult patients who were diagnosed with EE and treated with a swallowed corticosteroid inhaler between September 1, 1999, and May 31, 2003. All patients had received 6 wk of treatment with fluticasone 220 mEq/puff, four puffs swallowed twice daily for 6 wk.

RESULTS

Thirty-two patients replied (63%) with a mean follow-up duration of 3.3 yr. Ninety-one percent of patients reported recurrent symptoms; a mean of 8.8 months after treatment was completed. Sixty-nine percent of patients repeated treatment with the steroid inhaler at least once.

CONCLUSIONS

It appears that EE is a chronic remitting disorder that requires more than one topical steroid treatment course.

Treatment with topical steroids downregulates IL-5, eotaxin-1/CCL11, and eotaxin-3/CCL26 gene expression in eosinophilic esophagitis

OBJECTIVES

Our aim was to evaluate the changes induced by topical steroid treatment to the esophageal epithelial inflammatory eosinophilic and T-cell infiltrate and to IL-5, eotaxin-1/CCL11, and eotaxin-3/CCL26 esophageal gene expression levels in patients with eosinophilic esophagitis (EE).

METHODS

Esophageal biopsies were taken from eight adult patients at the moment of diagnosis and after 3-month treatment with fluticasone propionate. Eosinophils, CD8, and CD4 T cells were examined by immunohistochemistry. IL-5, eotaxin-1/CCL11, and eotaxin-3/CCL26 gene expression levels were measured by real-time PCR. Eight control samples were also analyzed.

RESULTS

A significant decrease in the eosinophil infiltrate and in CD8(+) T-cell density was observed in the esophageal epithelium from the patients upon steroid treatment. IL-5 was not detected in control samples, and expression levels were variably downregulated after treatment in six of the patients. Gene expression of eotaxin-1/CCL11 showed relevant downregulation in four cases and a modest twofold decrease in three of the patients studied. Mean CCL11 expression values upon steroid treatment were similar to control samples (19.4 +/- 28.6 vs 8.42 +/- 5, P= 0.7). Eotaxin-3/CCL26 gene expression levels were significantly increased in EE. Although they were significantly downregulated upon steroid treatment, control expression levels were not reached in any of the cases analyzed (580.9 +/- 943.9 vs 1.45 +/- 1.0, P= 0.001).

CONCLUSIONS

Our results confirm that eotaxin-3/CCL26 is significantly increased in EE esophageal samples. However, the individual analysis of IL-5, CCL11, and CCL26 expression data suggests that several cytokines and chemokines could participate in the physiopathology of EE in humans.

New visions for food allergy: an iPAC summary and future trends

The spectrum of food allergy consists of a variety of different clinical pictures including immunoglobulin (Ig)E, and non-IgE food allergy as well as mixed, IgE and non-IgE disorders. In addition, eosinophilic diseases of the gastrointestinal (GI) tract with occasional IgE-type sensitization are increasingly recognized. As a consequence, the clinical picture of food allergy is pleomorphic and can range from chronic GI symptoms to severe anaphylaxis. The diagnosis of food allergy is mostly hampered by the lack of reliable in vitro tests for non-IgE-mediated diseases, and in most cases relies on a reoccurrence of symptoms upon re-exposure to the antigen; in general during a standardized food challenge. Currently, there is no safe and efficient treatment for food allergy and the treatment relies on avoidance diets. Priorities for research have been identified by iPAC (international Pediatric Allergy and Asthma Consortium) and outlined in this review. They include studies to better identify the pathogenesis of food allergy, including genetic aspects; studies to develop diagnostic and follow-up tests; studies for standardization of food challenges; as well as studies addressing a safe and efficient treatment of food allergy.

Scope of drug-induced, infectious and allergic esophageal injury

PURPOSE OF REVIEW

The most common cause of esophageal injury is gastroesophageal reflux disease, however other less recognized causes may affect the esophagus. In this review we will focus on pill-induced esophageal injury, infections of the esophagus and eosinophilic esophagitis.

RECENT FINDINGS

Esophageal infections are less frequent since HIV infection has become better controlled with antiviral therapies. The most emergent 'allergic' disease of the esophagus is eosinophilic esophagitis, which has become increasingly recognized in children and adults over the last decade. Eosinophilic esophagitis is a clinicopathologic disorder characterized by a dense esophageal eosinophilia generally occurring in association with upper gastrointestinal symptoms, primarily intermittent dysphagia, and refractory to proton pump inhibitor therapy.

SUMMARY

Drug-induced esophageal injury remains underdiagnosed and should be better recognized.

Eosinophilic oesophagitis: a common cause of dysphagia in young adults?

Eosinophilic oesophagitis (EO) is an increasingly recognised chronic, relapsing inflammatory condition of the oesophagus. There has been a mini-epidemic of EO in the last decade. The incidence of this condition is higher in children and is commoner in males. There is either a family or personal history of atopic conditions present in a significant number of patients and can also be familial in up to 10%. The classical symptom in an adult is chronic, intermittent solid-food dysphagia and food impaction, often necessitating emergency endoscopic removal. Despite the history of dysphagia for a number of years, patients remain well with no weight loss, which can mislead clinicians to diagnose a functional problem with a resulting delay in the diagnosis. There are various endoscopic features of EO; commonly multiple rings and linear furrows, though these can be subtle and the mucosa may be macroscopically normal. The hallmark of this condition is the histological presence of > or =15 eosinophils/high power field (HPF) in the oesophageal mucosa. Therapeutic options include avoidance of dietary allergens, topical or systemic steroids, Montelukast, Mepolizumab (anti-IL-5 antibody) and endoscopic dilation of strictures unresponsive to medical therapy.

Eosinophilic gastroenteritis

Eosinophilic gastroenteritis is an infrequently diagnosed condition that is characterized by prominent eosinophilic infiltration of the stomach or small intestine, generally localized to one level of the intestinal wall; the variable organ locus and wall depth produce heterogeneous clinical presentations. A strong association with atopy is present in most cases, supported by circumstantial evidence and the demonstration of Th-2 proinflammatory cytokine profiles in animal studies. A high degree of suspicion is required to establish the diagnosis, which must be based on intense gastrointestinal eosinophilia. Management is directed toward removal of offending allergens and use of anti-inflammatory agents. Novel and emerging treatments on the horizon are biologic therapies and selective anti-eosinophil agents.

Eosinophilic esophagitis in adults

Eosinophilic esophagitis in adults is a disease characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of long-standing solid food dysphagia and food impactions. First described in 1978, this syndrome is being recognized increasingly in the developed world, with multiple case series reported from the United States, Europe, and Australia during the past decade. Diagnosis requires the presence of greater than or equal to 15 eosinophils/high-power field on esophageal biopsies. Successful treatment in adults has been reported with the use of systemic and topical swallowed steroids. Endoscopic treatment has been associated with increased an risk for tears and perforations.

Idiopathic eosinophilic disorders of the gastrointestinal tract in children

Over the last decade, eosinophilic gastrointestinal diseases have emerged as increasingly recognised diseases affecting both adults and children. While the exact morbidity is uncertain, it has become evident that they carry a significant cost to affected patients. Recent investigations shed light on basic mechanisms of eosinophilic recruitment and inflammation, and suggest a critical role for Th2 cytokines, such as eotaxin, and allergen exposure in their pathogenesis. Eosinophilic oesophagitis (EO) is the best characterised of these diseases, and improved understanding of its basic biology stimulated development of new treatment regimens. Current evidence supports the use of elemental diets and systemic or topical corticosteroids to treat EO. A major clinical problem is the fact that most patients relapse when medical treatment is discontinued, thus making nutritional management an attractive long term option. Many areas remain unanswered in the management of patients with EGIDs, including identification of optimal treatment protocol, development of appropriate non-invasive monitoring, and choice of appropriate therapeutic endpoints.

Eosinophilic esophagitis in children: clinical manifestations

During the past decade, the increasing number of recognized cases of eosinophilic esophagitis in children and adults has resulted in a dramatic expansion of the medical literature surrounding it. Clinical and basic research has contributed to a better, but still incomplete, body of knowledge regarding its clinical and histologic manifestations, as well as its immunologic and genetic pathogenesis. This article provides a broad framework for recognizing the remarkable variety of clinical manifestations of eosinophilic esophagitis in children, which must be considered as part of the differential diagnosis in many different clinical situations.

Eosinophils and allergic diseases of the gastrointestinal tract

The association between increased tissue eosinophilia and allergic disease is particularly striking in the case of the gastrointestinal tract. About 80% of individuals with eosinophilic gastrointestinal disorders (EGIDs) are atopic, while half of the patients with gastrointestinal allergy show tissue eosinophilia. The function of eosinophils in gastrointestinal allergic disorders is unclear; however, a proinflammatory action is most likely. Cytokines (interleukins 5 and 3, granulocyte-monocyte colony-stimulating factor) and chemokines (eotaxin, RANTES, etc.) released by Th2 lymphocytes, mast cells and other tissue cells have been identified as major regulators of eosinophil chemotaxis and activation, but a convincing mechanism by which eosinophils are activated in an allergen-dependent manner is still lacking. The diagnostic approach comprises both histological and laboratory methods to assess eosinophilia and eosinophil activation, as well as tools to assess the allergic disease while excluding other gastrointestinal diseases such as food intolerances, infections and tumours. Treatment of allergic EGIDs includes elimination or elemental diets and drug therapy using classical anti-allergic agents such as topical corticosteroids and new approaches such as LTD4 receptor antagonists or antibodies against IL-5 or eotaxin.

Atopic characteristics of adult patients with eosinophilic esophagitis

BACKGROUND & AIMS

The association of sensitization to food allergens, atopic disorders, and eosinophilic esophagitis (EE) is well known in children, but not in adults. Our purpose was to identify the spectrum of specific allergic sensitivities to environmental and food allergens within a series of adult patients with EE.

METHODS

The case series consisted of 23 adult patients with biopsy-proven EE referred for allergy evaluation at an academic clinic. All patients had data that included serum measurement of specific immunoglobulin (Ig)E antibodies to common foods and spices. Patients diagnosed with allergic rhinitis had a relevant clinical history of respiratory allergy and evidence of specific IgE to environmental aeroallergens.

RESULTS

The series consisted of 16 men and 7 women with a median age of 34 years (range, 18-57 y). Eighteen of 23 had an atopic diathesis, allergic rhinitis being the most common. Seventeen of 21 patients were polysensitized to several different environmental allergens, and 19 of 23 (82%) had serum IgE specific for one or more food-associated allergens (median, 5 foods), with wheat, tomato, carrot, and onion identified most commonly. The preponderance of environmental and food allergy was similar across all age groups and did not favor younger adults.

CONCLUSIONS

By using objective measures, our series confirms the high degree of atopy in adults with EE, similar to that seen in the pediatric population. These patients tend to be polysensitized to several environmental allergens, and the profiles of serum IgE specific for food allergens suggest that sensitization may partly be a response to inhaled allergens.

Esophageal granular cell tumor and eosinophilic esophagitis: two interesting entities identified in the same patient

We illustrate the case of a 41-year-old male with allergic manifestations since childhood. He sought medical attention for intermittent, progressive dysphagia from which he had been suffering for a number of years, having felt the sensation of a retrosternal lump and a self-limited obstruction to the passage of food. Endoscopy detected a submucosal tumor in the upper third of the esophagus, which was typified, via biopsy, as a granular cell tumor with benign characteristics and probably responsible for the symptoms. Two years later, the patient sought medical attention once again as these symptoms had not abated, hence digestive endoscopy was repeated. This revealed stenosis of the junction between the middle and lower thirds of the organ which had not been detected previously but was passable under gentle pressure. Eosinophilic esophagitis was detected after biopsies were taken. Esophageal manometry identified a motor disorder affecting the esophageal body. Following three months of treatment using fluticasone propionate applied topically, the symptoms went into remission, esophageal stenosis disappeared and the esophageal biopsies returned to normal. This is the first documented case of the link between granular cell tumors and Eosinophilic esophagitis, two different disorders which could cause dysphagia in young patients.

Comparison of oral prednisone and topical fluticasone in the treatment of eosinophilic esophagitis: a randomized trial in children

BACKGROUND & AIMS

Although eosinophilic esophagitis is recognized increasingly, outcome data guiding therapy are limited. We conducted a prospective randomized trial comparing oral prednisone (P) and swallowed fluticasone (F) for histologic and clinical response.

METHODS

Patients were randomized to receive P or F for 4 weeks, followed by an 8-week weaning protocol. Esophageal histology was evaluated at baseline and after 4 weeks of therapy. Clinical assessments were performed at weeks 0, 4, 12, 18, and 24.

RESULTS

Eighty patients with eosinophilic esophagitis were enrolled: 40 in the P arm and 40 in the F arm. Histologic improvement was seen in 30 of 32 P and 34 of 36 F patients, with a greater degree of histologic improvement in the P group. All P and 35 of 36 F patients were free of presenting symptom(s) at week 4. Symptom relapse was seen in 45% of patients by week 24. Kaplan-Meier analysis showed no difference between P and F with regard to relapse rate (P = .7399). No significant difference in time to relapse was found between groups (P = .2529). Systemic adverse effects were noted in 40% of the P arm, whereas esophageal candidal overgrowth was seen in 15% of the F arm.

CONCLUSIONS

Systemic and topical corticosteroids were effective in achieving initial histologic and clinical improvement. P resulted in a greater degree of histologic improvement, without evidence of an associated clinical advantage over F in terms of symptom resolution, relapse rates, or time to relapse. Symptom relapse was common to both groups upon therapy discontinuation, highlighting the need for maintenance treatment protocols.

IL-13 involvement in eosinophilic esophagitis: transcriptome analysis and reversibility with glucocorticoids

BACKGROUND

Eosinophilic esophagitis (EE) is an emerging worldwide disease that mimics gastroesophageal reflux disease. Early studies have established that esophageal eosinophilia occurs in association with T(H)2 allergic responses, and we recently identified an EE-specific esophageal transcriptome that included eotaxin-3.

OBJECTIVE

We sought to determine the mechanism by which this T(H)2 response leads to EE.

METHODS

Real-time PCR and microarray analysis were performed on RNA extracted from esophageal biopsy specimens and primary esophageal epithelial cell cultures stimulated with IL-13 (0-100 ng/mL). Transient transfections in esophageal cell lines were performed with plasmids containing the luciferase gene driven by eotaxin-3 promoter fragments and modified forms of signal transducer and activator of transcription 6.

RESULTS

The IL-13 mRNA level was markedly increased (16-fold) in esophageal biopsy specimens from patients with EE compared with those from healthy individuals. Furthermore, IL-13 treatment of primary esophageal epithelial cells was sufficient to induce a global-expression transcript profile that remarkably overlapped with the EE-specific esophageal transcriptome. In addition, esophageal epithelial cells markedly produce eotaxin-3 after IL-13 stimulation through a transcriptional mechanism dependent on signal transducer and activator of transcription 6. Lastly, increased IL-13 mRNA levels and the EE transcriptome were largely reversible with glucocorticoid treatment in vivo.

CONCLUSIONS

Taken together, we propose that the pathogenesis of EE is mediated by an IL-13-stimulated keratinocyte-derived transcriptome that is largely reversible with corticosteroid treatment. Furthermore, we identify an in vivo IL-13-induced transcriptome that has potential utility for target assessment after anti-IL-13 therapeutics.

CLINICAL IMPLICATIONS

IL-13-induced pathways and genes are fundamental processes in the cause and manifestations of EE; as such, therapeutic agents that interfere with IL-13 might be particularly useful for disease treatment.

How to manage refractory GERD

Patients who are unresponsive to 4-8 weeks' treatment with PPIs twice daily might have so-called refractory GERD. The first investigation these patients should undergo is upper endoscopy to exclude a diagnosis of peptic ulcer disease or cancer and identify the presence of esophagitis. The presence of esophagitis in these patients is suggestive of a pill-induced injury, an autoimmune skin disease involving the esophagus, eosinophilic esophagitis or, less likely, a hypersecretory syndrome or a genotype that confers altered metabolism of PPIs. Refractory reflux syndromes associated with normal endoscopy findings are more problematic to diagnose and further testing may be required, including prolonged 48 h pH testing, impedance measurements (for nonacid reflux), esophageal manometry and gastric function tests. For patients with refractory GERD who do not have esophagitis, possible etiologies include nocturnal gastric acid breakthrough, nonacid GER, missed GER or other diseases such as achalasia, gastroparesis or functional heartburn.

Eosinophilic esophagitis in children: clinical manifestations

During the past decade, the increasing number of recognized cases of eosinophilic esophagitis in children and adults has resulted in a dramatic expansion of the medical literature surrounding it. Clinical and basic research has contributed to a better, but still incomplete, body of knowledge regarding its clinical and histologic manifestations, as well as its immunologic and genetic pathogenesis. This article provides a broad framework for recognizing the remarkable variety of clinical manifestations of eosinophilic esophagitis in children, which must be considered as part of the differential diagnosis in many different clinical situations.

Eosinophilic esophagitis: association with allergic disorders

Atopy has been linked to eosinophilic gastrointestinal disorders because of the role eosinophils play in atopic disorders. It has also been found that these disorders coexist. The goal of this article is to take a step back, and considering only eosinophilic esophagitis, attempt to determine from the available body of clinical and research literature: (1) Is the coexistence of these disorders attributable to a preconceived bias? If so, what is the source of the bias and how can it be removed? (2) Is there a cause and effect relationship? If so, can this relationship be harnessed for diagnostic and therapeutic modalities?

Translational research on the pathogenesis of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is an inflammatory disease of the esophagus characterized by eosinophilic infiltration of the esophageal epithelium. EE is a relatively new disease from clinical and research standpoints. A recent surge in basic and translational studies has emerged to understand its pathogenesis since its recognition as a separate entity from acid-induced gastroesophageal reflux disease in 1995. Our understanding of this disease is still limited, however. In this article, available evidence from translational studies on EE is discussed, focusing on the allergic nature of the disease and highlighting the role of various inflammatory cells found in the esophagus of patients who have EE. Esophageal remodeling in EE is also discussed.

Epidemiology and etiology of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is an inflammatory disease of the esophagus characterized by eosinophilic infiltration of the esophageal mucosa. Symptoms of EE are variable, and include gastroesophageal reflux symptoms, abdominal pain, growth failure, and dysphagia. Dysphagia is a more common presentation in adults and older children. Serious complications of EE consisting of esophageal food impactions necessitating urgent endoscopic removal of the food and esophageal strictures requiring endoscopic balloon dilatations are also seen. The potential severity of these symptoms points to the importance of proper recognition and management of the disease, especially given that EE has become more prevalent over the past decade. In this article, available evidence on the epidemiology and etiology of EE is discussed.

Basic pathogenesis of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is a newly recognized disease, which has largely been called idiopathic EE, emphasizing the poor understanding of its pathogenesis. EE is a severe disease of the esophagus characterized by an accumulation of eosinophils in the esophageal mucosa, and is highly associated with atopic disease. Nevertheless, the nomenclature "eosinophilic esophagitis" describes only the tip of the iceberg of a complex disorder, as the pathogenesis of EE involves multiple tissues, cell types, and genes, and derives from complex genetic and environmental factors. This article defines the fundamental knowledge available to date that characterizes the mechanisms by which certain etiological factors cause EE, reviewing human studies, murine models, and recent knowledge regarding the involvement of environmental, cellular, molecular, and genetic factors in the development of EE.

Esophageal dysmotility in patients who have eosinophilic esophagitis

The understanding of esophageal motility alterations in patients who have eosinophilic esophagitis (EE) is in its infancy despite the common presenting complaint of dysphagia. A diversity of motility disorders has been reported in patients who have EE including achalasia, diffuse esophageal spasm, nutcracker esophagus, and nonspecific motility alterations including high-amplitude esophageal body contractions, tertiary contractions, abnormalities in lower esophageal sphincter pressure, and other peristaltic problems. Some evidence suggests that treatment of EE will improve motility. Technological advances such as high-resolution manometry and combined manometry with impedance may provide new insight into more subtle motility abnormalities.

Histopathologic features of eosinophilic esophagitis

The pathology of eosinophilic esophagitis (EE) when fully developed in humans is highly characteristic and readily discriminated from the histology of the normal esophagus. The histologic alterations are not pathognomonic for any of the multiple causes of EE, and the correct diagnosis can be made only if the histology is correlated with clinical findings. The histology of the normal esophagus is reviewed and contrasted with the findings in EE. The characteristic findings in EE are illustrated. Selected research in humans and animal models pertinent to EE are briefly reviewed.

Noninvasive markers of eosinophilic esophagitis

There has been an increasing awareness and recognition of eosinophilic esophagitis (EE), a chronic condition with periods of exacerbation and remission, over the last decade. The complex pathophysiology of EE and eosinophil physiology provide several candidate biomarkers that could be studied on various noninvasively obtained body specimens. This article reviews several potential noninvasive biomarkers of EE.

Pharmacologic treatment of eosinophilic esophagitis

There are several treatment options available for patients who have eosinophilic esophagitis (EE). These options include dilatation for mechanical esophageal abnormalities, pharmacologic therapy, and dietary management. Providing the appropriate therapy depends on the significance of clinical symptoms, association of abnormal anatomy, and histologic involvement of underlying the esophageal tissue. This article focuses on the pharmacotherapy of EE.

Integrated approach to treatment of children and adults with eosinophilic esophagitis

Over the last decade, treatment plans for eosinophilic esophagitis included the use of elemental formula, elimination diets, systemic corticosteroids, and the gavage of aerosolized steroids. Except for one placebo-controlled blinded prospective study, most decision making has been based on retrospective or uncontrolled studies and clinical experience. In this article, three authors from diverse backgrounds combine their resources to propose treatment paths with justification based on their clinical experience and interpretation of the literature.

Treatment of eosinophilic esophagitis: drugs, diet, or dilation?

A number of recent studies have demonstrated that a variety of treatments effectively improve symptoms and histology in the majority of patients with eosinophilic esophagitis. Therapeutic options include pharmacologic treatments, such as oral and topical corticosteroids and leukotriene-receptor antagonists. In children, the high response rates to dietary modification and elimination suggest that certain foods may serve as environmental triggers for the eosinophilic infiltration. Because many adults present with strictures, endoscopic esophageal dilation is another management modality. Despite these treatment options, several controversies exist in the recommended treatment strategy. Whether the goal of therapy is resolution of symptoms, tissue eosinophilia, or both remains uncertain owing to the paucity of data on the natural history of the condition. Furthermore, important differences in the clinical presentations of eosinophilic esophagitis in children and adults point toward the possible need for different treatment approaches in the two patient populations.

Eosinophilic esophagitis: is it all allergies?

Eosinophilic esophagitis (EE) is an increasingly recognized disorder in the adult population, most often manifested by symptoms of dysphagia and food impaction. Mechanisms involving eotaxin-3, interleukin 5, and signal transducer and activator of transcription 6 have been studied and may represent future therapeutic targets. Patients commonly have a personal and family history of atopy, and both food allergies and aeroallergens have also been investigated as triggers of EE. Traditional allergy-testing methods, including skin prick testing and specific IgE testing, have been used to identify food and environmental allergies. However, new studies suggest that patch testing could add to diagnostic accuracy in EE because the disorder might not be a classic type I allergic response. Although studies of treatment of adults with EE have thus far focused on swallowed fluticasone proprionate, many trials in children have assessed the efficacy of food elimination and elemental diets. These diets, which have been extremely successful in reducing symptoms, have also been shown to induce histological improvement and remission. No similar studies have been conducted in adults; the tolerability of such an intervention may prove more difficult in this population. This article reviews the underlying pathophysiology of EE and describes evolving options for more accurately identifying food and environmental allergies. We also discuss the pediatric trials using food elimination and avoidance diets and suggest that this type of intervention may be an important area of future research in the adult population.