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Hirano I, Chan ES, Rank MA, Sharaf RN, Stollman NH, Stukus DR, Wang K, Greenhawt M, Falck-Ytter YT. AGA institute and the joint task force on allergy-immunology practice parameters clinical guidelines for the management of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2020; 124:416-423. [PMID: 32336462 DOI: 10.1016/j.anai.2020.03.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona and Division of Pulmonology Phoenix Children's Hospital Phoenix, Arizona
| | - Rajiv N Sharaf
- Division of Gastroenterology, Department of Medicine, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Neil H Stollman
- Division of Gastroenterology, Alta Bates Summit Medical Center, Oakland, California
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Kenneth Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio
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202
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Eluri S, Iglesia EGA, Massaro M, Peery AF, Shaheen NJ, Dellon ES. Practice patterns and adherence to clinical guidelines for diagnosis and management of eosinophilic esophagitis among gastroenterologists. Dis Esophagus 2020; 33:doaa025. [PMID: 32378700 PMCID: PMC7350163 DOI: 10.1093/dote/doaa025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 12/11/2022]
Abstract
Real-world practice patterns of eosinophilic esophagitis (EoE) among gastroenterologists are not well-described. The aim is to describe practice patterns of EoE diagnosis and management and assess concordance with consensus guidelines. We conducted a cross-sectional online survey of gastroenterologists in the USA using Qualtrics, which was dispersed through the North Carolina Society of Gastroenterology (NCSG) and the American College of Gastroenterology member listservs. A similar survey was sent to NCSG members in 2010 and responses were compared in a subanalysis. Of 240 respondents, 37% (n = 80) worked in an academic setting versus 63% (n = 138) community practice setting. Providers saw a median of 18 (interquartile range 2-100) EoE patients annually and 24% (n = 52) were 'very familiar' with EoE guidelines. A proton-pump inhibitor (PPI) trial was required by 37% of providers prior to EoE diagnosis. In total, 60% used a ≥15 eosinophils per high-power field cut point for diagnosis and 62% biopsied from the proximal and distal esophagus on initial exam. Only 12% (n = 28) followed EoE diagnosis guidelines. For first-line treatment, 7% used dietary therapy, 32% topical steroids, and 61% used PPIs; 67% used fluticasone as first-line steroid; 41% used maintenance steroid treatment in responders. In the NCSG cohort, a higher proportion in 2017 followed guideline diagnosis recommendations compared with 2010 (14% vs. 3%; P = 0.03) and a higher proportion used dietary therapy as first-line treatment (13% vs. 3%; P = 0.046). There is variability in EoE practice patterns for EoE management, with management differing markedly from consensus guidelines. Further education and guideline dissemination are needed to standardize practice.
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Affiliation(s)
- Swathi Eluri
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Edward G A Iglesia
- Division of Pediatric Allergy, Immunology, and Rheumatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael Massaro
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Anne F Peery
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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203
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Azzano P, Villard Truc F, Collardeau-Frachon S, Lachaux A. Children with eosinophilic esophagitis in real life: 10 years' experience with a focus on allergic management. Allergol Immunopathol (Madr) 2020; 48:244-250. [PMID: 31813622 DOI: 10.1016/j.aller.2019.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/26/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND OBJECTIVES Eosinophilic esophagitis (EoE) is frequently miss-diagnosed or overlooked for several years because of the invasiveness of investigations and the non-specificity of symptoms in childhood. Due to the lack of specific recommendations in children, its management remains very heterogeneous, especially concerning allergy testing. The aim of this study is to analyze our population and practices, in comparison with the literature, with a focus on allergic management, to harmonize and optimize our practice. MATERIAL AND METHODS We included all children with a diagnosis of EoE at the Hospital Femme Mere Enfant, Bron, France. Data were collected via retrospective chart review. RESULTS 108 patients were included with an average age of 9.5 years. Average delay before diagnosis was 6.65 years. Symptoms varied with age, with a predominance of vomiting (60% of patients), feeding difficulties (72%) and growth difficulties (24%) in children <5 years, whereas older children often presented with feeding blockage (64%) and dysphagia (61%). Cough was frequent in our cohort (18.5%), especially in children <10 years (38.5% between three and five years). The allergic background was frequent (70.3%) and 80% of our patients benefited from allergy testing. Allergy testing was particularly useful to guide therapy as elimination diet represented an effective treatment in 60% of our patients CONCLUSIONS: Allergy testing has to be harmonized to include major allergens (egg, milk, peanut, fish, wheat, and soy), including prick and patch tests. Allergy-testing based diet seemed to be the best compromise between efficiency and constraints, especially in mono-sensitized patients.
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204
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Eosinophilic Esophagitis Histology Remission Score: Significant Relations to Measures of Disease Activity and Symptoms. J Pediatr Gastroenterol Nutr 2020; 70:598-603. [PMID: 31977951 PMCID: PMC7183895 DOI: 10.1097/mpg.0000000000002637] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Eosinophilic esophagitis (EoE) is characterized by remissions and relapses. Guidelines defining remission do not exist and therefore remission is inconsistently identified. We sought to define histology remission in EoE. METHODS Esophageal biopsies, obtained at the time the validated pediatric EoE symptoms scores v2.0 (PEESS v2.0) questionnaire was completed (N = 42), were scored using the validated EoE Histology Scoring System. An EoE Histology Remission Score (EoEHRS) was constructed and specified that in all esophageal sites sampled the peak eosinophil count was <15 per high power field (HPF); in addition, neither the total grade (severity of pathology) nor stage (extent of pathology) scores could exceed 3 (possible total maximum score for each was 24). Spearman correlation coefficients were generated for histology/symptom correlations; coefficient range 0.31 to 0.50 was considered moderate. RESULTS EoE Histology Scoring System composite and individual feature scores from proximal and distal esophageal biopsies correlated moderately with PEESS v2.0 mean scores (0.48-0.36, P < 0.01), and with scores in the dysphagia (0.39-0.30, P ≤ 0.01), pain (0.48-0.34, P ≤ 0.01), and gastroesophageal reflux disease (0.51-0.32, P ≤ 0.01) domains. Biopsies that met full EoEHRS criteria had reduced biomarkers, specifically expression of the mast cell markers CPA3 and tryptase mRNA, and reduced eosinophil peroxidase deposition (P < 0.03), compared to those with nonremission scores. Subjects whose biopsies met EoEHRS remission criteria reported reduced symptoms for all domains except nausea and vomiting (P ≤ 0.01). CONCLUSIONS The EoEHRS correlated with reduced biomarkers of disease activity and reduced symptoms, and therefore may be useful to inform clinical care and interstudy comparisons.
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205
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Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical review on the management of eosinophilic esophagitis: a report from the AGA institute and the joint task force on allergy-immunology practice parameters. Ann Allergy Asthma Immunol 2020; 124:424-440.e17. [PMID: 32336463 PMCID: PMC8171057 DOI: 10.1016/j.anai.2020.03.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
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Affiliation(s)
- Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona
| | - Rajiv N Sharaf
- Division of Gastroenterology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Division of Allergy Immunology Center for Immunity, Infection, and Inflammation, University of California, San Diego Rady Children's Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M Spergel
- Division of Allergy-Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland Veterans Affairs Medical Center and University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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206
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Lee K, Choe BH, Kang B, Kim S, Kim JY, Shim JO, Lee YM, Lee EH, Jang HJ, Ryoo E, Yang HR. Nationwide Multicenter Study of Eosinophilic Esophagitis in Korean Children. Pediatr Gastroenterol Hepatol Nutr 2020; 23:231-242. [PMID: 32483544 PMCID: PMC7231742 DOI: 10.5223/pghn.2020.23.3.231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/13/2020] [Accepted: 03/28/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE In East Asian countries, there are only a few epidemiologic studies of eosinophilic esophagitis (EoE) and no studies in children. We investigated the incidence and compared the clinical characteristics of EoE and eosinophilic gastroenteritis involving the esophagus (EGEIE) in Korean children. METHODS A total of 910 children, who had symptoms of esophageal dysfunction, from 10 hospitals in Korea were included. EoE was diagnosed according to diagnostic guidelines and EGEIE was diagnosed when there were >15 eosinophils in the esophagus per high power field (HPF) and >20 eosinophils per HPF deposited in the stomach and duodenum with abnormal endoscopic findings. RESULTS Of the 910 subjects, 14 (1.5%) were diagnosed with EoE and 12 (1.3%) were diagnosed with EGEIE. Vomiting was the most common symptom in 57.1% and 66.7% of patients with EoE and EGEIE, respectively. Only diarrhea was significantly different between EoE and EGEIE (p=0.033). In total, 61.5% of patients had allergic diseases. Exudates were the most common endoscopic findings in EoE and there were no esophageal strictures in both groups. The median age of patients with normal endoscopic findings was significantly younger at 3.2 years, compared to the median age of 11.1 years in those with abnormal endoscopic findings (p=0.004). CONCLUSION The incidence of EoE in Korean children was lower than that of Western countries, while the incidence of EGEIE was similar to EoE. There were no clinical differences except for diarrhea and no differences in endoscopic findings between EoE and EGEIE.
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Affiliation(s)
- Kunsong Lee
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
| | - Byung-Ho Choe
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Seung Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Young Kim
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Jung Ok Shim
- Department of Pediatrics, Korea University Guro Hospital, Seoul, Korea
| | - Yoo Min Lee
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Eun Hye Lee
- Department of Pediatrics, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Hyo-Jeong Jang
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Eell Ryoo
- Department of Pediatrics, Gachon University Gil medical Center, Incheon, Korea
| | - Hye Ran Yang
- Department of Pediatrics, Seoul National University Bundang Hospital, Sungnam, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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207
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Rustagi S, Mullins D, Yanney E. Current updates in diagnosis and management of eosinophilic esophagitis. Curr Probl Pediatr Adolesc Health Care 2020; 50:100783. [PMID: 32446911 DOI: 10.1016/j.cppeds.2020.100783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis is a relatively new, moderately-well understood disease. It is one of the leading causes of dysphagia in the pediatric population. Thought to be triggered by food ingestion, it is distinctly different from food allergies. Although endoscopy is required for diagnosis, this article will review warning signs and symptoms that aid with evaluation and diagnosis of this disease. Treatment modalities and management are evolving and more research is needed.
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Affiliation(s)
- Shelly Rustagi
- Department of Pediatric Gastroenterology, Dayton Children's Hospital, One Children's Plaza, Dayton, OH 45404, United States; Boonshoft School of Medicine, Wright State University, Dayton, OH, United States.
| | - Denise Mullins
- Department of Pediatric Gastroenterology, Dayton Children's Hospital, One Children's Plaza, Dayton, OH 45404, United States
| | - Erica Yanney
- Department of Pediatric Gastroenterology, Dayton Children's Hospital, One Children's Plaza, Dayton, OH 45404, United States
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208
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Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters. Gastroenterology 2020; 158:1789-1810.e15. [PMID: 32359563 PMCID: PMC9473155 DOI: 10.1053/j.gastro.2020.02.039] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
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Affiliation(s)
- Matthew A. Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo
Clinic, Scottsdale, Arizona
| | - Ravi N. Sharaf
- Division of Gastroenterology, Donald and Barbara
Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T. Furuta
- Digestive Health Institute, Children’s
Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of
Colorado School of Medicine, Aurora, Colorado
| | - Seema S. Aceves
- Division of Allergy Immunology Center for Immunity,
Infection, and Inflammation, University of California, San Diego Rady
Children’s Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children’s
Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M. Spergel
- Division of Allergy-Immunology, Children’s
Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania,
Philadelphia, Pennsylvania
| | - Yngve T. Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland
Veterans Affairs Medical Center and University Hospitals, Case Western Reserve
University School of Medicine, Cleveland, Ohio
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of
Gastroenterology and Hepatology, University of North Carolina School of Medicine,
Chapel Hill, North Carolina
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209
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Hirano I, Chan ES, Rank MA, Sharaf RN, Stollman NH, Stukus DR, Wang K, Greenhawt M, Falck-Ytter YT. AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis. Gastroenterology 2020; 158:1776-1786. [PMID: 32359562 PMCID: PMC9473154 DOI: 10.1053/j.gastro.2020.02.038] [Citation(s) in RCA: 186] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern
University Feinberg School of Medicine, Chicago, Illinois
| | - Edmond S. Chan
- Division of Allergy and Immunology, Department of
Pediatrics, British Columbia Children’s Hospital, University of British
Columbia, Vancouver, British Columbia, Canada
| | - Matthew A. Rank
- Division of Allergy, Asthma, and Clinical
Immunology, Mayo Clinic, Scottsdale, Arizona and Division of Pulmonology Phoenix
Children’s Hospital Phoenix, Arizona
| | - Ravi N. Sharaf
- Division of Gastroenterology, Department of
Medicine, Department of Healthcare Policy and Research, Weill Cornell Medicine, New
York, New York
| | - Neil H. Stollman
- Division of Gastroenterology, Alta Bates Summit
Medical Center, Oakland, California
| | - David R. Stukus
- Division of Allergy and Immunology, Nationwide
Children’s Hospital and The Ohio State University College of Medicine,
Columbus, Ohio
| | - Kenneth Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic
College of Medicine, Rochester, Minnesota
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children’s Hospital
Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Yngve T. Falck-Ytter
- Division of Gastroenterology and Hepatology,
Veterans Affairs Northeast Ohio Healthcare System, Case Western Reserve University
School of Medicine, Cleveland, Ohio
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210
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Collins MH, Dellon ES, Katzka DA, Hirano I, Williams J, Lan L. Budesonide Oral Suspension Significantly Improves Eosinophilic Esophagitis Histology Scoring System Results: Analyses From a 12-Week, Phase 2, Randomized, Placebo-controlled Trial. Am J Surg Pathol 2020; 43:1501-1509. [PMID: 31498177 DOI: 10.1097/pas.0000000000001361] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Budesonide oral suspension (BOS) is a novel topical corticosteroid, which has been shown to improve symptoms and endoscopic appearance, and reduce peak eosinophil counts in patients with eosinophilic esophagitis (EoE). This trial evaluated the effect of BOS or placebo on the severity (grade) and extent (stage) of 8 histopathologic features observed in EoE, using the validated eosinophilic esophagitis histologic scoring system (EoE HSS). Patients with EoE aged 11 to 40 years with dysphagia were randomized to receive either BOS (2.0 mg twice daily) or placebo for 12 weeks. Mean (SD) EoE HSS grade and stage total scores at baseline for placebo and BOS groups were: grade, 0.42 (0.16) and 0.49 (0.14), respectively; stage: 0.38 (0.14) and 0.46 (0.11), respectively. These scores significantly decreased (improved) from baseline for patients receiving BOS versus placebo (grade: least squares mean change [SE]: placebo vs. BOS, -0.04 [0.03] vs. -0.24 [0.02]; P<0.0001; stage: -0.01 [0.02] vs. -0.19 [0.02]; P<0.0001). EoE HSS total scores improved for 6 of the 8 and 5 of the 8 histopathologic features for grade and stage, respectively, versus placebo. Change in EoE HSS total scores correlated moderately but significantly with change in endoscopic severity (endoscopic reference score; grade: R=0.5349; stage: R=0.5416; both P<0.0001). Change in EoE HSS stage total score correlated weakly with change in Dysphagia Symptom Questionnaire scores (grade: R=0.1925; P=0.0740; stage: R=0.2135; P=0.0471). These data demonstrate that the EoE HSS is a valuable endpoint of treatment response in randomized clinical trials and should be considered for future trials for EoE.
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Affiliation(s)
- Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Lan Lan
- Shire, a Takeda Company, Lexington, MA
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211
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Management of eosinophilic esophagitis in children according to atopic status: A retrospective cohort in northeast of France. Arch Pediatr 2020; 27:122-127. [DOI: 10.1016/j.arcped.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/22/2019] [Accepted: 02/16/2020] [Indexed: 01/07/2023]
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212
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Hirano I, Safroneeva E, Roumet MC, Comer GM, Eagle G, Schoepfer A, Falk GW. Randomised clinical trial: the safety and tolerability of fluticasone propionate orally disintegrating tablets versus placebo for eosinophilic oesophagitis. Aliment Pharmacol Ther 2020; 51:750-759. [PMID: 32149424 DOI: 10.1111/apt.15670] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/21/2019] [Accepted: 02/03/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND APT-1011, a fluticasone propionate orally disintegrating tablet formulation, is under investigation for the treatment of eosinophilic oesophagitis (EoE). AIMS To evaluate the safety and tolerability of APT-1011 administered to patients with EoE and to assess the effect on clinical symptoms of EoE, endoscopic appearance and oesophageal eosinophilia. METHODS A randomised, double-blind, placebo-controlled, multicentre, phase 1b/2a study was conducted at seven medical centres in the US to evaluate the safety and tolerability of APT-1011 over 8 weeks in adults and adolescents with EoE. Participants were randomised to placebo (n = 8), 1.5 mg APT-1011 BID (n = 8) or 3.0 mg APT-1011 QD (n = 8). Safety and tolerability were assessed as the primary outcome; histologic and endoscopic measures were assessed as exploratory outcomes. RESULTS There were no deaths, serious treatment-emergent adverse events (TEAEs), severe TEAEs or discontinuations from the study related to a TEAE. In one participant randomised to 1.5 mg APT-1011 BID, a reduction in cortisol was observed, but without evidence of adrenal insufficiency. Compared with placebo, treatment with APT-1011 resulted in greater reductions in oesophageal eosinophil counts, EoE Endoscopic Reference Score, patient global assessment and symptom-based EoE activity index from baseline to end of treatment (Week 8). CONCLUSIONS APT-1011 was safe and well tolerated in adolescents and adults with EoE. Exploratory efficacy outcomes demonstrated improvement in histologic and endoscopic findings as well evidence of symptom improvement. The results of this study support the continued development of APT-1011 for the treatment of EoE (NCT-01386112).
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Affiliation(s)
- Ikuo Hirano
- Department of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Marie C Roumet
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | | | - Gina Eagle
- Adare Pharmaceuticals, Lawrenceville, NJ, USA
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Gary W Falk
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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213
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Siriwat R, Gurbani N, Xu Y, Hossain MM, Simakajornboon N. Sleep manifestations, sleep architecture in children with Eosinophilic esophagitis presenting to a sleep clinic. Sleep Med 2020; 68:160-166. [DOI: 10.1016/j.sleep.2019.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 01/07/2023]
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214
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Henderson A, Magier A, Schwartz JT, Martin LJ, Collins MH, Putnam PE, Mukkada VA, Abonia JP, Rothenberg ME, Fulkerson PC. Monitoring Eosinophilic Esophagitis Disease Activity With Blood Eosinophil Progenitor Levels. J Pediatr Gastroenterol Nutr 2020; 70:482-488. [PMID: 31834110 PMCID: PMC7772866 DOI: 10.1097/mpg.0000000000002583] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES A minimally invasive biomarker to monitor disease activity is one of the greatest unmet clinical needs of the pediatric eosinophilic esophagitis (EoE) population. We aimed to determine whether circulating eosinophil progenitors (EoPs) could be used as a biomarker to identify pediatric patients with active EoE. METHODS In a prospective observational study, peripheral blood samples, symptom history, and laboratory data were collected from pediatric patients undergoing endoscopy for evaluation of EoE on dietary therapy at Cincinnati Children's Hospital. Peripheral blood EoP level was determined by flow cytometry. RESULTS Thirty-four children with active (n = 16) and inactive (n = 18) EoE were included in the analysis. EoP levels in the peripheral blood were 3-fold higher in patients with active EoE than inactive EoE (P < 0.0025). Blood absolute eosinophil count did not distinguish between active and inactive EoE (P = 0.16). A cut-off EoP level ≥17 accurately detected active disease in 79% of patients with 94.4% specificity and 62.5% sensitivity (area under the curve 0.81; P < 0.0024). Antihistamine use lowered the threshold EoP level to detect active EoE. CONCLUSIONS This study suggests that blood EoP levels may be used as a biomarker to detect active EoE disease in patients undergoing food trials and potentially reduce the need for repeated endoscopies. Larger prospective studies are needed to investigate the effects of antihistamines and swallowed steroids on EoP mobilization into the peripheral blood and longitudinal studies to assess the performance of the assay in individual patients over time.
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Affiliation(s)
- Anna Henderson
- Division of Gastroenterology, Hepatology and Nutrition, the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Adam Magier
- Division of Allergy and Immunology, the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Justin T. Schwartz
- Division of Allergy and Immunology, the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lisa J. Martin
- Division of Human Genetics, the University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Margaret H. Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, the University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Philip E. Putnam
- Division of Gastroenterology, Hepatology and Nutrition, the University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Vincent A. Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, the University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, the University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Pablo Abonia
- Division of Allergy and Immunology, the University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Marc E. Rothenberg
- Division of Allergy and Immunology, the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Patricia C. Fulkerson
- Division of Allergy and Immunology, the University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, the University of Cincinnati College of Medicine, Cincinnati, OH
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215
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Madison JM, Bhardwaj V, Braskett M. Strategy for Food Reintroduction Following Empiric Elimination and Elemental Dietary Therapy in the Treatment of Eosinophilic Gastrointestinal Disorders. Curr Gastroenterol Rep 2020; 22:25. [PMID: 32222940 DOI: 10.1007/s11894-020-00758-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW This review presents the available data regarding efficacy of nutritional therapy, highlighting clinical decision points and a strategy for reintroduction of foods following an elemental diet for treatment of eosinophilic gastrointestinal disorders. RECENT FINDINGS Elemental and empiric elimination diets are highly effective treatments for eosinophilic gastrointestinal diseases. Standardization in the reintroduction phase, after utilizing the diet for disease remission, is lacking. Clinicians are confronted with multiple challenges regarding the best practice for food reintroduction and identification of potential dietary triggers including order of foods being challenged and duration between endoscopic procedures. Individualization is required for preference and adherence to optimize quality of life and treatment success for this burdensome and life altering immune driven gastrointestinal disorder. Age specific concerns for children, teenagers, and adults should be assessed using a patient centric approach.
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Affiliation(s)
- Jill M Madison
- Division of Clinical Immunology & Allergy, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Vrinda Bhardwaj
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Melinda Braskett
- Division of Clinical Immunology & Allergy, Children's Hospital Los Angeles, Los Angeles, CA, USA.
- Clinical Pediatrics, Keck School of Medicine of USC, Los Angeles, CA, USA.
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216
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Hirano I, Furuta GT. Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis. Gastroenterology 2020; 158:840-851. [PMID: 31836530 PMCID: PMC8063595 DOI: 10.1053/j.gastro.2019.09.052] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/26/2019] [Accepted: 09/07/2019] [Indexed: 02/07/2023]
Abstract
Treatment of eosinophilic esophagitis has progressed from elemental formula for children and esophageal dilation for adults to selective exclusion of food triggers and swallowed topical corticosteroids. Management guidelines are available from the American Gastroenterological Association and the Joint Task Force on Allergy Immunology Practice Parameters. We cannot, however, evaluate the efficacy of treatments without a definition of response. We propose a treat-to-target approach, based on symptoms and findings from endoscopy and histology. This approach addresses dissociations between outcomes, such as symptom persistence despite normalization of histologic features and symptom resolution after esophageal dilation despite histologic features of active disease. Eosinophilic esophagitis can now be treated with biologic agents that target specific immune pathways, and findings from prospective trials have indicated that less-restrictive, empiric, elimination diets can be effective and reduce the need for repeated endoscopic assessment of disease activity during food reintroduction. We also discuss eosinophilic esophagitis subtypes, factors associated with disease, and advances in management.
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Affiliation(s)
- Ikuo Hirano
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
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217
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Hernandez PV, Amer S, Lam-Himlin DM, DiSantis DJ, Menias CO, Horsley-Silva JL. Eosinophilic esophagitis: imaging features with endoscopic and pathologic correlation. Abdom Radiol (NY) 2020; 45:591-600. [PMID: 31894379 DOI: 10.1007/s00261-019-02374-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE We aim to review the imaging features of eosinophilic esophagitis on fluoroscopy and present how they can correlate with endoscopic and pathologic findings. RESULTS Eosinophilic esophagitis is a chronic immune-mediated disease that results in esophageal dysfunction. Upper esophagogastroduodenoscopy is high yield and required for biopsies to demonstrate the hallmark histologic findings of eosinophil-predominant inflammation. While esophagogastroduodenoscopy is currently mandatory for diagnosis, imaging findings can provide valuable information regarding the structural and functional properties of the esophagus. In addition, fluoroscopic studies may be very helpful in the setting of subtle findings and to evaluate fibrotic remodeling changes. CONCLUSION Radiologic examinations are a valuable tool in the assessment of eosinophilic esophagitis and can highlight changes of fibrostenotic disease, as overall narrowing can be more conspicuous fluoroscopically than endoscopically. As the disease increases in prevalence, it is critical that physicians recognize this condition and facilitate diagnosis and treatment.
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218
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Abstract
Eosinophilic gastrointestinal disorders (EGID) are a group of disorders characterized by pathologic eosinophilic infiltration of the esophagus, stomach, small intestine, or colon leading to organ dysfunction and clinical symptoms (J Pediatr Gastroenterol Nutr; Spergel et al., 52: 300-306, 2011). These disorders include eosinophilic esophagitis (EoE), eosinophilic gastritis (EG), eosinophilic gastroenteritis (EGE), eosinophilic enteritis (EE), and eosinophilic colitis (EC). Symptoms are dependent not only on the location (organ) as well as extent (layer invasion of the bowel wall). Common symptoms of EoE include dysphagia and food impaction in adults and heartburn, abdominal pain, and vomiting in children. Common symptoms of the other EGIDs include abdominal pain, nausea, vomiting, early satiety, diarrhea, and weight loss. These disorders are considered immune-mediated chronic inflammatory disorders with strong links to food allergen triggers. Treatment strategies focus on either medical or dietary therapy. These options include not only controlling symptoms and bowel inflammation but also on identifying potential food triggers. This chapter will focus on the clinical presentation, pathophysiology, and treatment of these increasingly recognized disorders.
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Affiliation(s)
- Nirmala Gonsalves
- Feinberg School of Medicine, Northwestern University, 676 N St. Claire St, Suite 1400, Chicago, IL, 60614, USA.
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219
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Mari A, Tsoukali E, Yaccob A. Eosinophilic Esophagitis in Adults: A Concise Overview of an Evolving Disease. Korean J Fam Med 2020; 41:75-83. [PMID: 32062959 PMCID: PMC7093678 DOI: 10.4082/kjfm.18.0162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease that encompasses esophageal symptoms along with eosinophilic infiltration of the esophageal epithelium. EoE is an evolving disease that has been a subject of interest to many researchers since the first studies recognized this condition as a new and distinct clinicopathological entity 25 years ago. Clinical presentation in adult patients may include dysphagia, food impaction, vomiting, and reflux symptoms. The diagnosis of EoE is based on the combination of clinical history suggestive of esophageal dysfunction, endoscopic features indicative of the disease, and histology revealing eosinophilic infiltration of the esophageal epithelium that persists after a trial of proton pump inhibitor therapy along with the exclusion of other disorders that may be associated with esophageal tissue eosinophilia. The interplay between EoE and gastroesophageal reflux disease (GERD) is complex, and differentiating these two conditions continues to be difficult and challenging in clinical practice. The mainstay treatment includes dietary modification, topical steroids, and/or endoscopic dilation. The primary care physician (PCP) plays an important role in improving patient care and quality of life by ensuring early referral and participating in management and follow-up. This article provides an overview of the current knowledge base regarding the disease including epidemiology, genetics, pathogenesis, common clinical presentations, the interplay between EoE and GERD, diagnostic approaches, and therapeutic options available to the PCP.
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Affiliation(s)
- Amir Mari
- Gastroenterology Institute, Nazareth EMMS Hospital, Nazareth, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | - Emmanouela Tsoukali
- Gastroenterology and Hepatology Department, Evangelismos General Hospital of Athens, Athens, Greece
| | - Afif Yaccob
- Gastroenterology and Liver Disease Department, Rambam Healthcare Campus, Haifa, Israel
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220
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Lucendo AJ. Pharmacological treatments for eosinophilic esophagitis: current options and emerging therapies. Expert Rev Clin Immunol 2020; 16:63-77. [PMID: 31842634 DOI: 10.1080/1744666x.2019.1705784] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The epidemiology of eosinophilic esophagitis (EoE) has increased rapidly to represent a common cause of chronic and recurrent esophageal symptoms. Current treatment options have limitations so the development of novel therapies is a matter of growing interest.Areas covered: This article provides an up-to-date discussion of current therapies and investigational options for EoE. Established anti-inflammatory treatments for EoE at present include dietary therapy, proton pump inhibitors and swallowed topic steroids, which should be combined with endoscopic dilation in case of strictures. Refractoriness, high recurrence rates, and need for long-term therapies have promoted the investigation of novel, esophageal-targeted formulas of topic corticosteroids, and monoclonal antibodies (including mepolizumab, reslizumab, QAX576, RPC4046, dupilumab, omalizumab, infliximab, and vedolizumab) for EoE, with some having been demonstrated as effective and safe in the short term. Several additional promising therapies are also discussed.Expert opinion: Several therapeutic targets have shown efficacy and will be approved to treat EoE, especially corticosteroid-sparing options and those for patients with multiple Th2-associated diseases. Personalized therapeutic strategies for initial and maintenance treatments of EoE must be rationally designed, to reduce the burden of disease and answer meaningfully the needs of all stakeholders involved in EoE.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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221
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Abstract
Food allergies, defined as an immune response to food proteins, affect as many as 8% of young children and 2% of adults in western countries, and their prevalence appears to be rising like all allergic diseases. In addition to well-recognized urticaria and anaphylaxis triggered by IgE antibody- mediated immune responses, there is an increasing recognition of cell-mediated disorders, such as eosinophilic esophagitis and food protein-induced enterocolitis. Non-IgE-Mediated gastrointestinal food allergies are a heterogeneous group of food allergies in which there is an immune reaction against food but the primary pathogenesis is not a production of IgE and activation of mast cells and basophils. Those diseases tend to affect mainly the gastrointestinal tract and can present as acute (FPIES) or chronic reaction, such as Eosinophilic Esophagitis (EoE), Food Protein-Induced Allergic Proctocolitis (FPIAP). The role of food allergy in Non-EoE gastrointestinal Eosinophilic disorders (Non- EoE EGID) is poorly understood. In some diseases like EoE, T cell seems to play a major role in initiating the immunological reaction against food, however, in FPIES and FPIAP, the mechanism of sensitization is not clear. Diagnosis requires food challenges and/or endoscopies in most of the patients, as there are no validated biomarkers that can be used for monitoring or diagnosis of Non-IgE mediated food allergies. The treatment of Non-IgE food allergy is dependent on diet (FPIES, and EoE) and/or use of drugs (i.e. steroids, PPI) in EoE and Non-EoE EGID. Non-IgE mediated food allergies are being being investigated.
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Affiliation(s)
- Antonella Cianferoni
- Division of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States
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222
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Wong J, Goodine S, Samela K, Vance KS, Chatfield B, Wang Z, Sayej WN. Efficacy of Dairy Free Diet and 6-Food Elimination Diet as Initial Therapy for Pediatric Eosinophilic Esophagitis: A Retrospective Single-Center Study. Pediatr Gastroenterol Hepatol Nutr 2020; 23:79-88. [PMID: 31988878 PMCID: PMC6966220 DOI: 10.5223/pghn.2020.23.1.79] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/14/2019] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Management of eosinophilic esophagitis (EoE) varies from center to center. In this study, we evaluated the effectiveness of a dairy-free diet (DFD) and the 6-Food Elimination Diet (SFED) as initial therapies for the treatment of EoE in our practice. METHODS This was a retrospective study of children who had been treated for EoE at Connecticut Children's Medical Center, Hartford, CT, USA. Pre- and post-treatment endoscopy findings and histology results of patients treated with DFD or SFED were examined. RESULTS One hundred fifty-two patients (age 9.2±5.2 years, 76.3% male, 69.7% caucasian) met the inclusion criteria for initial treatment with DFD (n=102) or SFED (n=50). Response for DFD was 56.9% and for SFED was 52.0%. Response based on treatment duration (<10, 10-12, and >12 weeks) were 81.8%, 50.0%, and 55.1% for DFD, and 68.8%, 50.0%, and 40.0% for SFED. Response based on age (<6, 6-12, and >12 years) were 59.3%, 42.9%, and 67.5% for DFD, and 36.4%, 58.8%, and 72.7% for SFED. In patients treated with DFD, concomitant proton pump inhibitor (PPI) administration resulted in improved outcomes (p=0.0177). Bivariate regression analysis showed that PPI with diet is the only predictor of response (p=0.0491), however, there were no significant predictors on multiple regression analysis. CONCLUSION DFD and SFED are effective first line therapies for EoE. DFD should be tried first before extensive elimination diets. Concomitant therapy with PPI's may be helpful.
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Affiliation(s)
- Jonathan Wong
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Sue Goodine
- Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Kate Samela
- Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Katherine S Vance
- Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Beth Chatfield
- Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Zhu Wang
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA.,Department of Pediatric Research, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Wael N Sayej
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA.,Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
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223
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Abstract
Physicians may encounter blood or tissue eosinophilia through a routine complete blood count with differential or a tissue pathology report. In this article, the basic biology of eosinophils is reviewed and definitions of blood eosinophilia, as well as the challenges of defining tissue eosinophilia, are discussed. Conditions associated with eosinophilia are briefly discussed as well as a general approach to evaluating eosinophilia. Future challenges include determining which eosinophil-associated diseases benefit from eosinophil-targeted therapy and identifying biomarkers for disease activity and diagnosis.
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Affiliation(s)
- Fei Li Kuang
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, 4 Memorial Drive, B1-27, Bethesda, MD 20892, USA.
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224
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Vanoni S, Zeng C, Marella S, Uddin J, Wu D, Arora K, Ptaschinski C, Que J, Noah T, Waggoner L, Barski A, Kartashov A, Rochman M, Wen T, Martin L, Spence J, Collins M, Mukkada V, Putnam P, Naren A, Chehade M, Rothenberg ME, Hogan SP. Identification of anoctamin 1 (ANO1) as a key driver of esophageal epithelial proliferation in eosinophilic esophagitis. J Allergy Clin Immunol 2020; 145:239-254.e2. [PMID: 31647967 PMCID: PMC7366251 DOI: 10.1016/j.jaci.2019.07.049] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 07/13/2019] [Accepted: 07/29/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND The pathology of eosinophilic esophagitis (EoE) is characterized by eosinophil-rich inflammation, basal zone hyperplasia (BZH), and dilated intercellular spaces, and the underlying processes that drive the pathologic manifestations of the disease remain largely unexplored. OBJECTIVE We sought to investigate the involvement of the calcium-activated chloride channel anoctamin 1 (ANO1) in esophageal proliferation and the histopathologic features of EoE. METHODS We examined mRNA and protein expression of ANO1 in esophageal biopsy samples from patients with EoE and in mice with EoE. We performed molecular and cellular analyses and ion transport assays on an in vitro esophageal epithelial 3-dimensional model system (EPC2-ALI) and murine models of EoE to define the relationship between expression and function of ANO1 and esophageal epithelial proliferation in patients with EoE. RESULTS We observed increased ANO1 expression in esophageal biopsy samples from patients with EoE and in mice with EoE. ANO1 was expressed within the esophageal basal zone, and expression correlated positively with disease severity (eosinophils/high-power field) and BZH. Using an in vitro esophageal epithelial 3-dimensional model system revealed that ANO1 undergoes chromatin modification and rapid upregulation of expression after IL-13 stimulation, that ANO1 is the primary apical IL-13-induced Cl- transport mechanism within the esophageal epithelium, and that loss of ANO1-dependent Cl- transport abrogated esophageal epithelial proliferation. Mechanistically, ANO1-dependent regulation of basal cell proliferation was associated with modulation of TP63 expression and phosphorylated cyclin-dependent kinase 2 levels. CONCLUSIONS These data identify a functional role for ANO1 in esophageal cell proliferation and BZH in patients with EoE and provide a rationale for pharmacologic intervention of ANO1 function in patients with EoE.
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Affiliation(s)
- Simone Vanoni
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; PharmGenetix Gmbh, Niederalm-Anif, Austria
| | - Chang Zeng
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sahiti Marella
- Mary H Weiser Food Allergy Center and Department of Pathology, Ann Arbor, Mich
| | - Jazib Uddin
- Mary H Weiser Food Allergy Center and Department of Pathology, Ann Arbor, Mich
| | - David Wu
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kavisha Arora
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Jianwen Que
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Taeko Noah
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Mary H Weiser Food Allergy Center and Department of Pathology, Ann Arbor, Mich
| | - Lisa Waggoner
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Artem Barski
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrey Kartashov
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark Rochman
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ting Wen
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lisa Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jason Spence
- Departments of Biomedical Engineering, Internal Medicine and Cell and Developmental Biology, University of Michigan, Ann Arbor, Mich
| | - Margaret Collins
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Vincent Mukkada
- Division of Gastroenterology, Nutrition and Hepatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Phillip Putnam
- Division of Gastroenterology, Nutrition and Hepatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anjaparavanda Naren
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Simon P Hogan
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Mary H Weiser Food Allergy Center and Department of Pathology, Ann Arbor, Mich.
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225
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Gonsalves NP, Aceves SS. Diagnosis and treatment of eosinophilic esophagitis. J Allergy Clin Immunol 2020; 145:1-7. [PMID: 31910983 PMCID: PMC6986782 DOI: 10.1016/j.jaci.2019.11.011] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is an eosinophil-rich, TH2 antigen-mediated disease of increasing pediatric and adult worldwide prevalence. Diagnosis requires greater than or equal to 15 eosinophils per high-power field on light microscopy. Symptoms reflect esophageal dysfunction, and typical endoscopic features include linear furrows, white plaques, and concentric rings. Progressive disease leads to pathologic tissue remodeling, with ensuing esophageal rigidity and loss of luminal diameter caused by strictures. Therapies include proton pump inhibitors, elimination diets, and topical corticosteroids. Effective treatment can reverse tissue fibrosis in some patients, as well as decrease the rate of food impactions. Esophageal dilation might be required to increase luminal patency. The chronic nature of EoE necessitates long-term therapy to avoid disease recurrence and complications. This review serves the function of providing the current state-of-the-art diagnostic criteria and disease management for adult and pediatric EoE.
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Affiliation(s)
- Nirmala P Gonsalves
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Ill.
| | - Seema S Aceves
- Division of Allergy Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, and Rady Children's Hospital, San Diego, Calif.
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Suryawala K, Palle S, Altaf MA. Epidemiology, Clinical Presentation, and Seasonal Variation in the Diagnosis of Children with Eosinophilic Esophagitis in Oklahoma. South Med J 2020; 113:37-41. [DOI: 10.14423/smj.0000000000001049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Atwal K, Hubbard GP, Venter C, Stratton RJ. The use of amino acid-based nutritional feeds is effective in the dietary management of pediatric eosinophilic oesophagitis. Immun Inflamm Dis 2019; 7:292-303. [PMID: 31692292 PMCID: PMC6842817 DOI: 10.1002/iid3.273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Eosinophilic oesophagitis (EoE) is an immune-mediated, chronic disease characterized by eosinophilic inflammation and esophageal dysfunction. Specific food allergens including cow's milk protein, are partially causative to disease progression, and dietary management forms three main options; the elemental diet (ED), the empirical elimination diet (EED), and the targeted elimination diet (TED). The dietary choice should be individualized, however, the European Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines recommend an ED for pediatric EoE with multiple food allergies, failure to thrive, unresponsive disease or unable to follow a highly restricted diet. The aim of this narrative review was to explore the effectiveness of the ED (using amino acid formula [AAF]), in the management of pediatric EoE. METHODS Literature searches were performed to identify eligible studies that described outcomes including eosinophil count, clinical symptoms, growth, and medications. RESULTS Overall, 10 eligible studies were found, with n = 462 patients assigned to receive AAF from a total of n = 748 (average age 6.7 years), for a duration of 4 to 8 weeks. The use of AAF reduced eosinophil levels and demonstrated remission (defined as ≤10 eosinophils per high power field) in 75%-100% of children with improvements, if not resolution, in clinical symptoms. AAF was more clinically effective than the use of the EED or TED, where remission rates were 75%-81% and 40%-69%, respectively. Few studies collected growth outcomes, however where documented these were positive for those on AAF. The long-term impacts of each diet were not thoroughly explored. CONCLUSIONS The use of AAF is a clinically effective management option for pediatric EoE, and further research is required to guide long-term management.
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Affiliation(s)
| | | | - Carina Venter
- Section of Allergy and Immunology, Children's Hospital ColoradoUniversity of Colorado Denver School of MedicineColorado
| | - Rebecca J. Stratton
- Medical AffairsNutricia LtdTrowbridgeUnited Kingdom
- Faculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
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Limketkai BN, Shah SC, Hirano I, Bellaguarda E, Colombel JF. Epidemiology and implications of concurrent diagnosis of eosinophilic oesophagitis and IBD based on a prospective population-based analysis. Gut 2019; 68:2152-2160. [PMID: 30923072 DOI: 10.1136/gutjnl-2018-318074] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Eosinophilic oesophagitis (EoO) and IBD are immune-mediated diseases of the gastrointestinal tract with possible overlapping pathogenic mechanisms. Our aim was to define the epidemiology and clinical implications of concurrent EoO and IBD diagnoses. DESIGN We conducted a prospective cohort analysis using the Truven MarketScan database (2009-2016) to estimate the incidence and prevalence of EoO in patients with Crohn's disease (CD) or UC and vice versa. Cox proportional hazards and Kaplan-Meier methods were used to estimate the risk of EoO-related or IBD-related complications among patients with concurrent diagnoses. RESULTS Among 134 013 536 individuals, the incidence of EoO, CD and UC were 23.1, 51.2 and 55.2 per 100 000 person-years, respectively. The risk of EoO was higher among patients with CD (incidence rate ratio [IRR] 5.4, p<0.01; prevalence ratio (PR) 7.8, p<0.01) or UC (IRR 3.5, p<0.01; PR 5.0, p<0.01), while the risk of IBD was higher among patients with EoO (CD: IRR 5.7, p<0.01; PR 7.6, p<0.01; UC: IRR 3.4, p<0.01; PR 4.9, p<0.01) versus individuals without either diagnosis. Concurrent diagnosis of EoO and IBD was associated with greater composite risk of IBD-related complications (CD: adjusted HR (aHR) 1.09, p=0.01; UC: aHR 1.10, p=0.04) but lower composite risk of EoO-related complications (aHR 0.59; p<0.01). CONCLUSION Based on a population-based prospective cohort analysis, the risk of EoO is significantly higher among patients with IBD and vice versa. Concurrent diagnoses might modify the risk of IBD-related and EoO-related complications. Studies defining the mechanisms underlying these observations are needed.
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Affiliation(s)
- Berkeley N Limketkai
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - Shailja C Shah
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ikuo Hirano
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Emanuelle Bellaguarda
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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Eosinophilic Esophagitis Is Rarely Continually Symptomatic 10 Years After an Initial Treatment Course in Adults. Dig Dis Sci 2019; 64:3568-3578. [PMID: 31065898 DOI: 10.1007/s10620-019-05636-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/19/2019] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Despite its initial description over 25 years ago, there is little known about the course of eosinophilic esophagitis (EoE) after an initial course of medical or dietary treatment. We aim to assess the long-term symptomology and quality of life (QoL) metrics in patients 10 years after initial treatment for eosinophilic esophagitis. METHODS Inclusion criteria: single center study of EoE patients diagnosed over 10 years ago with completion of an 18-question structured telephone interview. A cohort of patient's prospectively underwent an esophageal barium exam, esophageal sponge cytology, and evaluation by a esophagologist at greater than 10 years' time since original diagnosis. RESULTS A total of 54 patients were included in the study. The average age at follow-up was 55.0, with the majority male (64.8%). At the original diagnosis, 62.9% and 37.0% were initially treated with topical steroids and a proton pump inhibitor (PPI), respectively,compared to 59.3% and 7.4% after 10 years, and 7.4% of patients reported a history of dilatations. Only 11.8% noted avoidance of trigger foods, with 62.7% noting an unlimited diet without caution. QoL decrease secondary to EoE was noted to be trivial to minimal in 56.9% of patients, mild in 19.6%, moderate in 15.7% and severe in 7.8%. In the prospective follow-up cohort, the results of telephone survey results matched the direct physician-obtained interview in 88% of cases. CONCLUSION Ten years after diagnosis, treated EoE is rarely continually symptomatic, requires mainly PPI-based therapies and is associated with a minimal decrease in QoL scores.
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Aceves S, Collins MH, Rothenberg ME, Furuta GT, Gonsalves N. Advancing patient care through the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR). J Allergy Clin Immunol 2019; 145:28-37. [PMID: 31758958 PMCID: PMC6981250 DOI: 10.1016/j.jaci.2019.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/19/2022]
Abstract
Recent advances in rare disease research are accelerated by the work of consortia that have been supported by the National Institutes of Health. Development of such consortia rely on multidisciplinary relationships and engagement with patient advocacy groups, as well as the National Institutes of Health and industry and academic partners. In this rostrum we present the development of such a process that focuses on eosinophilic gastrointestinal diseases. Principal investigators, patient advocacy groups, research assistants, and trainees work together to perform natural history studies that promote clinical trial readiness tools, conduct clinical trials, train a new generation of investigators, and perform innovative pilot studies.
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Affiliation(s)
- Seema Aceves
- Division of Allergy Immunology, University of California, San Diego, and Rady Children's Hospital, San Diego, La Jolla, Calif
| | - Margaret H Collins
- Division of Pathology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colo.
| | - Nirmala Gonsalves
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Ill
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231
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Chan MQ, Balasubramanian G. Esophageal Dysphagia in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:534-553. [PMID: 31741211 DOI: 10.1007/s11938-019-00264-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia. RECENT FINDINGS Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.
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Affiliation(s)
- Megan Q Chan
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA
| | - Gokulakishnan Balasubramanian
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA.
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Yantiss RK, Greenson JK, Spechler S. American registry of pathology expert opinions: Evaluating patients with eosinophilic esophagitis: Practice points for endoscopists and pathologists. Ann Diagn Pathol 2019; 43:151418. [PMID: 31731033 DOI: 10.1016/j.anndiagpath.2019.151418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, United States of America.
| | - Joel K Greenson
- Department of Pathology, University of Michigan, Ann Arbor, MI, United States of America
| | - Stuart Spechler
- Center for Esophageal Diseases, Baylor University Medical Center, the Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, TX, United States of America
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233
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Mari A, Abu Baker F, Mahamid M, Khoury T, Sbeit W, Pellicano R. Eosinophilic esophagitis: pitfalls and controversies in diagnosis and management. Minerva Med 2019; 111:9-17. [PMID: 31755670 DOI: 10.23736/s0026-4806.19.06322-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Formerly considered a rare disorder, eosinophilic esophagitis (EoE) has emerged as a leading cause of feeding problems in children and an increasingly recognized cause of dysphagia and food impaction in adults. Our understanding of EoE and its complex interplay with gastro-esophageal reflux disease (GERD) has evolved over the past decade and culminated in the introduction of proton pump inhibitor (PPI) responsive EoE as a distinct entity which has added to this complexity. It is now clear that this entity is on the same spectrum as the original EoE, and that PPIs should be considered as part of treatment protocol and should not be recommended as a diagnostic tool. As such, removing the PPI trial from the diagnostic algorithm has been encouraged recently. Recent guidelines and reviews thoroughly address various aspects in EoE pathogenesis and diagnostic workup as well as management endpoints, treatment options and novel therapies. However, despite the recent extensive study and the advances in our knowledge of this disease, unmet needs and pitfalls in diagnostic workup and management of these patients are still to be clarified and will be under focus in this review.
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Affiliation(s)
- Amir Mari
- Gastroenterology Unit, Nazareth Hospital EMMS, Faculty of Medicine, Bar Ilan University, Safed, Israel -
| | - Fadi Abu Baker
- Gastroenterology Unit, Hillel Yaffe MC, Technion, Haifa, Israel
| | - Mahmud Mahamid
- Gastroenterology Unit, Nazareth Hospital EMMS, Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Tawfik Khoury
- Gastroenterology Unit, Nazareth Hospital EMMS, Faculty of Medicine, Bar Ilan University, Safed, Israel.,Department of Gastroenterology, Galilee MC, Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Wisam Sbeit
- Department of Gastroenterology, Galilee MC, Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Rinaldo Pellicano
- Gastroenterology Unit, Molinette-San Giovanni Antica Sede Hospitals, Turin, Italy
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234
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Transnasal Endoscopy in Unsedated Children With Eosinophilic Esophagitis Using Virtual Reality Video Goggles. Clin Gastroenterol Hepatol 2019; 17:2455-2462. [PMID: 30708107 PMCID: PMC6663663 DOI: 10.1016/j.cgh.2019.01.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/21/2018] [Accepted: 01/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Evaluation and treatment of children with eosinophilic esophagitis (EoE) requires serial endoscopic, visual, and histologic assessment by sedated esophagogastroduodenoscopy (EGD). Unsedated transnasal endoscopy (TNE) was reported to be successful in a pilot study of children. We evaluated video goggle and virtual reality-based unsedated TNE in children with EoE, collecting data on rates of completion, adverse events, and adequacy of visual and histologic findings. METHODS We performed a retrospective study of 190 children and young adults (age, 3-22 y) who underwent video goggle or virtual reality-based unsedated TNE from January 2015 through February 2018. We analyzed data on patient demographics, procedure completion, endoscope type, adverse events, visual and histologic findings, estimated costs, and duration in the facility. Esophageal biopsies from the first 173 subjects who underwent TNE were compared with those from previous EGD evaluations. RESULTS During 300 attempts, 294 TNEs were performed (98% rate of success). Fifty-four patients (age, 6-18 y) underwent multiple TNEs for dietary or medical management of EoE. There were no significant adverse events. Visual and histologic findings were adequate for assessment of EoE. TNE reduced costs by 53.4% compared with EGD (TNE $4393.00 vs EGD $9444.33). TNE was used increasingly from 2015 through 2017, comprising 31.8% of endoscopies performed for EoE. The total time spent in the clinic (front desk check-in to check-out) in 2018 was 71 minutes. CONCLUSIONS In a retrospective study of 190 children and young adults (age, 3-22 y) who underwent video goggle or virtual reality-based unsedated TNE, TNE was safe and effective and reduced costs of EoE monitoring. Advantages of TNE include reduced risk and cost associated with anesthesia as well as decreased in-office time, which is of particular relevance for patients with EoE, who require serial EGDs.
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235
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Saffari H, Condie RM, Watson BR, Krstyen JJ, Peterson KA, Hoffman JM, Gleich GJ, Pease LF. Biodistribution of orally administered 99mTc-heparin to assess eosinophilic esophagitis associated inflammation. CHEMICAL ENGINEERING SCIENCE: X 2019. [DOI: 10.1016/j.cesx.2019.100049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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236
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Kim GH, Park YS, Jung KW, Kim M, Na HK, Ahn JY, Lee JH, Kim DH, Choi KD, Song HJ, Lee GH, Dellon ES, Jung HY. An Increasing Trend of Eosinophilic Esophagitis in Korea and the Clinical Implication of the Biomarkers to Determine Disease Activity and Treatment Response in Eosinophilic Esophagitis. J Neurogastroenterol Motil 2019; 25:525-533. [PMID: 31587544 PMCID: PMC6786448 DOI: 10.5056/jnm19066] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/19/2019] [Accepted: 07/20/2019] [Indexed: 12/17/2022] Open
Abstract
Background/Aims The epidemiology and pathogenesis of eosinophilic esophagitis (EoE) remain unclear in Asian countries. We investigated clinicopathological characteristics and diagnostic trends of EoE, and evaluated 3 tissue biomarkers for correlation with disease activity and treatment response in Korean patients with EoE. Methods We retrospectively reviewed 25 271 esophageal biopsies performed during upper endoscopies between 2006 and 2017. We diagnosed EoE based on ≥ 15 eosinophils/high-power field (HPF) and, symptoms of esophageal dysfunction. We performed immunohistochemical analysis for tryptase, eosinophilic derived neurotoxin (EDN), and eotaxin-3. Results We diagnosed EoE in 72 patients (53 men and 19 women; mean age, 46.2 years) with presenting symptoms of, dysphagia (15.3%), epigastric pain (31.9%), and heartburn (30.6%). The diagnostic rate of EoE considerably increased between 2006 and 2017, from 0.29 diagnoses to 7.99 diagnoses per 1000 esophageal biopsies ( P < 0.001). The mean peak eosinophil count (PEC) was 56.0 (± 77.8)/HPF. Whereas the EDN (rho = 0.667, P < 0.001) and eotaxin-3 levels (rho = 0.465, P < 0.001) correlated with PEC, tryptase and PEC were weakly correlated (rho = 0.291, P = 0.013). EDN (rho = 0.279, P = 0.017), and tryptase (rho = 0.279, P = 0.033) correlated with the inflammatory score of Eosinophilic Esophagitis Endoscopic Reference Score. Immunohistochemical analysis and changes in tryptase, EDN, and eotaxin-3 levels were associated with histologic and endoscopic improvements. Conclusions EoE incidence considerably increased during the 12-year period, regardless of endoscopic esophageal biopsy rate. Tryptase, EDN, and eotaxin-3 levels in esophageal biopsy specimens could be promising biomarkers for disease activity, symptom, and endoscopic response in Korea.
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Affiliation(s)
- Ga Hee Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
| | - Young Soo Park
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
| | - Mimi Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hi ll, North Carolina, USA
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Asan Digestive Disease Research I nstitute, Seoul, Korea
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Ishibashi F, Fukushima K, Onizuka R, Tanaka R. Risk of progression to eosinophilic esophagitis in patients with asymptomatic esophageal eosinophilia: A retrospective pilot study. JGH OPEN 2019; 4:422-428. [PMID: 32514448 PMCID: PMC7273718 DOI: 10.1002/jgh3.12270] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 09/09/2019] [Accepted: 09/20/2019] [Indexed: 12/17/2022]
Abstract
Background and Aim As the number of patients with eosinophilic esophagitis (EoE) has increased worldwide, the likelihood of diagnosing esophageal eosinophilia (EE) in screening endoscopy has also increased. Many of these EE patients do not display any symptoms (i.e. they display asymptomatic EE: aEE), and the risk of aEE patients developing EoE has yet to be demonstrated. Methods A total of 62 250 cases were found in the endoscopic registries of two digestive disease centers in the context of gastric cancer screening from April 2016 to August 2018, and these were reviewed. Results Thirty‐seven aEE patients (0.059%) were found in the registries, and the histories of endoscopic findings and symptoms were successfully traced for 29 of them. While 11 aEE (37.9%) patients did not show any change in endoscopic findings, 18 (62.1%) exhibited exacerbation. A comparison of the two groups showed both relative youth and diffuse disease distribution to be independent risk factors for progression (P = 0.0034 and 0.0078, respectively). Of the 18 aEE patients whose findings showed progression, 6 developed EoE (5 (17.2%) developed proton‐pump inhibitor (PPI)‐responsive EoE, and only 1 (3.4%) developed PPI‐resistant EoE). A comparison of the non‐EoE and EoE groups showed relative youth to be an independent risk factor for progression to EoE (P = 0.0146). Conclusions While some aEE patients developed symptomatic EE, the existence among them of PPI‐resistant EoE was extremely rare. Younger age and diffuse disease distribution at first detection in endoscopic findings are risk factors for progression to symptomatic EE in aEE patients.
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Affiliation(s)
- Fumiaki Ishibashi
- Shinjuku Tsurukame Clinic Digestive Disease Center Tokyo Japan.,Koganei Tsurukame Clinic Endoscopic Center Tokyo Japan.,Department of Gastroenterology and Hepatology Tokyo Medical and Dental University Tokyo Japan
| | - Keita Fukushima
- Shinjuku Tsurukame Clinic Digestive Disease Center Tokyo Japan.,Koganei Tsurukame Clinic Endoscopic Center Tokyo Japan.,Department of Gastroenterology and Hepatology Tokyo Medical and Dental University Tokyo Japan
| | - Ryoichi Onizuka
- Shinjuku Tsurukame Clinic Digestive Disease Center Tokyo Japan.,Koganei Tsurukame Clinic Endoscopic Center Tokyo Japan
| | - Ryu Tanaka
- Shinjuku Tsurukame Clinic Digestive Disease Center Tokyo Japan.,Koganei Tsurukame Clinic Endoscopic Center Tokyo Japan
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Abstract
Eosinophilic esophagitis is a recently defined condition that has dramatically increased in prevalence in the last several decades. It may occur at any age, but the clinical presentation in young children is often more vague than the classic solid food dysphagia and food impacting that are the major presenting symptoms of eosinophilic esophagitis in adults and adolescents. Successful therapies exist, including medications and dietary modifications, but disease typically recurs when the intervention is discontinued.
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Affiliation(s)
- Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 1001 Main Street, Buffalo, NY 14203, USA.
| | - Weyman Lam
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 1001 Main Street, Buffalo, NY 14203, USA
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One-Hour Esophageal String Test: A Nonendoscopic Minimally Invasive Test That Accurately Detects Disease Activity in Eosinophilic Esophagitis. Am J Gastroenterol 2019; 114:1614-1625. [PMID: 31567192 PMCID: PMC6784776 DOI: 10.14309/ajg.0000000000000371] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Eosinophilic esophagitis (EoE), a chronic food allergic disease, lacks sensitive and specific peripheral biomarkers. We hypothesized that levels of EoE-related biomarkers captured using a 1-hour minimally invasive Esophageal String Test (EST) would correlate with mucosal eosinophil counts and tissue concentrations of these same biomarkers. We aimed to determine whether a 1-hour EST accurately distinguishes active from inactive EoE or a normal esophagus. METHODS In a prospective, multisite study, children and adults (ages 7-55 years) undergoing a clinically indicated esophagogastroduodenoscopy performed an EST with an esophageal dwell time of 1 hour. Subjects were divided into 3 groups: active EoE, inactive EoE, and normal esophageal mucosa. Eosinophil-associated protein levels were compared between EST effluents and esophageal biopsy extracts. Statistical modeling was performed to select biomarkers that best correlated with and predicted eosinophilic inflammation. RESULTS One hundred thirty-four subjects (74 children, 60 adults) with active EoE (n = 62), inactive EoE (n = 37), and patient controls with a normal esophagus (n = 35) completed the study. EST-captured eosinophil-associated biomarkers correlated significantly with peak eosinophils/high-power field, endoscopic visual scoring, and the same proteins extracted from mucosal biopsies. Statistical modeling, using combined eotaxin-3 and major basic protein-1 concentrations, led to the development of EoE scores that distinguished subjects with active EoE from inactive EoE or normal esophagi. Eighty-seven percent of children, 95% of parents, and 92% of adults preferred the EST over endoscopy if it provided similar information. DISCUSSION The 1-hour EST accurately distinguishes active from inactive EoE in children and adults and may facilitate monitoring of disease activity in a safe and minimally invasive fashion.
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240
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Weerasekera K, Sim D, Coughlan F, Inns S. Eosinophilic esophagitis incidence in New Zealand: high but not increasing. Clin Exp Gastroenterol 2019; 12:367-374. [PMID: 31534357 PMCID: PMC6681430 DOI: 10.2147/ceg.s216126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
Abstract
Background and aim Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory condition of the esophagus. Recent literature has shown an increasing incidence of the disease. However, no epidemiological data exist regarding New Zealand rates of EoE. The disease is associated with atopy, and New Zealand's high rate of atopic disease means the disease may be important in our population. We carried out a retrospective study to describe the incidence of EoE in the Wellington region of New Zealand, as well as key histological and clinical factors associated with the disease. Method A search was made of laboratory and endoscopic databases in the Wellington region to identify all diagnosed cases in the five years between January 1, 2011, and December 31, 2015. Case notes were examined to determine the key demographic and clinical parameters in the cases. Incidence rates were calculated for each year, and the effects of age group and sex on the incidence rates were analyzed. Result We found 152 cases of EoE in the Wellington region with an annual incidence of 6.95 per 100,000 person/years. We found no evidence of a significant difference in incidence rates by year in our study population. There was a significantly lower incidence rate in those aged <16 compared to those aged ≥16 (RR=0.26). Males had a higher incidence rate than females with an estimated rate ratio of 2.45 (p<0.05). Conclusion Our results are in contrast to previous reports of increasing incidence rates and may reflect a leveling off of incidence. Further research is needed to determine whether the low incidence in our pediatric age group is due to ascertainment bias or due to a real difference in the epidemiology of EoE in NZ compared to other countries.
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Affiliation(s)
| | - Dalice Sim
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Finbarr Coughlan
- Department of Pathology, Capital & Coast District Health Board, Wellington, New Zealand
| | - Stephen Inns
- Department of Medicine, University of Otago, Wellington, New Zealand
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241
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Pharmacotherapies for the Treatment of Eosinophilic Esophagitis: State of the Art Review. Drugs 2019; 79:1419-1434. [DOI: 10.1007/s40265-019-01173-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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242
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Hopp R. A new acronym for PPI-REE? Ann Allergy Asthma Immunol 2019; 121:747. [PMID: 30502820 DOI: 10.1016/j.anai.2018.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/04/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Russell Hopp
- University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, Nebraska.
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243
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Alterio T, Cardile S, Trayers C, Valenti S, Loddo I, Mardare R, Mosca A, Nobili V. Eosinophilic esophagitis in children: current knowledge to open new horizons. Scand J Gastroenterol 2019; 54:822-829. [PMID: 31535579 DOI: 10.1080/00365521.2019.1641214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Eosinophilic Esophagitis (EoE) is a chronic immune/antigen-mediated condition which is also driven by genetic and environmental factors. It has been deeply investigated over the last years and its incidence is widely increasing in childhood. Although atopic diseases are closely linked with EoE, it does not recognize a classical IgE-mediate immune pathogenesis but it is rather a T helper type 2 inflammatory process. Familial clustering supports genetic predisposition in EoE and recent advances in understanding the genetic basis for EoE may eventually translate into targeted management of the disease. EoE diagnosis is based on clinical symptoms, micro, and macroscopic findings along with exclusion of gastroesophageal reflux disease (GERD) evidence. Management of the disease encompasses both dietary and pharmacological solutions that need to be specifically targeted on patients' history, clinical symptoms, and diagnostic evaluations. New therapies, currently not available in children, may represent the basis for future therapeutic options in the next years.
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Affiliation(s)
- Tommaso Alterio
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy
| | - Sabrina Cardile
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy
| | - Claire Trayers
- Department of Paediatric and Perinatal Pathology, Cambridge University Hospitals (CUH), Addenbrooke's Hospital , Cambridge , UK
| | - Simona Valenti
- Department of Pediatrics, University of Messina , Messina , Italy
| | - Italia Loddo
- Department of Laboratory Medicine and Advanced Biotechnologies, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT) - IRCCS , Palermo , Italy
| | - Roxana Mardare
- Department of Pediatrics, Cambridge University Hospitals (CUH), Addenbrookes Hospital , Cambridge , UK
| | - Antonella Mosca
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy
| | - Valerio Nobili
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy.,Department of Pediatrics, University "La Sapienza" , Rome , Italy
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244
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Abstract
BACKGROUND AND OBJECTIVE Eosinophilic esophagitis (EoE) is an increasingly recognized childhood disease. Esophageal atresia (EA) is the most frequent congenital malformation of the esophagus. Recently, cases of EoE occurring in patients with EA have been reported, although the exact prevalence of EoE in EA remains unknown. The aim is to investigate the prevalence of EoE among EA in adolescents and to describe these patients' characteristics. METHODS Systematic upper gastrointestinal endoscopies with multistage esophageal biopsies were prospectively performed in 63 adolescents with EA. A standardized form was used to collect clinical and endoscopic data. Diagnosis of EoE was made as ≥15 intraepithelial eosinophils/high power field, whatever the response on proton pump inhibitors therapy. RESULTS Six patients (9.5%) presented an EoE (17-100 eosinophils/high power field). An atopic condition was reported more frequently in the eosinophil ≥15 group than in patients with no EoE (66% vs 16%; P = 0.014). Except for chest pain, symptoms and endoscopic features were similar in patients with EoE and patients with no EoE. CONCLUSION In our series of 63 patients born with EA, mainly distal tracheoesophageal fistula, the prevalence of EoE is increased, and therefore should be considered in adolescents with EA.
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245
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Linhart B, Freidl R, Elisyutina O, Khaitov M, Karaulov A, Valenta R. Molecular Approaches for Diagnosis, Therapy and Prevention of Cow´s Milk Allergy. Nutrients 2019; 11:E1492. [PMID: 31261965 PMCID: PMC6683018 DOI: 10.3390/nu11071492] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 12/12/2022] Open
Abstract
Cow´s milk is one of the most important and basic nutrients introduced early in life in our diet but can induce IgE-associated allergy. IgE-associated allergy to cow´s milk can cause severe allergic manifestations in the gut, skin and even in the respiratory tract and may lead to life-threatening anaphylactic shock due to the stability of certain cow´s milk allergens. Here, we provide an overview about the allergen molecules in cow´s milk and the advantages of the molecular diagnosis of IgE sensitization to cow´s milk by serology. In addition, we review current strategies for prevention and treatment of cow´s milk allergy and discuss how they could be improved in the future by innovative molecular approaches that are based on defined recombinant allergens, recombinant hypoallergenic allergen derivatives and synthetic peptides.
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Affiliation(s)
- Birgit Linhart
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, 1090 Vienna, Austria.
| | - Raphaela Freidl
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, 1090 Vienna, Austria
| | - Olga Elisyutina
- NRC Institute of Immunology FMBA of Russia, 115478, Moscow, Russia
| | - Musa Khaitov
- NRC Institute of Immunology FMBA of Russia, 115478, Moscow, Russia
| | - Alexander Karaulov
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergy, Sechenov First Moscow State Medical University, 119435 Moscow, Russia
| | - Rudolf Valenta
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, 1090 Vienna, Austria
- NRC Institute of Immunology FMBA of Russia, 115478, Moscow, Russia
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergy, Sechenov First Moscow State Medical University, 119435 Moscow, Russia
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246
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Eosinophilic Esophagitis: the Potential Role of Biologics in its Treatment. Clin Rev Allergy Immunol 2019; 59:150-159. [DOI: 10.1007/s12016-019-08749-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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247
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Wheeler JC, Vanoni S, Zeng C, Waggoner L, Yang Y, Wu D, Uddin J, Karns R, Kottyan L, Mukkada V, Rothenberg ME, Hogan SP. 17β-Estradiol protects the esophageal epithelium from IL-13-induced barrier dysfunction and remodeling. J Allergy Clin Immunol 2019; 143:2131-2146. [PMID: 30578870 PMCID: PMC6556402 DOI: 10.1016/j.jaci.2018.10.070] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/30/2018] [Accepted: 10/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence of eosinophilic esophagitis (EoE) is greater in male than female subjects, and the underlying molecular basis for this sex bias remains unclear. OBJECTIVE We sought to delineate the contribution of the sex hormone estrogen to the EoE phenotype and esophageal epithelial barrier function and remodeling. METHODS We performed demographic and incidence analyses of EoE in male and female subjects from a single-center pediatric cohort. Estrogen-responsive gene expression analyses and estrogen receptor (ESR) immunofluorescence staining of esophageal biopsy specimens from patients with EoE and control subjects were performed. The effect of 17β-estradiol (E2) on IL-13-induced signaling pathways, gene expression, and esophageal epithelial architecture and barrier function in a primary human esophageal keratinocyte cell (EPC2) culture system (EPC2-air-liquid interface) was examined. RESULTS We observed a male predominance in patients with EoE. Analyses of RNA sequencing data sets revealed a significant dysregulation of the estrogen-responsive gene network and expression of ESR1 and ESR2 in esophageal biopsy specimens from patients with EoE compared with control subjects. IL-13 stimulation of EPC2-air-liquid interface cells led to altered cellular architecture with induced dilation of intercellular spaces and barrier dysfunction. Pretreatment of EPC2s with E2 prior to IL-13 exposure abrogated IL-13-induced architectural changes and esophageal barrier dysfunction. Mechanistically, E2-protective effects were dependent on ESR2 and associated with diminishing of IL-13-induced tyrosine kinase 2 and signal transducer and activator of transcription 6 phosphorylation and EoE-dysregulated gene expression. CONCLUSIONS Estrogen-responsive genes are modified in patients with EoE compared with control subjects. E2 attenuated IL-13-induced architectural changes and esophageal epithelial barrier dysfunction through inhibition of the IL-13/tyrosine kinase 2/signal transducer and activator of transcription 6 pathway via ESR2-dependent process. Estrogen hormone signaling may protect against development of EoE in female subjects.
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Affiliation(s)
- Justin C Wheeler
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Simone Vanoni
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chang Zeng
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lisa Waggoner
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yanfen Yang
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Wu
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jazib Uddin
- Center for Autoimmune Genomics and Etiology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rebekah Karns
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leah Kottyan
- Center for Autoimmune Genomics and Etiology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Vincent Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Simon P Hogan
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Mary H Weiser Food Allergy Center, Department of Pathology, University of Michigan, Ann Arbor, Mich.
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248
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Ferreira CT, Vieira MC, Furuta GT, Barros FCLFD, Chehade M. Eosinophilic esophagitis – Where are we today? JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2019. [DOI: 10.1016/j.jpedp.2018.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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249
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Navarro P, Arias Á, Arias-González L, Laserna-Mendieta EJ, Ruiz-Ponce M, Lucendo AJ. Systematic review with meta-analysis: the growing incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies. Aliment Pharmacol Ther 2019; 49:1116-1125. [PMID: 30887555 DOI: 10.1111/apt.15231] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/11/2019] [Accepted: 02/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The frequency of eosinophilic oesophagitis (EoE) occurrence is escalating. Current diagnostic criteria recently proposed for the disease, determine that previous estimates of incidence and prevalence are outdated. AIM To gauge the current incidence and prevalence of EoE by performing a systematic review of population-based studies. METHODS Three electronic databases were searched from their inception dates to September 2018. A total of 2386 documents were screened; 29 studies reported on the prevalence and incidence of EoE in the general population. RESULTS The pooled prevalence of EoE was 34.4 cases per 100 000 inhabitants (95% CI, 23.1-47.5), and was higher for adults (42.2; 95% CI, 31.1-55) than for children (34; 95% CI, 22.3-49.2). The pooled EoE incidence rates were 6.6/100 000 person-years (95% CI, 3-11.7) in children and 7.7/100 000 (95% CI, 1.8-17.8) in adults. No differences were found between North American and European studies using varied sources of data (insurance and administrative databases compared to hospital-bases case series). Subgroup analysis according to risk of bias did not change results significantly. A steady rise in EoE incidence and prevalence rates was observed over time, comparing studies conducted under subsequent definitions for EoE. No significant publication bias was found. CONCLUSIONS In a systematic review and meta-analysis, we found a sharp increase, higher than previous estimates, in the incidence and prevalence of EoE in population based studies. Results from studies carried out in developed countries show broad consistency and provide evidence of increasing pooled prevalence and incidence of EoE rates over time.
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Affiliation(s)
- Pilar Navarro
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Ángel Arias
- Research Support Unit, Complejo Hospitalario La Mancha Centro, Alcázar de San Juan, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Laura Arias-González
- Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | | | - Miriam Ruiz-Ponce
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Alfredo J Lucendo
- Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
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250
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Ferreira CT, Vieira MC, Furuta GT, Barros FCLFD, Chehade M. Eosinophilic esophagitis-Where are we today? J Pediatr (Rio J) 2019; 95:275-281. [PMID: 30075121 DOI: 10.1016/j.jped.2018.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The objective of this review is to provide an overview of the practical diagnostic and therapeutic approaches to eosinophilic esophagitis and to increase the visibility of the disease among pediatricians. SOURCES A search of the MEDLINE, Embase, and CINAHL databases and recent consensus statements and guidelines were performed. SUMMARY OF THE FINDINGS The definition of eosinophilic esophagitis is based on symptoms and histology. It is important to rule out other diseases associated with esophageal eosinophil-predominant inflammation. It is not yet clear whether the increased prevalence is due to a real increase in incidence or a result of increased awareness of the disease. Various options for management have been used in pediatric patients, including proton pump inhibitors, dietary restriction therapies, swallowed topical steroids, and endoscopic dilations. More recently, proton pump inhibitor-responsive esophageal eosinophilia and eosinophilic esophagitis have been contemplated on the same spectrum, and proton pump inhibitors should be considered the initial step in the treatment of these patients. CONCLUSIONS Eosinophilic esophagitis is a relatively new disease with a remarkable progression of its incidence and prevalence in the past two to three decades, and diagnostic criteria that are constantly evolving. It is important to better understand the pathogenesis of the disease, the predisposing factors, the natural history, and the categorization of varying phenotypes to develop diagnostic and therapeutic strategies that meet the clinical needs of patients.
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Affiliation(s)
- Cristina Targa Ferreira
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Pediatria, Porto Alegre, RS, Brazil; Hospital Santo Antonio, Porto Alegre, RS, Brazil.
| | - Mario Cesar Vieira
- Pontifícia Universidade Católica do Paraná (PUC-PR), Departamento de Pediatria, Curitiba, PR, Brazil; Hospital Pequeno Príncipe, Centro de Gastroenterologia Pediátrica, Curitiba, PR, Brazil
| | - Glenn T Furuta
- Children's Hospital Colorado, Hepatology and Nutrition, Digestive Health Institute, Aurora, United States; University of Colorado School of Medicine, Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Aurora, United States
| | | | - Mirna Chehade
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for Eosinophilic Disorders, New York, United States
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