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Mechanisms and clinical management of eosinophilic oesophagitis: an overview. Nat Rev Gastroenterol Hepatol 2023; 20:101-119. [PMID: 36253463 DOI: 10.1038/s41575-022-00691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/03/2023]
Abstract
Since the first description of eosinophilic oesophagitis (EoE) less than three decades ago, we have observed a striking increase in the number of patients diagnosed with EoE and the understanding of its clinical and immunopathogenic background. Nonetheless, a plethora of open questions await elucidation. In this Review, we discuss the current state of knowledge regarding the underlying mechanisms, particularly environmental factors and their interaction with genetic susceptibility. Subsequently, we discuss how to translate these factors into the diagnostic and therapeutic management of this chronic, immune-mediated disorder. Finally, we dissect the still long list of unmet needs, such as reasons for and handling refractory EoE and atypical clinical presentations. These open questions can guide us through future research steps and potentially foster reconsideration of the diagnostic guidelines of EoE.
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Vieira GG, Ribeiro LBM, Truppel SK, Rosário Filho NA, Vieira MC. Endoscopic and histological characteristics in patients with eosinophilic esophagitis responsive and non-responsive to proton pump inhibitors. J Pediatr (Rio J) 2020; 96:638-643. [PMID: 31361987 PMCID: PMC9432158 DOI: 10.1016/j.jped.2019.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/25/2019] [Accepted: 05/29/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To compare endoscopic and histologic features of pediatric patients with eosinophilic esophagitis (EoE) responding to proton pump inhibitor (PPI) to those not responding to PPI. METHODS Endoscopic reports and photographs of patients with symptoms of esophageal dysfunction and ≥15 eosinophils per high-powered field (eos/hpf) in esophageal biopsies prior to PPI trial were reviewed. Patients were classified as responsive to PPI (PPIREoE) or non-responsive to PPI (PPINREoE) according to response totreatment (<15 eos/hpf) at second endoscopy after 8 weeks. RESULTS Of the 231 patients (72.3% male), 64 (27.7%) were responsive to the proton pump inhibitors. Edema (77.3% vs. 62.5%, p=0.031) and vertical lines (69.5% vs. 51.6%, p=0.014) were more frequent in PPINREoE patients. An eosinophil count in the mid-esophagus ≥ 35 eos/HPF (25.1% vs. 12.5%) was more frequent in these patients (p=0.001). Those with eosinophil count < 15 eos/HPF in the mid-esophagus at the first endoscopy were more likely to respond to treatment with proton pump inhibitors compared to patients with 15-34 eos/HPF (p=0.004, OR: 3.26, 95% CI: 1.46-7.24) and to patients with ≥ 35 eos/HPF (p=0.006, OR: 3.20, 95% CI: 1.39-7.41). CONCLUSION Edema and vertical lines at the endoscopy and a higher eosinophil count in the mid-esophagus were more frequent in patients who were non-responsive to proton pump inhibitors. As there were no significant differences in the other findings between the groups, it cannot be affirmed that these characteristics are sufficient to differentiate between PPINREoE and PPIREoE patients.
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Affiliation(s)
| | | | - Sabine Kruger Truppel
- Hospital Pequeno Príncipe, Centro de Gastroenterologia Pediátrica, Curitiba, PR, Brazil
| | - Nelson Augusto Rosário Filho
- Universidade Federal do Paraná (UFPR), Departamento de Pediatria, Curitiba, PR, Brazil Received 12 March 2019; accepted 29 May 2019
| | - Mário César Vieira
- Pontifícia Universidade Católica do Paraná (PUC-PR), Escola de Medicina, Curitiba, PR, Brazil; Hospital Pequeno Príncipe, Centro de Gastroenterologia Pediátrica, Curitiba, PR, Brazil.
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3
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Vieira GG, Ribeiro LBM, Truppel SK, Rosário Filho NA, Vieira MC. Endoscopic and histological characteristics in patients with eosinophilic esophagitis responsive and non‐responsive to proton pump inhibitors. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Roh JH, Ryoo E, Tchah H. Clinical Manifestations of Eosinophilic Esophagitis in Children and Adolescents: A Single-Center, Matched Case-Control Study. Pediatr Gastroenterol Hepatol Nutr 2020; 23:319-328. [PMID: 32704493 PMCID: PMC7354874 DOI: 10.5223/pghn.2020.23.4.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/15/2019] [Accepted: 11/30/2019] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To examine the prevalence and clinical manifestations of eosinophilic esophagitis (EoE) in Korea children. METHODS The study was designed as a 1:2 matching case-control study. Using information from the endoscopic database of a tertiary center, we retrospectively reviewed the medical records of patients aged 18 years or younger who underwent upper gastrointestinal endoscopy between January 2014 and December 2017. A total of 21 patients were diagnosed with EoE based on current diagnostic criteria. In addition, 42 controls with normal esophageal biopsy findings matched to each EoE case by sex, age (±1 months), and season were randomly selected during the study period. RESULTS The mean age of EoE diagnosis was 12.1±4.0 years and the male-to-female ratio was 2:1. The proportion of allergic diseases in patients with EoE (28.6%) was higher than that in the controls (6.8%) (p=0.04). Most EoE patients tested for allergy were positive for at least one antigen, which was significantly different to the controls (88.2% vs. 47.4%, p=0.01). Characteristic endoscopic findings of EoE were noted in 19 patients (90.5%), but 2 patients (9.5%) showed normal esophageal mucosa. The clinical symptoms of EoE were improved by a proton-pump inhibitor in 10 patients (50.0%), and by an H2 blocker in 9 patients (45.0%). Only one patient (5.0%) required inhaled steroids. CONCLUSION While EoE is rare in the Korean pediatric population, the results of this study will improve our understanding of the clinical manifestations of the disease.
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Affiliation(s)
- Ji Hyeon Roh
- Department of Pediatrics, Gachon University Gil Medical Center, Incheon, Korea
| | - Eell Ryoo
- Department of Pediatrics, Gachon University Gil Medical Center, Incheon, Korea
| | - Hann Tchah
- Department of Pediatrics, Gachon University Gil Medical Center, Incheon, Korea
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5
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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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Hiremath G, Locke A, Sivakumar A, Thomas G, Mahadevan-Jansen A. Clinical translational application of Raman spectroscopy to advance Benchside biochemical characterization to bedside diagnosis of esophageal diseases. J Gastroenterol Hepatol 2019; 34:1911-1921. [PMID: 31124184 DOI: 10.1111/jgh.14738] [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] [Received: 04/08/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022]
Abstract
Esophageal diseases result in significant mortality, morbidity, and health care costs worldwide. Current approaches to detect and monitor esophageal diseases have severe limitations. Advanced imaging technologies are being developed to complement current approaches to improve diagnostic, therapeutic and surveillance protocols in order to advance the field. Raman spectroscopy-based technologies hold promise to increase the sensitivity for detection of diseased and high-risk lesions in vitro and in vivo in real time. This technique allows for the investigation of microstructural changes and also facilitates the discovery of disease-specific biochemical alterations with the potential to provide novel insights into the pathobiology of these conditions. Raman spectroscopy has been increasingly applied in precancerous and cancerous esophageal conditions. However, its application in benign esophageal diseases is still in the early stages. Continuing its application in cancerous and precancerous conditions and expanding its use to benign esophageal disorders could lay a foundation for integration of this technology in clinical practice and diagnostic paradigms and development of an accurate and cost-effective tool for use in a clinical setting. Furthermore, Raman spectroscopy can also be used as an innovative technique to advance our understanding of the biochemical transformations associated with esophageal diseases and answer a myriad of fundamental questions in the field. In this review, we described the principles of Raman spectroscopy and instrumentation while providing an overview of current applications, challenges, and future directions in the context of esophageal diseases with an emphasis on its clinical translational application.
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Affiliation(s)
- Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrea Locke
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Adithya Sivakumar
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Giju Thomas
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Anita Mahadevan-Jansen
- Vanderbilt Biophotonics Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
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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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8
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Norder Grusell E, Mjörnheim AC, Finizia C, Ruth M, Bergquist H. The diagnostic value of GerdQ in subjects with atypical symptoms of gastro-esophageal reflux disease. Scand J Gastroenterol 2019; 53:1165-1170. [PMID: 30353750 DOI: 10.1080/00365521.2018.1503708] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Symptoms are essential in the clinical diagnosis of gastro-esophageal reflux disease (GERD). Questionnaires such as GerdQ have been developed as diagnostic aids. GerdQ has been thoroughly validated in well-characterized GERD patients, but has not yet been fully evaluated in a population that includes subjects with atypical symptoms. AIM To evaluate GerdQ in a population with typical and/or atypical symptoms of GERD, defined by 24-h pH monitoring. The secondary aim was to investigate the outcome of GerdQ depending on the response to proton pump inhibitor (PPI) treatment. METHODS The study included 646 subjects referred for 24-h pH monitoring due to a clinical suspicion of GERD. All subjects completed GerdQ before performing a 24-h pH monitoring. RESULTS In total, 377 (58%) subjects were diagnosed with GERD based on symptoms and 24-h pH monitoring (GERDpH). Of these, 46% had atypical main symptoms. Overall, GerdQ (at cut-off 8) predicted GERDpH with a sensitivity and specificity of 62% and 74%, respectively. A high specificity but poor sensitivity for diagnosis of GERDpH was found for atypical main symptoms such as cough, dysphagia and globus. GerdQ had a relatively high sensitivity and specificity in predicting PPI response and a PPV of 99% at cut-off 8. CONCLUSIONS GerdQ has a diagnostic value in an unselected population presenting with typical and/or atypical symptoms of GERD, but a low sensitivity for diagnosis of GERDpH was found in subjects with predominant symptoms such as cough, dysphagia and globus.
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Affiliation(s)
- Elisabeth Norder Grusell
- a Department of Otorhinolaryngology, Head and Neck Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Ann-Christine Mjörnheim
- a Department of Otorhinolaryngology, Head and Neck Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Caterina Finizia
- a Department of Otorhinolaryngology, Head and Neck Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Magnus Ruth
- a Department of Otorhinolaryngology, Head and Neck Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Henrik Bergquist
- a Department of Otorhinolaryngology, Head and Neck Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
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Wong S, Ruszkiewicz A, Holloway RH, Nguyen NQ. Gastro-oesophageal reflux disease and eosinophilic oesophagitis: What is the relationship? World J Gastrointest Pathophysiol 2018; 9:63-72. [PMID: 30386667 PMCID: PMC6209579 DOI: 10.4291/wjgp.v9.i3.63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/17/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic oesophagitis (EoE) and gastro-oesophageal reflux disease (GORD) are the most common causes of chronic oesophagitis and dysphagia associated with oesophageal mucosal eosinophilia. Distinguishing between the two is imperative but challenging due to overlapping clinical and histological features. A diagnosis of EoE requires clinical, histological and endoscopic correlation whereas a diagnosis of GORD is mainly clinical without the need for other investigations. Both entities may exhibit oesophageal eosinophilia at a similar level making a histological distinction between them difficult. Although the term proton-pump inhibitor responsive oesophageal eosinophilia has recently been retracted from the guidelines, a relationship between EoE and GORD still exists. This relationship is complex as they may coexist, either interacting bidirectionally or are unrelated. This review aims to outline the differences and potential relationship between the two conditions, with specific focus on histology, immunology, pathogenesis and treatment.
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Affiliation(s)
- Stephanie Wong
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Andrew Ruszkiewicz
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Anatomical Pathology, SA Pathology, Adelaide SA 5000, Australia
| | - Richard H Holloway
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Nam Q Nguyen
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
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10
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Durrani SR, Mukkada VA, Guilbert TW. Eosinophilic Esophagitis: an Important Comorbid Condition of Asthma? Clin Rev Allergy Immunol 2018; 55:56-64. [PMID: 29455359 DOI: 10.1007/s12016-018-8670-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Eosinophilic esophagitis and asthma are frequently found as comorbid conditions in children and adults along with other manifestations of atopic diathesis. These two conditions have similar T helper 2 responses-driven pathophysiology and share common management strategies such as using systemic corticosteroids and targeted anti-cytokine biologic therapies. Review of the literature finds that asthma is often a comorbid condition in eosinophilic esophagitis in both children and adults; however, the EoE-asthma relationship remains poorly characterized mechanistically and clinically. EoE and asthma commonly share several comorbid conditions such as allergic rhinitis and gastroesophageal reflux disease; therefore, addressing these comorbid conditions has the potential to improve and/or maintain control in both diseases. Similar to asthma, patients with EoE frequently demonstrate elevations in serum markers of atopy, including serum IgE levels, peripheral eosinophil counts, and T helper 2-related cytokines. Gastroesophageal reflux disease is thought to affect asthma through microaspirations, airway hyperresponsiveness, and increased vagal tone. The understanding of the relationship between gastroesophageal reflux and EoE is still evolving but seems to be bidirectional and interactive. In terms of treatment, similar classes of medications have been used in both EoE and asthma. In both children and adults, EoE remission can be achieved by food trigger avoidance and use of corticosteroids and biologic therapies. Asthma control is mostly achieved through inhaled corticosteroids, and long but biologic therapies are increasingly used in severe subsets of the disease. Significant clinical and mechanistic work needs to be accomplished to better understand the relationship between asthma, EoE, and their interaction with other allergic diseases. Understanding whether shared mechanisms exist can lead to the development of new diagnostic and therapeutic strategies. The following review examines the existing literature regarding prevalence, common comorbidities, and potential therapeutic approach and identifies gaps in knowledge and future directions.
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Affiliation(s)
- Sandy R Durrani
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA. .,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Vincent A Mukkada
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Theresa W Guilbert
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Abstract
INTRODUCTION Despite consensus eosinophilic esophagitis (EoE) statement published in 2011 calling for a 2-month trial of protons pump inhibitor (PPI), the guidelines are not followed by many. We studied the practice patterns in our community and response to a PPI retrial in patients previously diagnosed with "idiopathic EoE." METHODS All patients presenting to the senior author's practice with suspected EoE from 2011 to 2015. Two cohorts were studied: (1) patients diagnosed in the community as "idiopathic EoE"; (2) treatment naïve patients given a PPI trial at University of South Florida. PPI responsive eosinophilia was defined after 2 months of high dose PPIs after initial diagnosis of mucosal eosinophilia and histologic response of <15 eosinophils per HPF. SPSS v19.0 was used to calculate mean difference and odds ratios (OR) and 95% confidence intervals. RESULTS In total, 78 patients met inclusion criteria, 46 patients had outside diagnosis of "idiopathic EoE," and 41 patients received a PPI trial at University of South Florida. In total, 34/46 (73.9%) community patients were placed on a PPI, 3/46 (6.5%) were placed on elimination diets, 31/46 (67.4%) steroids, and 21/46 (45.7%) were treated with both steroids/PPIs. Fewer patients received PPI trials in the community 3/46 (6.5%) versus 26/34 (76.5%) at our center [OR, 46.6 (95% CI, 11.3-191.5); P<0.0001]. In total, 12/26 (46.2%) were PPI responders on our retrial despite previously being diagnosed with idiopathic EoE. The group initially diagnosed at our center had a higher PPI response rate 12/15 (80%) versus 12/26 (46.2%) in the community group [OR, 7.58 (1.42, 40.55; P=0.018)]. CONCLUSIONS The importance of a PPI trial is misunderstood and may be confused with the more traditional PPI trial for gastroesophageal reflux disease. This algorithm is critical and should be done before empiric steroids/diet therapies.
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Muñoz-Mendoza D, Chapa-Rodríguez A, Bahna SL. Eosinophilic Esophagitis Clinical Manifestations and Differential Diagnosis. Clin Rev Allergy Immunol 2018; 55:7-18. [PMID: 29290036 DOI: 10.1007/s12016-017-8663-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Diana Muñoz-Mendoza
- Department of Pediatrics, Allergy and Immunology Section, Louisiana State University Health Sciences Center in Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA
| | - Adrián Chapa-Rodríguez
- Department of Pediatrics, Gastroenterology and Nutrition Section, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA, USA
| | - Sami L Bahna
- Department of Pediatrics, Allergy and Immunology Section, Louisiana State University Health Sciences Center in Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA.
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Abstract
Over the past decades eosinophilic esophagitis (EoE) has been increasingly diagnosed, and significant progress has been made in our understanding of its pathophysiology. As EoE cannot be cured yet, treatment goals are suppression of disease activity and symptoms as well as the prevention of progression to a more severe disease phenotype. Disease-modifying treatment options can be divided into dietary therapy and immunosuppressive medications, of which topical steroids have been most investigated, yet are still prescribed off-label. In this review, we will summarize recent advances in our understanding of EoE and discuss the mechanisms of action of current treatment options, with emphasis on the role of the esophageal epithelial barrier and the effects of proton-pump inhibitors in the management of patients with EoE.
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Abstract
PURPOSE OF REVIEW To update rapidly evolving concepts regarding the controversial entity of 'proton pump inhibitor (PPI)-responsive esophageal eosinophilia,' referring to patients with clinical, endoscopic and histologic features of eosinophilic esophagitis (EoE) who achieve remission on PPI therapy. RECENT FINDINGS Up to half of pediatric and adult patients with typical EoE symptoms and histology achieve clinico-pathologic remission on PPI therapy, irrespective of whether esophageal pH monitoring demonstrates abnormal acid reflux. In patients with clinical and histologic features of EoE, genotypic and phenotypic features of PPI responders and nonresponders are virtually indistinguishable, and different from those of patients with gastroesophageal reflux disease. In PPI responders, PPIs effects on esophageal Th2 inflammation and gene expression are similar to those of topical steroids in PPI nonresponders. These therapies, along with diets, recently have been shown to be potentially interchangeable in two small series. SUMMARY Proton pump inhibitor-responsive esophageal eosinophilia is an inappropriate disease descriptor, arbitrarily based on a response to a single drug, and should be abandoned. Patients who have esophageal eosinophilia and esophageal symptoms that resolve with PPI therapy have phenotypic, molecular, mechanistic, and therapeutic features indistinguishable from similar patients who do not respond to PPIs. These patients with PPI responsiveness should be considered within the spectrum of EoE.
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Soto-Solís R, Santana-de Anda K, González-Uribe N, Gallegos C, Romo-Aguirre C, Remes-Troche J, Ballesteros-Amozurrutia M. How to improve the diagnosis of eosinophilic esophagitis: Experience from a case series in Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Licari A, Castagnoli R, Marseglia GL. Eosinophilic esophagitis after congenital diaphragmatic hernia. Ital J Pediatr 2016; 42:96. [PMID: 27821174 PMCID: PMC5100315 DOI: 10.1186/s13052-016-0307-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is an increasingly diagnosed disease, especially in the western world. Although its pathogenesis remains poorly understood, there is strong evidence that the eosinophilic inflammation in EoE is primarily triggered by immune dysregulation secondary to allergic sensitization to dietary or aero-allergens. Recent studies have reported a higher prevalence of EoE in children with congenital gastrointestinal malformations, i.e. esophageal atresia and/or tracheoesophageal fistula. CASE PRESENTATION We present the case history of a 2-year-old boy who developed EoE in the aftermath of congenital diaphragmatic hernia (CDH) repair. CONCLUSIONS To the best of our knowledge, the following case report describes for the first time the possible association between CDH and EoE. Given the increasing reported prevalence of EoE in children with congenital gastrointestinal malformations, EoE should be rule out also in CDH survivors.
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Affiliation(s)
- Amelia Licari
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Viale Golgi n. 19, 27100, Pavia, Italy.
| | - Riccardo Castagnoli
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Viale Golgi n. 19, 27100, Pavia, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Viale Golgi n. 19, 27100, Pavia, Italy
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Soto-Solís R, Santana-de Anda K, González-Uribe N, Gallegos C, Romo-Aguirre C, Remes-Troche JM, Ballesteros-Amozurrutia MA. How to improve the diagnosis of eosinophilic esophagitis: Experience from a case series in Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 82:5-12. [PMID: 27712908 DOI: 10.1016/j.rgmx.2016.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/29/2016] [Accepted: 07/12/2016] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic, immune disorder mediated largely by food antigens. It shares nonspecific symptoms with gastroesophageal reflux disease (GERD). EoE is rarely reported in Mexico, perhaps due to the racial characteristics of the population or because of insufficient diagnostic suspicion. AIMS Our aim was to describe a Mexican cohort with EoE and evaluate the usefulness of the clinical history and endoscopy in the EoE diagnosis, in comparison with GERD patients. MATERIALS AND METHODS A retrospective study was carried out on the clinical characteristics and endoscopic and histopathologic findings in patients with EoE, along with a case-control study on patients with GERD. The endoscopic images obtained were interpreted in a blind and randomized manner by 4 gastroenterologists, before and after providing them with information on the characteristic alterations of EoE. The esophageal biopsies were also blinded to 2 pathologists that evaluated their diagnostic correlation. The Fisher's exact test and Mann-Whitney U test were used in the statistical analysis. RESULTS Fourteen patients with EoE were included in the study. Ten (71%) of them were men and the mean age of the patients was 35 years. There were more subjects with a personal history of asthma (p=0.0023) and food impaction (p=0.04) in the EoE group. The initial evaluation of the endoscopic findings showed 53% correct EoE interpretations and rose to 96% in the second revision (sensitivity 100%, specificity 71%, PPV 65%, NPV 100%). CONCLUSIONS Mexican patients with EoE have similar characteristics to those of patients in western case series. Clinical awareness of the disorder increases endoscopic diagnosis in up to 40% of cases.
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Affiliation(s)
- R Soto-Solís
- Departamento de Gastroenterología y Endoscopia Gastrointestinal, Hospital Ángeles Pedregal, Ciudad de México, México
| | - K Santana-de Anda
- Departamento de Gastroenterología y Endoscopia Gastrointestinal, Hospital Ángeles Pedregal, Ciudad de México, México
| | - N González-Uribe
- Departamento de Gastroenterología y Endoscopia Gastrointestinal, Hospital Ángeles Pedregal, Ciudad de México, México
| | - C Gallegos
- Departamento de Patología, Hospital Ángeles Pedregal, Ciudad de México, México
| | - C Romo-Aguirre
- Departamento de Patología, Hospital Ángeles Pedregal, Ciudad de México, México
| | - J M Remes-Troche
- Instituto de Investigaciones Médico Biológicas de la Universidad Veracruzana, Veracruz, México
| | - M A Ballesteros-Amozurrutia
- Departamento de Gastroenterología y Endoscopia Gastrointestinal, Hospital Ángeles Pedregal, Ciudad de México, México.
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18
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Molina-Infante J, Katzka DA, Spechler SJ. Letter: proton pump inhibitor-responsive oesophageal eosinophilia - more than just gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2016; 44:911-2. [PMID: 27634238 DOI: 10.1111/apt.13781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- J Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, Caceres, Spain.
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - S J Spechler
- Department of Internal Medicine, VA North Texas Health Care System and the University of Texas Southwestern Medical Center, Dallas, TX, USA
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Savarino E, Girardin G, Della Coletta M, Ottonello A, Savarino V. Letter: proton pump inhibitor-responsive oesophageal eosinophilia - more than just gastro-oesophageal reflux disease. Authors' reply. Aliment Pharmacol Ther 2016; 44:912-3. [PMID: 27634239 DOI: 10.1111/apt.13786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- E Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - G Girardin
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - M Della Coletta
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - A Ottonello
- Department of Surgical and Diagnostic Integrated Sciences, University of Genoa, Genoa, Italy
| | - V Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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Molina-Infante J, Prados-Manzano R, Gonzalez-Cordero PL. The role of proton pump inhibitor therapy in the management of eosinophilic esophagitis. Expert Rev Clin Immunol 2016; 12:945-52. [PMID: 27097787 DOI: 10.1080/1744666x.2016.1178574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic esophageal disease characterized by a Th2 inflammatory response triggered by food/environmental allergens. Solid data confirm that up to half of patients with suspected EoE achieve complete remission on proton pump inhibitors (PPI) therapy. This disease phenotype is currently labelled as PPI-responsive esophageal eosinophilia (PPI-REE). Albeit initially believed to represent gastro-esophageal reflux disease (GERD), evolving evidence has underscored that PPI-REE and EoE show a significant overlap regarding clinic, endoscopic, histologic, Th2 immune-mediated inflammation and gene expression features. Moreover, PPI therapy can effectively reverse Th2 inflammation and the EoE transcriptome expression in PPI-REE patients. Therefore, EoE and PPI-REE likely represent a common allergic disorder, where PPI therapy should be considered a short- and long-term therapeutic asset, along with diet and topical steroids.
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Affiliation(s)
- Javier Molina-Infante
- a Department of Gastroenterology , Hospital San Pedro de Alcantara , Caceres , Spain
| | - Raul Prados-Manzano
- a Department of Gastroenterology , Hospital San Pedro de Alcantara , Caceres , Spain
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