Association Between Body Mass Index and Clinical and Endoscopic Features of Eosinophilic Esophagitis

Long-term prognosis and its associated predictive factors in patients with eosinophilic gastroenteritis

BACKGROUND

Eosinophilic gastroenteritis (EGE) is a chronic recurrent disease with abnormal eosinophilic infiltration in the gastrointestinal tract. Glucocorticoids remain the most common treatment method. However, disease relapse and glucocorticoid dependence remain notable problems. To date, few studies have illuminated the prognosis of EGE and risk factors for disease relapse.

AIM

To describe the clinical characteristics of EGE and possible predictive factors for disease relapse based on long-term follow-up.

METHODS

This was a retrospective cohort study of 55 patients diagnosed with EGE admitted to one medical center between 2013 and 2022. Clinical records were collected and analyzed. Kaplan-Meier curves and log-rank tests were conducted to reveal the risk factors for long-term relapse-free survival (RFS).

RESULTS

EGE showed a median onset age of 38 years and a slight female predominance (56.4%). The main clinical symptoms were abdominal pain (89.1%), diarrhea (61.8%), nausea (52.7%), distension (49.1%) and vomiting (47.3%). Forty-three (78.2%) patients received glucocorticoid treatment, and compared with patients without glucocorticoid treatments, they were more likely to have elevated serum immunoglobin E (IgE) (86.8% vs 50.0%, P = 0.022) and descending duodenal involvement (62.8% vs 27.3%, P = 0.046) at diagnosis. With a median follow-up of 67 mo, all patients survived, and 56.4% had at least one relapse. Six variables at baseline might have been associated with the overall RFS rate, including age at diagnosis < 40 years [hazard ratio (HR) 2.0408, 95% confidence interval (CI): 1.0082-4.1312, P = 0.044], body mass index (BMI) > 24 kg/m2 (HR 0.3922, 95%CI: 0.1916-0.8027, P = 0.014), disease duration from symptom onset to diagnosis > 3.5 mo (HR 2.4725, 95%CI: 1.220-5.0110, P = 0.011), vomiting (HR 3.1259, 95%CI: 1.5246-6.4093, P = 0.001), total serum IgE > 300 KU/L at diagnosis (HR 0.2773, 95%CI: 0.1204-0.6384, P = 0.022) and glucocorticoid treatment (HR 6.1434, 95%CI: 2.8446-13.2676, P = 0.003).

CONCLUSION

In patients with EGE, younger onset age, longer disease course, vomiting and glucocorticoid treatment were risk factors for disease relapse, whereas higher BMI and total IgE level at baseline were protective.

Changes in mucosal IgG4+- and IL-10+-cell frequencies in adults with eosinophilic esophagitis on a two-food elimination diet

Eosinophilic esophagitis (EoE) is increasingly diagnosed in patients with dysphagia. Type-2 immunity can induce EoE histopathology via non-IgE-dependent mechanisms, possibly involving IgG4 and IL-10. To elucidate the contribution of this response to EoE pathogenesis, we examined its association with clinical and histologic endpoints in adult EoE patients given a two-food elimination diet. IgG4- and IL-10-expressing cells were counted in esophageal biopsies and serum food-specific IgG4 measured at baseline and follow-up. Variables were correlated with histologic measures of disease activity. Patients exhibited significant reduction in esophageal eosinophilia and overall histology. A significant decrease in IL-10+-cell frequencies correlated with histologic changes. In contrast, a decline in serum and esophageal IgG4, while substantial, did not correlate with IL-10+-cell frequencies or histologic parameters. These results suggest a critical role of IL-10 in EoE pathogenesis. Conversely, IgG4 expression, while reflecting exposure to food antigens, is not obviously related to EoE histopathology or IL-10 expression.

Body mass index in relation to symptom presentation on diagnosis of eosinophilic esophagitis in children

BACKGROUND

The relationship between body mass index (BMI) and eosinophilic esophagitis (EoE) among children is not well characterized.

OBJECTIVE

To evaluate the presentations of EoE in pediatric patients of different weight classes.

METHODS

Records of newly diagnosed children with EoE at an academic center from 2015 to 2018 were evaluated regarding demographics, symptom presentation, and endoscopic findings and compared among the underweight, normal weight, overweight, and obese groups.

RESULTS

There were 341 patients aged 0 to 18 years old newly diagnosed with EoE from 2015 to 2018 (68.3% male, 233 of 341; 80.9% White, 276 of 341). Of the 341, 17 were underweight (4.9%), 214 normal weight (62.8%), 47 overweight (13.8%), and 63 obese (18.5%). Children with obese and overweight BMI were more likely to be diagnosed at an older age (P = .005) and to present with a chief complaint of abdominal pain (P = .02). Normal- and under-weight children were more likely to have an immunoglobulin E-mediated food allergy (P = .02). Normal weight children were more likely to be tested for food allergies (P = .02) and inhalant allergies (P = .004) and have linear furrows on endoscopy (P = .03), compared with children with overweight and obese BMI. No significant differences were found regarding race, sex, type of insurance, atopic dermatitis, asthma, or allergic rhinitis in relation to BMI status and EoE diagnosis.

CONCLUSION

Nearly one-third of children were obese or in overweight status on diagnosis with EoE. Children with BMI in the overweight or obese range were more likely to be older at diagnosis and to have a chief complaint of abdominal pain on presentation.

Predictors of histologic response to mepolizumab in pediatric eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic, allergic disease of the esophagus. Current treatment options are limited. One experimental therapy is antibodies against interleukin-5 (IL-5). However, it is unknown why some patients respond to anti-IL-5 treatment whereas others do not. We sought to delineate predictors of histologic response to anti-IL-5 therapy in pediatric EoE.

METHODS

This post hoc analysis of a multicenter, double-blind clinical trial (ClinicalTrial.gov identifier: NCT00358449) evaluated mepolizumab for the treatment of EoE in pediatric patients. Predictors were assessed for their association with a histologic response at week 12 of treatment. A histologic response was defined as either <15 eosinophils per hpf or a reduction in peak eosinophil counts by ≥50%. Predictors on univariate analysis with P  < 0.10 were included in multivariate logistic regression models. Statistical significance for multivariate comparisons was set at P  < 0.05.

RESULTS

Patients with a higher BMI were more likely to attain histologic response at week 12, defined as <15 eosinophils per hpf [aOR, 1.31; 95% confidence interval (CI), 1.07-1.60; P  = 0.008]. Higher BMI (aOR, 1.70; 95% CI, 1.06-2.74; P  = 0.029) and signs of exudate plaques on endoscopy (aOR, 18.30; 95% CI, 2.11-158.53; P  = 0.008) were significant predictors of histologic response at week 12 where a histologic response was defined as a reduction in peak eosinophil counts by ≥50.

CONCLUSION

Higher BMI and signs of exudative plaques on endoscopy may be predictors of histologic response in pediatric EoE patients treated with antibodies against IL-5. Further studies are needed to validate our findings.

Stem cell factor inhibition reduces Th2 inflammation and cellular infiltration in a mouse model of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a T helper (Th)2-mediated inflammatory disorder characterized endoscopically by eosinophilic infiltration leading to fibrosis of the esophagus. Stem cell factor (SCF), a multifunctional cytokine, is upregulated in several allergic diseases, including in patients with EoE. Mast cells and eosinophils express c-kit, the cell surface receptor for SCF, and have been found to play an important role in EoE. Therefore, we investigated whether blocking SCF represents a potential therapeutic approach for EoE. Esophageal inflammation was induced in mice using peanut allergen. In mice with experimental EoE, we found that SCF was upregulated in the esophageal tissue. In EoE mice injected with a polyclonal antibody specific for SCF, we observed a decrease in both mast cells and eosinophils by histological and flow cytometric analysis. Furthermore, Th2 cytokines in the esophagus were decreased in anti-SCF treated mice, as were levels of Th2 cytokines from lung-draining and esophageal lymph nodes. Serum levels of peanut-specific immunoglobulin E were reduced following treatment with anti-SCF. In Kitlf/f-Col1-Cre-ERT mice, which have SCF deleted primarily in myofibroblasts that develop in EoE, we observed similar results as the anti-SCF treated animals for inflammatory cell accumulation, cytokines, and histopathology. These results indicate that therapeutic treatments targeting SCF can reduce allergic inflammation in EoE.

Higher Body Mass Index Is Associated With Decreased Treatment Response to Topical Steroids in Eosinophilic Esophagitis

BACKGROUND & AIMS

Understanding which eosinophilic esophagitis (EoE) patients will respond to treatment with topical corticosteroids (tCS) remains challenging, and it is unknown whether obesity impacts treatment response. This study aimed to determine whether treatment outcomes to tCS in EoE patients vary by body mass index (BMI).

METHODS

This retrospective cohort study of the University of North Carolina EoE Clinicopathologic database assessed subjects age 14 years or older with a new diagnosis of EoE. Their BMI was calculated and histologic, symptom, and endoscopic responses were recorded after tCS treatment. The treatment response of obese (BMI, ≥30 kg/m2) and nonobese EoE status was compared using bivariate and multivariate analyses.

RESULTS

We identified 296 EoE patients treated with tCS. Baseline characteristics were similar, although obese EoE patients had more heartburn and hiatal hernias. Histologic response was higher for those who were nonobese compared with obese at fewer than 15 (61% vs 47%; P = .049) and 6 or fewer (54% vs 38%; P = .02) eosinophils per high-power field, respectively. In addition, nonobese patients had significantly greater endoscopic and symptomatic responses. On multivariate analysis, increasing BMI was associated independently with decreased histologic response after accounting for age, heartburn, dilation, and hiatal hernia whether BMI was assessed as a continuous variable (adjusted odds ratio [aOR], 0.93; 95% CI, 0.89-0.98), as nonobese vs obese (aOR, 0.38; 95% CI, 0.21-0.68), or in 4 categories (overweight vs normal [aOR, 0.46; 95% CI, 0.26-0.84] or obese vs normal [aOR, 0.26; 95% CI, 0.13-0.51]).

CONCLUSIONS

As BMI increases in EoE patients, the odds of histologic, symptomatic, and endoscopic responses to tCS decreases, with obese patients having an approximately 40% decrease in odds of response.

The Impact of Obesity on the Fibrostenosis Progression of Eosinophilic Esophagitis in a U.S. Veterans Cohort

Whether obesity is protective against progression of EoE is unknown. The aim of this study was to assess factors that alter the progression of EoE and determine if BMI is correlated with reduced disease severity. In this retrospective analysis of the Department of Veterans Affairs electronic health records, patients with EoE who received at least one dilation were identified using ICD and CPT codes. Kaplan-Meier curves determined the relationship between BMI and time to second esophageal dilation as a measurement of severity of disease. Cox proportional hazards models assessed the risk of second dilation adjusted for potential confounders. Of 2890 patients with EoE and at least one dilation, 40% were obese (n = 1165). There were no clinically significant differences in demographics between obese and non-obese patients. Non-obese patients were more likely to be smokers and had a higher mean average of the number of dilation visits compared to obese patients (p < 0.05). When stratified by obesity, non-obese individuals had a median time to next dilation of 6.53 years (95% CI (5.83, 7.79)) compared to 9.24 years for obese individuals (95% CI (7.40, 15.04)). When stratified by six BMI categories, median time to second dilation increased with increasing BMI. The hazard ratio of second dilation for obese individuals was 0.81 (95% CI (0.72-0.92)). EoE patients with a higher BMI were less likely to undergo a second dilation compared to those with a lower BMI. Obesity may have a protective role in EoE or severe strictures may lead to malnourishment. Further research into these possibilities is needed.

The Impact of Obesity on the Fibrostenosis Progression of Eosinophilic Esophagitis in a U.S. Veterans Cohort

Whether obesity is protective against progression of EoE is unknown. The aim of this study was to assess factors that alter the progression of EoE and determine if BMI is correlated with reduced disease severity. In this retrospective analysis of the Department of Veterans Affairs electronic health records, patients with EoE who received at least one dilation were identified using ICD and CPT codes. Kaplan-Meier curves determined the relationship between BMI and time to second esophageal dilation as a measurement of severity of disease. Cox proportional hazards models assessed the risk of second dilation adjusted for potential confounders. Of 2890 patients with EoE and at least one dilation, 40% were obese (n = 1165). There were no clinically significant differences in demographics between obese and non-obese patients. Non-obese patients were more likely to be smokers and had a higher mean average of the number of dilation visits compared to obese patients (p < 0.05). When stratified by obesity, non-obese individuals had a median time to next dilation of 6.53 years (95% CI (5.83, 7.79)) compared to 9.24 years for obese individuals (95% CI (7.40, 15.04)). When stratified by six BMI categories, median time to second dilation increased with increasing BMI. The hazard ratio of second dilation for obese individuals was 0.81 (95% CI (0.72-0.92)). EoE patients with a higher BMI were less likely to undergo a second dilation compared to those with a lower BMI. Obesity may have a protective role in EoE or severe strictures may lead to malnourishment. Further research into these possibilities is needed.

Disease Burden and Unmet Need in Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory disease of increasing prevalence, characterized by symptoms of dysphagia and reduced quality of life. A dysregulated type 2 immune response to food and aeroallergen leads to barrier dysfunction, chronic esophageal inflammation, remodeling, and fibrosis. Patients with EoE have impaired quality of life because of dysphagia and other symptoms. They may also suffer social and psychological implications of food-related illness and expensive out-of-pocket costs associated with treatment. Disease burden in EoE is often compounded by the presence of comorbid type 2 inflammatory diseases. Current conventional treatments include elimination diet, proton pump inhibitors, and swallowed topical corticosteroids, as well as esophageal dilation in patients who have developed strictures. These treatments demonstrate variable response rates and may not always provide long-term disease control. There is an unmet need for long-term histologic, endoscopic, and symptomatic disease control; for targeted therapies that can normalize the immune response to triggers, reduce chronic inflammation, and limit or prevent remodeling and fibrosis; and for earlier diagnosis, defined treatment outcomes, and a greater understanding of patient perspectives on treatment. In addition, healthcare professionals need a better understanding of the patient perspective on disease burden, the disconnect between symptoms and disease activity, and the progressive nature of EoE and the need for continuous monitoring and maintenance treatment. In this review, we explore the progression of disease over the patient's lifespan, highlight the patient perspective on disease, and discuss the unmet need for effective long-term treatments.

British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults

BACKGROUND

Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE.

METHODS

The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance.

RESULTS

Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research.

CONCLUSIONS

These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.

Clinicopathological Differences between Eosinophilic Esophagitis and Asymptomatic Esophageal Eosinophilia

Objective According to consensus guidelines, eosinophilic esophagitis (EoE) is defined as a clinicopathological entity whose symptoms and histology must always be considered together. However, endoscopic findings typical of EoE are often seen in asymptomatic esophageal eosinophilia (aEE). We aimed to clarify the clinicopathological features of aEE. Methods We retrospectively compared cases of aEE and those of symptomatic EoE. Materials We reviewed 146 patients who underwent upper gastrointestinal endoscopy and were confirmed histopathologically to have esophageal eosinophil infiltration of at least 15 eosinophils per high-power field. They were divided into the aEE group (n=75) and the EoE group (n=71). Patients' clinicopathological findings were then collected and examined. Results The EoE group experienced dysphagia (47.9%), heartburn (40.8%), food impaction (40.8%), chest pain (16.9%), and other symptoms (8.5%). There was no significant difference between the two groups with regard to age, sex, current smoking status, or alcohol consumption. The aEE group had a significantly higher body mass index (p<0.01) and significantly lower frequency of concurrent allergic diseases (p<0.01) than the EoE group. No significant differences were found between the two groups with regard to the mean peripheral blood eosinophil count, non-specific immunoglobulin E concentration, peak eosinophil infiltration in the biopsy specimens, EoE histology scoring system, phenotype and location of typical endoscopic findings of EoE, or thickness of the esophagus wall or the mucosal and submucosal layer as measured by endoscopic ultrasonography. Two patients in the aEE group who were followed up without treatment subsequently developed esophageal symptoms. Conclusion aEE and EoE may have the same clinicopathological features.

Obesity reduces the requirement for subsequent esophageal stricture dilation in adults with eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) causes esophageal narrowing and strictures, but factors that modify the severity of strictures and requirement for subsequent dilation are not well described. The aim of this study was to identify characteristics that impact the need for repeat (> 1) esophageal dilations in EoE patients.

METHODS

This was a single center retrospective cohort study over a 12-year period (September 2005-October 2017). Patients were identified using ICD9, ICD10, and CPT codes for esophageal dilation, eosinophilic esophagitis, and esophageal obstruction. Data for EoE clinical characteristics, treatments, and BMI were extracted and correlated to the number of esophageal dilations and time elapsed between dilations.

RESULTS

Of the 21 patients who met inclusion criteria, 11 (52%) had at least two dilations and 9 (43%) had three dilations. There was no differences baseline demographics between patients who needed ≥ 2 vs. those who needed one dilation. However, patients with a BMI > 30 had a significantly longer median time to second dilation compared to non-obese patients (4.9 years vs. 1.8 years; p = 0.027). Stratification by either high dose PPI or inhaled steroid use did not change this result.

CONCLUSIONS

EoE patients with strictures who are obese have a reduced requirement for subsequent esophageal dilation. While the mechanism for this is not clear, increased attention of non-obese patients with fibrostenotic EoE is indicated as they are at higher risk for recurrent strictures.

Malnutrition in Eosinophilic Gastrointestinal Disorders

Primary eosinophilic gastrointestinal disorders (EGIDs) are emerging chronic/remittent inflammatory diseases of unknown etiology, which may involve any part of the gastrointestinal (GI) tract, in the absence of secondary causes of GI eosinophilia. Eosinophilic esophagitis is the prototype of eosinophilic gastrointestinal disorders and is clinically characterized by symptoms related to esophageal inflammation and dysfunction. A few studies have assessed the nutritional status of patients with eosinophilic gastrointestinal disorders, showing conflicting results. This review summarizes the current evidence on the nutritional status of patients with EGIDs, focusing on the pediatric point of view and also speculating potential etiological mechanisms.

Early life factors are associated with risk for eosinophilic esophagitis diagnosed in adulthood

Early life exposures have been associated with pediatric eosinophilic esophagitis (EoE), but it is unknown if a similar association is present in adults. We aimed to assess the association between early life risk factors and development of EoE in adulthood. To do this, we conducted a case-control study which was nested within a prospective cohort study of adults undergoing outpatient endoscopy. Cases of EoE were diagnosed per consensus guidelines; controls did not meet these criteria. Subjects and their mothers were contacted to collect information on four key early life exposures: antibiotics taken during the first year of life, Cesarean delivery, preterm delivery (≤37 weeks' gestation), and neonatal intensive care unit (NICU) admission. We calculated the odds of EoE given in each exposure and assessed agreement between subjects and their mothers. For the 40 cases and 40 controls enrolled, we observed a positive association between each of the early life exposures and development of EoE (antibiotics in infancy, OR = 4.64, 95% CI = 1.63-13.2; Cesarean delivery, OR = 3.08, 95% CI = 0.75-12.6; preterm delivery, OR = 2.92, 95% CI = 0.71-12.0; NICU admission, OR = 4.00, 95% CI = 1.01-15.9). Results were unchanged after adjusting for potential confounders, though only early antibiotic use had CIs that did not cross 1.0. Moderate to strong agreement was observed between 54 subject-mother pairs (antibiotics, K = 0.44, P = 0.02; Cesarean delivery, K = 1.0, P < 0.001; preterm delivery, K = 0.80, P < 0.001; NICU, K = 0.76, P < 0.001). In sum, antibiotics in infancy was significantly associated with increased risk of EoE diagnosed in adulthood, while positive trends were seen with other early life factors such as Cesarean delivery, preterm delivery, and NICU admission. This may indicate persistent effects of early life exposures and merits additional study into conserved pathogenic mechanisms.

New Developments in the Diagnosis and Treatment of Eosinophilic Esophagitis

PURPOSE OF REVIEW

Eosinophilic esophagitis (EoE) is a chronic, allergen-driven, immune-mediated disease of the esophagus that progresses to esophageal fibrostenosis if left untreated. The aim of this review is to provide a concise update on recent clinically relevant advances in the development of diagnostic and therapeutic approaches for EoE.

RECENT FINDINGS

Current diagnostic and disease monitoring protocols for EoE rely on repetitive endoscopic evaluations and esophageal tissue acquisition for histopathologic analysis. Recent advancements in EoE diagnosis include endoscopic functional lumen imaging probe (FLIP), transnasal endoscopy (TNE), and the emergence of non-invasive diagnostic tools including cytosponge, esophageal string test, and mucosal impedance probe. Biomarkers for EoE have not yet proven their clinical utility. No Food and Drug Administration (FDA)-approved drugs currently exist for the treatment of EoE. Topical corticosteroid, proton-pump inhibitors (PPI), elimination diet, and dilation are the current treatment modalities for confirmed EoE. Promising results from clinical trials are emerging for biologic agents that target the interleukin (IL)-13 and the IL-4/IL-13 receptor, specifically, RPC4046 and dupilumab, respectively. New diagnostic algorithms, non-invasive diagnostic strategies, and treatment modalities for EoE are emerging. Patients with EoE continue to require a multimodal and multi-disciplinary management approach.

Medical and dietary management of eosinophilic esophagitis

OBJECTIVE

Eosinophilic esophagitis (EoE) is a disease of chronic, allergen-driven, T-helper 2 (Th2) immune-mediated inflammation that progresses to fibrostenosis of the esophagus if left untreated. There are currently no Food and Drug Administration (FDA)-approved drugs for the treatment of EoE. This review focuses on the medical and dietary management of EoE.

DATA SOURCES

Manuscripts on EoE treatments were identified on PubMed.

STUDY SELECTIONS

Original research, randomized control trials, retrospective studies, meta-analyses, case series, and on occasions, case reports of high relevance, were selected and reviewed.

RESULTS

Current treatment strategies available to EoE patients center on monotherapy or combination therapy with dietary modification to exclude antigenic stimulation and topical corticosteroids to control Th2-mediated tissue inflammation and pathologic remodeling. Dilation as a rescue therapy for the narrowed, fibrostenotic, symptomatic esophagus can potentially be avoided with optimal medical and elimination diet therapies. The molecular mechanisms underlying EoE pathogenesis are being unraveled, from which targeted therapies can be developed and evaluated in preclinical and clinical studies. Current clinical research efforts focus on optimization of topical corticosteroid delivery, dosing, frequency, and duration of treatment, either alone or in combination with tailored elimination diet. Preliminary clinical trials with biologics targeting interleukin (IL)-5 and IL-13/IL-4 have been completed.

CONCLUSION

Topical corticosteroid, elimination diet, and dilation are the current treatment modalities for confirmed EoE. The use of proton-pump inhibitors (PPI) is being suggested as a potential regimen to treat EoE, based on evolving understanding of PPI-responsive esophageal eosinophilia (PPI-REE). The complexity of EoE treatment regimens and frequent follow-ups require a multimodal, multi-disciplinary management approach to optimize patient care.

Eosinophilic Esophagitis Clinical Manifestations and Differential Diagnosis

As a chronic inflammatory disease with eosinophilic infiltrate of the esophagus, eosinophilic esophagitis (EoE) causes a variety of gastrointestinal (GI) clinical manifestations. None of the symptoms, endoscopic features, or biopsy findings is pathognomonic of the disease, even with high degrees of esophageal eosinophilia. The pathogenesis has been explored by several studies, yet it still far from being completely understood. Evidence supports a role of allergen-driven Th2 lymphocyte mechanism, though not in every patient. This article addresses the disease's clinical manifestations, endoscopic findings, diagnosis, and differential diagnoses. In addition to the current diagnostic criteria, we summarize some recently emerging procedures that promise of enhancing more precise diagnosis and institution of early appropriate management, with consequent better quality of life and reduction of complications.

Tissue Remodeling in Chronic Eosinophilic Esophageal Inflammation: Parallels in Asthma and Therapeutic Perspectives

Chronic eosinophilic inflammation is associated with tissue remodeling and fibrosis in a number of chronic T-helper 2 (Th2)-mediated diseases including eosinophilic esophagitis (EoE) and asthma. Chronic inflammation results in dysregulated tissue healing, leading to fibrosis and end organ dysfunction, manifesting clinically as irreversible airway obstruction in asthma and as esophageal rigidity, strictures, narrowing, dysmotility, dysphagia, and food impactions in EoE. Current therapies for EoE and asthma center on reducing inflammation-driven tissue remodeling and fibrosis with corticosteroids, coupled with symptomatic control and allergen avoidance. Additional control of Th2 inflammation can be achieved in select asthma patients with biologic therapies such as anti-IL-5 and anti-IL-13 antibodies, which have also been trialed in EoE. Recent molecular analysis suggests an emerging role for structural cell dysfunction, either inherited or acquired, in the pathogenesis and progression of EoE and asthma tissue remodeling. In addition, new data suggest that inflammation-independent end organ rigidity can alter structural cell function. Herein, we review emerging data and concepts for the pathogenesis of tissue remodeling and fibrosis primarily in EoE and relevant pathogenetic parallels in asthma, focusing additionally on emerging disease-specific therapies and the ability of these therapies to reduce tissue remodeling in subsets of patients.