Upper gastrointestinal tract eosinophilic disorders: pathobiology and management

Contribution of endoscopy in the management of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a clinicopathological entity characterized by a set of symptoms similar to gastroesophageal reflux disease and eosinophilic infiltration of the esophageal epithelium. EoE is an emerging worldwide disease as documented in many countries. Recent reports indicate that EoE is increasingly diagnosed in both pediatric and adult patients although the epidemiology of this new disease entity remains unclear. It is unclear whether EoE is a new disease or a new classification of an old esophageal disorder. Esophagogastroduodenoscopy (EGD) and biopsies with histological examination of esophageal mucosa are required to establish the diagnosis of EoE, verify response to therapy, assess disease remission, document and dilate strictures and evaluate symptom recurrence of EoE. Repeated endoscopies with biopsies are necessary for monitoring of disease progression and treatment efficacy. EGD has a fundamental role in the diagnosis and management of EoE, forming an essential part of the investigation and follow-up of this condition. EoE is now considered a systemic disorder and not only a local condition with an important immunological background. One of the aims of research in EoE is to study non-invasive markers, such as immune indicators found in plasma, that correlate with local presence of EoE in esophageal tissues. Studies over the next few years will provide new information about diagnosis, pathogenesis, endoscopic/histologic criteria, non-invasive markers, novel and more efficacious treatments, as well as establishing natural history. Randomized clinical trials are urgently called for to inform non-invasive diagnostic tests, hallmarks of natural history and more efficacious treatment approaches for patients with EoE. The collaboration between pediatric and adult clinical and experimental studies will be paramount in the understanding and management of this disease.

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

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

Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review

BACKGROUND

Eosinophilic esophagitis (EoE) is an emerging clinicopathologic entity defined by abnormal esophageal eosinophilic infiltration. Our understanding of this disease is hampered by the lack of a uniform diagnostic standard. The aim of this systematic review was to determine the range of diagnostic strategies and histologic criteria in the EoE literature.

METHODS

The MEDLINE-indexed literature from 1950 through December 31, 2006 was independently searched by two investigators. To identify additional relevant studies, bibliographies were hand searched, as were the published proceedings of the 2000-2006 American College of Gastroenterology and American Gastroenterological Association national meetings. Data were extracted from all human EoE case reports, case series, cross-sectional and cohort studies, and clinical trials.

RESULTS

Of 318 publications initially identified, 116 original articles, 39 abstracts, and 69 reviews were included. We found 10 different histologic definitions of EoE, ranging from 5 to 30 eosinophils per high-powered field (hpf), though 41 (35%) of the original articles did not state their diagnostic criteria. In the 13 original articles (11%) reporting an hpf area, the eosinophil density per mm(2) varied 23-fold. There was also variation in esophageal biopsy protocols, but specific protocols were reported in just 45 (39%) original articles.

CONCLUSIONS

Significant variability in diagnostic criteria for eosinophilic esophagitis exists, and in a large proportion of studies, criteria are not reported. Because of this lack of a common disease definition, conclusions drawn from the cumulative EoE literature should be viewed with caution. A consensus research-quality standard for diagnosis of eosinophilic esophagitis is needed.