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Laserna-Mendieta EJ, Navarro P, Casabona-Francés S, Savarino EV, Pérez-Martínez I, Guagnozzi D, Barrio J, Perello A, Guardiola-Arévalo A, Betoré-Glaria ME, Blas-Jhon L, Racca F, Krarup AL, Gutiérrez-Junquera C, Fernández-Fernández S, la Riva SD, Naves JE, Carrión S, García-Morales N, Roales V, Rodríguez-Oballe JA, Dainese R, Rodríguez-Sánchez A, Masiques-Mas ML, Feo-Ortega S, Ghisa M, Maniero D, Suarez A, Llerena-Castro R, Gil-Simón P, de la Peña-Negro L, Granja-Navacerrada A, Alcedo J, Hurtado de Mendoza-Guena L, Pellegatta G, Pérez-Fernández MT, Santander C, Tamarit-Sebastián S, Arias Á, Lucendo AJ. Differences between childhood- and adulthood-onset eosinophilic esophagitis: An analysis from the EoE connect registry. Dig Liver Dis 2023; 55:350-359. [PMID: 36280437 DOI: 10.1016/j.dld.2022.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 09/19/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Direct comparisons of childhood- and adulthood-onset eosinophilic esophagitis (EoE) are scarce. AIM To compare disease characteristics, endoscopic and histological features, allergic concomitances and therapeutic choices across ages. METHODS Cross-sectional analysis of the EoE CONNECT registry. RESULTS The adulthood-onset cohort (those diagnosed at ≥18y) comprised 1044 patients and the childhood-onset cohort (patients diagnosed at <18 y), 254. Vomiting, nausea, chest and abdominal pain, weight loss, slow eating and food aversion were significantly more frequent in children; dysphagia, food bolus impaction and heartburn predominated in adults. A family history of EoE was present in 16% of pediatric and 8.2% of adult patients (p<0.001). Concomitant atopic diseases did not vary across ages. Median±IQR diagnostic delay (years) from symptom onset was higher in adults (2.7 ± 6.1) than in children (1 ± 2.1; p<0.001). Esophageal strictures and rings predominated in adults (p<0.001), who underwent esophageal dilation more commonly (p = 0.011). Inflammatory EoE phenotypes were more common in children (p = 0.001), who also presented higher eosinophil counts in biopsies (p = 0.015) and EREFS scores (p = 0.017). Despite PPI predominating as initial therapy in all cohorts, dietary therapy and swallowed topical corticosteroids were more frequently prescribed in children (p<0.001). CONCLUSIONS Childhood-onset EoE has differential characteristics compared with adulthood-onset, but similar response to treatment.
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Affiliation(s)
- Emilio José Laserna-Mendieta
- Department of Gastroenterology. Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Pilar Navarro
- Department of Gastroenterology. Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Sergio Casabona-Francés
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Department of Gastroenterology. Hospital Universitario de La Princesa, Madrid, Spain
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera Università di Padova, Padova, Italy
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain; Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology. Hospital Universitario Vall d'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Jesús Barrio
- Servicio de Gastroenterología. Hospital Universitario Río Hortega. Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | - Antonia Perello
- Department of Gastroenterology. Hospital de Viladecans, Viladecans, Spain; Facultad de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Antonio Guardiola-Arévalo
- Department of Gastroenterology. Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain; Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPaz), Madrid, Spain
| | | | - Leonardo Blas-Jhon
- Department of Gastroenterology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Francesca Racca
- Personalized Medicine Asthma and Allergy Clinic. Humanitas Clinical and Research Center (IRCCSS), Rozzano, Italy
| | - Anne Lund Krarup
- Department of Medicine and Department of Clinical Medicine. The North Danish Regional Hospital, Hjoerring and Aalborg University, Aalborg, Denmark
| | - Carolina Gutiérrez-Junquera
- Department of Pediatric Gastroenterology. Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Susana De la Riva
- Department of Gastroenterology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan E Naves
- Department of Gastroenterology, Parc de Salut Mar, Barcelona, Spain
| | - Silvia Carrión
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Department of Gastroenterology, Hospital de Mataró, Mataró, Spain
| | | | - Valentín Roales
- Department of Gastroenterology, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology. Hospital Universitario Arnau de Vilanova & Hospital Universitario Santa María, Lérida, Spain
| | - Raffaella Dainese
- Department of Allergy. Centre Hospitalier d'Antibes Juan-les-Pins, Antibes, France
| | | | | | - Sara Feo-Ortega
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain; Pediatric Gastroenterology Unit. Hospital General de Tomelloso, Tomelloso, Spain
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera Università di Padova, Padova, Italy
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera Università di Padova, Padova, Italy
| | - Adolfo Suarez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain; Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ronald Llerena-Castro
- Department of Gastroenterology. Hospital Universitario Vall d'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Paula Gil-Simón
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Servicio de Gastroenterología. Hospital Universitario Río Hortega. Gerencia Regional de Salud de Castilla y León (SACYL), Valladolid, Spain
| | | | | | - Javier Alcedo
- Department of Gastroenterology. Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Gaia Pellegatta
- Endoscopy Unit. Humanitas Clinical and Research Center (IRCCSS), Rozzano, Italy
| | - María Teresa Pérez-Fernández
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Department of Gastroenterology. Hospital Universitario de La Princesa, Madrid, Spain
| | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Department of Gastroenterology. Hospital Universitario de La Princesa, Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Sonsoles Tamarit-Sebastián
- Department of Gastroenterology. Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Research Unit. Hospital General Mancha-Centro, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology. Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.
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Navarro P, Laserna-Mendieta EJ, Casabona S, Savarino E, Pérez-Fernández MT, Ghisa M, Pérez-Martínez I, Guagnozzi D, Perelló A, Guardiola-Arévalo A, Racca F, Betoré E, Blas-Jhon L, Krarup AL, Martín-Domínguez V, Maniero D, Suárez A, Llerena-Castro R, de la Peña-Negro L, Navacerrada AG, Pellegatta G, Alcedo J, de Hurtado Mendoza-Guena L, Feo-Ortega S, Barrio J, Gutiérrez-Junquera C, Fernández-Fernández S, De la Riva S, E Navés J, Carrión S, Ciriza de Los Ríos C, García-Morales N, Rodríguez-Oballe JA, Dainese R, Rodríguez-Sánchez A, Masiques-Mas ML, Palomeque MT, Santander C, Tamarit-Sebastián S, Arias Á, Lucendo AJ. Accurate and timely diagnosis of Eosinophilic Esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry. United European Gastroenterol J 2022; 10:507-517. [PMID: 35578565 PMCID: PMC9189464 DOI: 10.1002/ueg2.12240] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/24/2022] [Indexed: 12/29/2022] Open
Abstract
Background Poor adherence to clinical practice guidelines for eosinophilic esophagitis (EoE) has been described and the diagnostic delay of the disease continues to be unacceptable in many settings. Objective To analyze the impact of improved knowledge provided by the successive international clinical practice guidelines on reducing diagnostic delay and improving the diagnostic process for European patients with EoE. Methods Cross‐sectional analysis of the EoE CONNECT registry based on clinical practice. Time periods defined by the publication dates of four major sets of guidelines over 10 years were considered. Patients were grouped per time period according to date of symptom onset. Results Data from 1,132 patients was analyzed and median (IQR) diagnostic delay in the whole series was 2.1 (0.7‐6.2) years. This gradually decreased over time with subsequent release of new guidelines (p < 0.001), from 12.7 years up to 2007 to 0.7 years after 2017. The proportion of patients with stricturing of mixed phenotypes at the point of EoE diagnosis also decreased over time (41.3% vs. 16%; p < 0.001), as did EREFS scores. The fibrotic sub‐score decreased from a median (IQR) of 2 (1‐2) to 0 (0‐1) when patients whose symptoms started up to 2007 and after 2017 were compared (p < 0.001). In parallel, symptoms measured with the Dysphagia Symptoms Score reduced significantly when patients with symptoms starting before 2007 and after 2012 were compared. A reduction in the number of endoscopies patients underwent before the one that achieved an EoE diagnosis, and the use of allergy testing as part of the diagnostic workout of EoE, also reduced significantly over time (p = 0.010 and p < 0.001, respectively). Conclusion The diagnostic work‐up of EoE patients improved substantially over time at the European sites contributing to EoE CONNECT, with a dramatic reduction in diagnostic delay.
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Affiliation(s)
- Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain
| | - Sergio Casabona
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - María Teresa Pérez-Fernández
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Viladecans, Viladecans, Spain
| | | | - Francesca Racca
- Personalized Medicine, Asthma and Allergy. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Elena Betoré
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Leonardo Blas-Jhon
- Department of Gastroenterology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Anne Lund Krarup
- Department of Medicine and Department of Clinical Medicine. The North Danish Regional Hospital, Hjoerring and Aalborg University, Aalborg, Denmark
| | - Verónica Martín-Domínguez
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Adolfo Suárez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ronald Llerena-Castro
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Gaia Pellegatta
- Endoscopy Unit. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Javier Alcedo
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Sara Feo-Ortega
- Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Pediatric Gastroenterology Unit. Hospital General de Tomelloso, Tomelloso, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carolina Gutiérrez-Junquera
- Department of Pediatric Gastroenterology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Susana De la Riva
- Department of Gastroenterology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan E Navés
- Department of Gastroenterology, Parc de Salut Mar, Barcelona, Spain
| | - Silvia Carrión
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Department of Gastroenterology, Hospital de Mataró, Mataró, Spain
| | - Constanza Ciriza de Los Ríos
- Department of Gastroenterology. Hospital Clínico Universitario San Carlos, Instituto de Investigacion Sanitaria San Carlos (IdISSC), Madrid, Spain.,Universidad Complutense, Madrid, Spain
| | | | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology, Hospital Universitario Arnau de Vilanova & Hospital Universitario Santa María, Lérida, Spain
| | - Raffaela Dainese
- Department of Gastroenterology, Centre Hospitalier d'Antibes Juan-les-Pins, Antibes, France
| | | | | | | | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Sonsoles Tamarit-Sebastián
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Research Unit. Hospital General Mancha-Centro, Alcázar de San Juan, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
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Kim SJ, Park MI, Kim GH, Lee MW, Jung K, Lee J, Seol SY, Jee SR, Lee HS, Jang JS, Cha JH. Practice Patterns for Eosinophilic Esophagitis Patients in Busan and Gyeongnam: A Korean Multicenter Database Study. J Neurogastroenterol Motil 2021; 27:71-77. [PMID: 32699187 PMCID: PMC7786091 DOI: 10.5056/jnm20069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 12/21/2022] Open
Abstract
Background/Aims The prevalence of eosinophilic esophagitis is increasing in Korea and there are few single-center studies regarding eosinophilic esophagitis in Korea. In particular, data about management for eosinophilic esophagitis are lacking. We aim to evaluate the practice patterns, including initial treatment and response, in the Busan city and Gyeongnam province area. Methods We retrospectively reviewed medical records to gain data on patient characteristics, medication, endoscopic images, and esophageal biopsy results. From January 2009 to December 2019, a total of 42 patients were diagnosed with eosinophilic esophagitis. Results The mean age was 50.7 (from 22 to 81) years and the cohort was predominantly male (78.6%, 33/42). The proton pump inhibitor was the preferred treatment as an initial trial for 64.3% (27/42) of patients, followed by swallowed topical steroids (16.7%, 7/42). Clinical improvement after proton pump inhibitor therapy was achieved in 88.9% (24/27) of patients. Two patients who did not achieve improvement showed a clinical and endoscopic response after swallowed topical steroids treatment. No patient received diet elimination or balloon dilatation therapy. Conclusions The treatment response of eosinophilic esophagitis was good in Busan city and Gyeongnam province area in Korea. Proton pump inhibitor therapy was the preferred and most effective treatment for eosinophilic esophagitis as the initial therapy.
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Affiliation(s)
- Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam-do, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moon Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jin Lee
- Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Korea
| | - Sang Young Seol
- Department of Internal Medicine, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Sam Ryong Jee
- Department of Internal Medicine, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Hong Sub Lee
- Department of Internal Medicine, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Jin Seok Jang
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Jae Hwang Cha
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
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Laserna-Mendieta EJ, Casabona S, Savarino E, Perelló A, Pérez-Martínez I, Guagnozzi D, Barrio J, Guardiola A, Asensio T, de la Riva S, Ruiz-Ponce M, Rodríguez-Oballe JA, Santander C, Arias Á, Lucendo AJ. Efficacy of Therapy for Eosinophilic Esophagitis in Real-World Practice. Clin Gastroenterol Hepatol 2020; 18:2903-2911.e4. [PMID: 31988045 DOI: 10.1016/j.cgh.2020.01.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/07/2020] [Accepted: 01/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Topical steroids, proton pump inhibitors (PPIs), and dietary interventions are recommended first- and second-line therapies for eosinophilic esophagitis (EoE). We investigated differences in their effectiveness in a real-world, clinical practice cohort of patients with EoE. METHODS We collected data on the efficacy of different therapies for EoE (ability to induce clinical and histologic remission) from the multicenter EoE CONNECT database-a database of patients with a confirmed diagnosis of EoE in Europe that began in 2016. We obtained data from 589 patients, treated at 11 centers, on sex, age, time of diagnosis, starting date of any therapy, response to therapy, treatment end dates, alternative treatments, and findings from endoscopy. The baseline endoscopy was used for diagnosis of EoE; second endoscopy was performed to evaluate response to first-line therapies. After changes in treatment, generally because lack of efficacy, a last endoscopy was performed. The time elapsed between endoscopies depended on the criteria of attending physicians. Clinical remission was defined by a decrease of more than 50% in Dysphagia Symptom Score; improvement in symptoms by less than 50% from baseline was considered as clinical response. Histologic remission was defined as a peak eosinophil count below 5 eosinophils/hpf. A peak eosinophil count between 5 and 14 eosinophils/hpf was considered histologic response. We identified factors associated with therapy selection and effectiveness using χ2 and multinomial logistic regression analyses RESULTS: PPIs were the first-line treatment for 76.4% of patients, followed by topical steroids (for 10.5%) and elimination diets (for 7.8%). Topical steroids were most effective in inducing clinical and histologic remission or response (in 67.7% of patients), followed by empiric elimination diets (in 52.0%), and PPIs (in 50.2%). Among the 344 patients who switched to a second-line therapy, dietary interventions were selected for 47.1% of patients, followed by PPIs (for 29.1%) and topical steroids (for 18.6%). Clinical and histologic remission or response was achieved by 80.7% of patients treated with topical steroids, 69.2% of patients given PPIs, and 41.7% of patients on empiric elimination diets. Multivariate analyses found the stricturing phenotype of EoE to be associated with selection of topical steroids over PPIs as the first-line therapy; lack of fibrotic features at initial endoscopy was associated with selection of elimination diets over topical steroids as a second-line therapy. The recruiting center was significantly associated with therapy choice; second-line treatment with topical steroids or PPIs were the only variables associated with clinical and histologic remission. CONCLUSIONS In an analysis of data from a large cohort of patients with EoE in Europe, we found topical steroids to be the most effective at inducing clinical and histologic remission, but PPIs to be the most frequently prescribed. Treatment approaches vary with institution and presence of fibrosis or strictures.
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Affiliation(s)
- Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain.
| | - Sergio Casabona
- Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Università di Padova, Padova, Italy
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Villadecans, Barcelona, Spain
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Antonio Guardiola
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain; Instituto de Investigación Sanitaria La Paz, Madrid, Spain
| | - Teresa Asensio
- Department of Allergy, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Miriam Ruiz-Ponce
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology, University Hospital Santa María - University Hospital Arnau de Vilanova, Lerida, Spain
| | - Cecilio Santander
- Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.
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Arias Á, Lucendo AJ. Epidemiology and risk factors for eosinophilic esophagitis: lessons for clinicians. Expert Rev Gastroenterol Hepatol 2020; 14:1069-1082. [PMID: 32749898 DOI: 10.1080/17474124.2020.1806054] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The rapid expansion in the epidemiology of eosinophilic esophagitis (EoE) is being documented, along with cumulative research assessing environmental exposures associated with EoE and susceptibility due to genetic variants. AREAS COVERED Incidence rates for EoE of 5-10 new cases per 100,000 inhabitants annually have shown an increase in recent reports of up to 20 in some countries; the highest prevalence being reported for Europe and North America, where EoE now affects more than 1 out of 1,000 people. EoE has been shown to be associated with several disorders, Th2-mediated atopies being the most common. Patients with EoE exhibit increased frequency of asthma, allergic rhinitis and eczema, and EoE has been considered as a late component of the atopic march. Risk variants in TSLP, CAPN14 and LRCC32 genes, among others, have all been related to EoE, and interact with prenatal and early life exposure potentially modifying abundance and composition of gut microbiome. Dysregulated interactions between bacteria and mucosal immunity emerge as leading causes of EoE. EXPERT OPINION The expanding epidemiology of EoE, the resources needed and subsequent increasing healthcare costs require additional effort to optimize cost-effective management and unveil mechanisms that enhance the development of future preventive strategies.
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Affiliation(s)
- Ángel Arias
- Research Unit, Hospital General Mancha Centro , Alcázar De San Juan, Spain.,Centro De Investigación Biomédica En Red De Enfermedades Hepáticas Y Digestivas (Ciberehd) , Madrid, Spain.,Instituto De Investigación Sanitaria La Princesa , Madrid, Spain
| | - Alfredo J Lucendo
- Centro De Investigación Biomédica En Red De Enfermedades Hepáticas Y Digestivas (Ciberehd) , Madrid, Spain.,Instituto De Investigación Sanitaria La Princesa , Madrid, Spain.,Department of Gastroenterology, Hospital General De Tomelloso , Ciudad Real, Spain
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Differences in Management of Eosinophilic Esophagitis in Europe: An Assessment of Current Practice. J Pediatr Gastroenterol Nutr 2020; 71:83-90. [PMID: 32097371 DOI: 10.1097/mpg.0000000000002672] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of the study was to assess differences in the diagnosis and management of eosinophilic esophagitis (EoE) by European pediatric (PG) and adult gastroenterologists (AG), and their self-reported adherence to guidelines. METHODS A multiple-choice questionnaire gauged the diagnostic and management strategies of gastroenterologists treating children or adults in 14 European countries and the United Arab Emirates (UAE). RESULTS Questionnaires were completed by 465 PG and 743 AG. PG were significantly more likely to take biopsies in patients with symptoms of esophageal dysfunction (86.2% PG vs 75.4% AG, P < 0.001) and to perform endoscopic follow-up (86.3% PG vs 80.6% AG, P < 0.001). After failure of proton-pump inhibitors (PPIs), topical steroids were the preferred second-line therapy; however, PG opted more frequently for elimination diets (47.5% PG vs 13.7% AG, P < 0.001). More PG than AG indicated having read recent guidelines (89.4% PG vs 58.2% AG, P < 0.001). Geographic differences in practice were reported, with respondents from the United Kingdom, Portugal, and Spain more often adhering to recommended biopsy protocols. Physicians in the UAE, France, Lithuania, and Poland tended to opt for steroid therapy or elimination diets as first-line therapy, in contrast to most other countries. CONCLUSIONS Significant differences in general practice between PG and AG were demonstrated with notable divergence from consensus guidelines. International practice variations are also apparent. Among other strategies, educational activities to highlight current recommendations may help harmonize and optimize clinical practice.
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Abstract
BACKGROUND AND AIMS Despite rising incidence of eosinophilic esophagitis (EoE), data on the follow-up and treatment outcomes in pediatric patients are scarce. Therefore, the aim of this study was to present data on the treatment outcomes in children diagnosed with EoE who were treated in a tertiary medical center. PATIENTS AND METHODS A retrospective study involving patients younger than 18 years who were diagnosed with EoE in our center between January 2011 and June 2017. RESULTS Thirty-two patients met inclusion criteria and were followed up for a mean of 3 years (range 0.5-6.8). Six months after the diagnosis, 28 (87.5%) children were still followed up; 21 (75%) were in clinical remission, including 10 (36%) who were in histological remission. After 12 months, 27 patients were still followed up; 21 (78%) achieved clinical remission, including 10 (37%) with histological remission. During follow-up, three patients developed gastroesophageal reflux disease (GERD). There was no difference in body mass index (BMI) Z score between baseline and 12 months follow-up (median - 0.3 vs - 0.3 SD, p = 0.862). CONCLUSIONS Absence of symptoms does not indicate mucosal healing; therefore, patients should be followed up endoscopically. Additionally, despite restricted diet, nutritional status remains unaffected. Finally, patients with EoE can develop significant GERD even years after the EoE diagnosis.
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Arias Á, Lucendo AJ. Molecular basis and cellular mechanisms of eosinophilic esophagitis for the clinical practice. Expert Rev Gastroenterol Hepatol 2019; 13:99-117. [PMID: 30791784 DOI: 10.1080/17474124.2019.1546120] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, allergen-driven inflammatory esophageal disease characterized by predominantly eosinophilic inflammation leading to esophageal dysfunction. Recent efforts to understand EoE have increased our knowledge of the disease. Areas covered: Multiple cells, molecules, and genes interplay with early life environmental factors in the pathophysiology of EoE to converge in the esophageal epithelium at the center of disease pathogenesis. Epithelial cells constitute a mayor cytokine source for TSLP and Calpain-14; an impaired epithelial barrier function allowing penetration of food and microbiota-derived antigens is involved in triggering and maintaining inflammation. Eosinophil and mast cell-derived products, including TGFβ, together with IL-1β and TNFα, promote epithelial mesenchymal transition in EoE, contributing to tissue remodeling by synthetizing and depositing extracellular matrix in subepithelial layers. This article aims to provide a state-of-the-art update on the pathophysiology of EoE applied to clinical practice, and latest research and developments with potential interest to improve the diagnosis and treatment of patients with EoE are revised. Expert commentary: Preliminary approaches have provided promising results toward incorporating minimally invasive methods for patient diagnosis and monitoring in clinical practice. Early diagnosis and optimized therapies will allow for personalized medicine in EoE.
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Affiliation(s)
- Ángel Arias
- a Research Unit , Hospital General La Mancha Centro , Alcázar de San Juan , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
| | - Alfredo J Lucendo
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,c Department of Gastroenterology , Hospital General de Tomelloso , Ciudad Real , Spain
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Arias Á, Lucendo AJ. Incidence and prevalence of eosinophilic oesophagitis increase continiously in adults and children in Central Spain: A 12-year population-based study. Dig Liver Dis 2019; 51:55-62. [PMID: 30115573 DOI: 10.1016/j.dld.2018.07.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To update population-based incidence, prevalence and trends for eosinophilic oesophagitis (EoE) in children and adults over the past decade. METHODS All patients referred to our EoE unit and living in the study area up to December 2017 were prospectively registered. Endoscopy and pathology databases and clinical charts were manually reviewed. Diagnosis of EoE was confirmed upon symptoms of oesophageal dysfunction and eosinophilia >15 eos/HPF. Annual incidence rates and prevalence were estimated with confidence intervals (CI) of 95%. RESULTS A total of 117 patients, including 19 children, were diagnosed with EoE in the 2006-2017 period. In 2017, the prevalence of EoE in children was 111.9 (95%CI, 67.4-174.6) cases/100,000 inhabitants and in adults 111.9 (95%CI, 90.8-136.5) also, and in both cases was significantly higher for male patients. The highest prevalences were observed in ages ranging between 20 and 24 and 35-39 years old. Mean incidence rates of the study period were 10.6 and 9.1 new cases/100,000 inhabitants/year in children and adults, respectively. Rise in the appearance of EoE during the study period exceeded that for endoscopic procedures. No seasonal variation was observed in the diagnosis of EoE. CONCLUSION The incidence and prevalence of EoE has increased sharply in central Spain, beyond previous estimations, with one out of every 893 inhabitants now being diagnosed.
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Affiliation(s)
- Ángel Arias
- Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Spain; Biomedical Research Network Center for Liver and Digestive Diseases (CIBEREHD), Madrid, Spain
| | - Alfredo J Lucendo
- Biomedical Research Network Center for Liver and Digestive Diseases (CIBEREHD), Madrid, Spain; Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.
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Huang KZ, Jensen ET, Chen HX, Landes LE, McConnell KA, Almond MA, Johnston DT, Durban R, Jobe L, Frost C, Donnelly S, Antonio B, Safta AM, Quiros JA, Markowitz JE, Dellon ES. Practice Pattern Variation in Pediatric Eosinophilic Esophagitis in the Carolinas EoE Collaborative: A Research Model in Community and Academic Practices. South Med J 2018; 111:328-332. [PMID: 29863219 DOI: 10.14423/smj.0000000000000817] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Differences in the initial management of pediatric eosinophilic esophagitis (EoE) by practice setting have not been well characterized. We aimed to characterize these differences for sites in the Carolinas EoE Collaborative (CEoEC), a multicenter network of academic and community practices. METHODS We performed a retrospective cohort study of pediatric EoE patients at five CEoEC sites: University of North Carolina (UNC) Hospital, Charlotte Asthma and Allergy Specialists, Greenville Health Systems, Wake Forest Baptist Medical Center, and the Medical University of South Carolina Hospital. Cases of EoE were defined by consensus guidelines. Data were extracted from electronic medical records. We tested for differences among sites and used a multinomial model (polytomous regression) to assess associations between treatment and site, adjusting on patient factors. RESULTS We identified 464 children with EoE across the CEoEC sites. The median age was highest at Wake Forest (11.4 years), the median eosinophil count was highest at UNC (69 eos/hpf), and UNC had the most male patients (82%). UNC used topical steroids for initial treatment in 86% of cases, compared with <1% in Greenville (P < 0.01). Greenville used dietary elimination more frequently than UNC (81% vs 2%, P < 0.01). Differences in treatment approach held after adjusting for potential baseline confounders. There was no significant association between patient factors and initial treatment approach. CONCLUSIONS Significant differences in EoE patient factors and treatment approaches were identified across CEoEC sites and were not explained by patient or practice factors. This suggests that institutional or provider preferences drive initial treatment approaches, and that more data are needed to drive best practice decisions.
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Affiliation(s)
- Kevin Z Huang
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Elizabeth T Jensen
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Hannah X Chen
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Lisa E Landes
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Kristen A McConnell
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - M Angie Almond
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Douglas T Johnston
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Raquel Durban
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Laura Jobe
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Carrie Frost
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Sarah Donnelly
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Brady Antonio
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Anca M Safta
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - J Antonio Quiros
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Jonathan E Markowitz
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Evan S Dellon
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
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Gomez Torrijos E, Gonzalez-Mendiola R, Alvarado M, Avila R, Prieto-Garcia A, Valbuena T, Borja J, Infante S, Lopez MP, Marchan E, Prieto P, Moro M, Rosado A, Saiz V, Somoza ML, Uriel O, Vazquez A, Mur P, Poza-Guedes P, Bartra J. Eosinophilic Esophagitis: Review and Update. Front Med (Lausanne) 2018; 5:247. [PMID: 30364207 PMCID: PMC6192373 DOI: 10.3389/fmed.2018.00247] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/15/2018] [Indexed: 12/13/2022] Open
Abstract
Background: Eosinophilic esophagitis (EoE) was first described in the 1990s, showing an increasing incidence and prevalence since then, being the leading cause of food impaction and the major cause of dysphagia. Probably, in a few years, EoE may no longer be considered a rare disease. Methods: This article discusses new aspects of the pathogenesis, symptoms, diagnosis, and treatment of EoE according to the last published guidelines. Results: The epidemiological studies indicate a multifactorial origin for EoE, where environmental and genetic factors take part. EoE affects both children and adults and it is frequently associated with atopic disease and IgE-mediated food allergies. In patients undergoing oral immunotherapy for desensitization from IgE-mediated food allergy the risk of developing EoE is 2.72%. Barrier dysfunction and T-helper 2 inflammation is considered to be pathogenetically important factors. There are different patterns of clinical presentation varying with age and can be masked by adaptation habits. Besides, symptoms do not usually correlate with histologic disease activity. The diagnostic criteria for EoE has evolved but mainly requires symptoms of esophageal dysfunction with histologic evidence of a peak value of at least 15 eosinophils per high-power field. Endoscopies have to be repeated in order to diagnose, monitor, and treat EoE. Treatment of EoE can be started either by drugs (PPIs and topical corticosteroids) or elimination diets. The multistage step-up elimination diet management approach of EoE is promising. Endoscopic dilation is used for patients with severe dysphagia/food impaction with inadequate response to anti-inflammatory treatment. Conclusions: Research in recent years has contributed to a better understanding of EoE's pathogenesis, genetic background, natural history, allergy workup, standardization in assessment of disease activity, evaluation of minimally invasive diagnostic tools, and new therapeutic approaches. However, several unmet needs are to be solved urgently, as finding a non-invasive disease-monitoring methods and biomarkers for routine practice, the development or new therapies, novel food allergy testing to detect triggering foods, drug, and doses required for initial therapy and safety issues with long-term maintenance therapy, amongst others. Besides, multidisciplinary management units of EoE, involving gastroenterologists, pediatricians, allergists, pathologists, dietitians, and ENT specialists are needed.
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Affiliation(s)
| | | | | | - Robledo Avila
- Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | - Jesus Borja
- Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | | | - M. Pilar Lopez
- Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | | | - Mar Moro
- Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - Ana Rosado
- Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - Vanessa Saiz
- Hospital UniversitarioReina Sofía de Córdoba, Cordoba, Spain
| | | | - Olga Uriel
- Hospital Universitario de Araba, Vitoria-Gasteiz, Spain
| | - Angelina Vazquez
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Pilar Mur
- Hospital Santa Barbara, Puertollano, Spain
| | - Paloma Poza-Guedes
- Allergy Section, Hospital Universitario de La Laguna, San Cristóbal de La Laguna, Spain
| | - Joan Bartra
- Allergy Section, Pneumology Department, Hospital Clínic Universitat de Barcelona, Barcelona, Spain
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Harris BR, Hon E, Gupta SK. Implementation of guidelines in eosinophilic esophagitis at an academic pediatric practice. Dis Esophagus 2018; 31:4994955. [PMID: 29757350 DOI: 10.1093/dote/doy029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Guidelines for eosinophilic esophagitis (EoE) require high-dose PPI (HD-PPI) trial to evaluate for PPI-responsive esophageal eosinophilia (PPI-REE) prior to EoE diagnosis and dedicated therapy. This involves a second esophagogastroduodenoscopy (EGD) to assess for PPI-REE. This study is to evaluate adherence to current guidelines in evaluation of PPI-REE and EoE. Retrospective review of new patients treated with HD-PPI after an index EGD showing >15 eos/hpf in esophageal biopsies. One hundred and eighty patients had an index EGD with esophageal eosinophilia of >15 eos/hpf. Of these, 97/180 (53.8%) received HD-PPI; remaining 83/180 were prescribed other interventions without a HD-PPI trial. Of the 180 patients, 143 (79.4%) patients returned for follow-up and of whom 96/143 (67.1%) underwent repeat EGD. Adherence to guidelines improves with time. Patients are vested in care.
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Affiliation(s)
- Brendan R Harris
- Department of Pediatrics and Division of Gastroenterology at Washington University in St. Louis School of Medicine
| | - Emily Hon
- Department of Pediatrics and Division of Gastroenterology at Indiana University School of Medicine
| | - Sandeep K Gupta
- Department of Pediatrics and Division of Gastroenterology at University of Illinois School of Medicine
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Abstract
PURPOSE OF REVIEW For patients with eosinophilic esophagitis (EoE), endoscopic dilation has been used primarily to provide immediate symptomatic relief of dysphagia. This report reviews the current position of esophageal dilation in the therapeutic algorithm for EoE, including effectiveness and safety issues. RECENT FINDINGS Esophageal strictures in EoE develop as a consequence of long-lasting esophageal eosinophilia, with patient age and diagnostic delay as well established risk factors. Endoscopic dilation leads to immediate symptomatic improvement in 95% of EoE patients who have strictures or narrow caliber esophagus. As dilation has no effect on the underlying eosinophil inflammation, repeated procedures are usually needed to maintain symptoms in remission. Adding an effective drug or dietary-based EoE therapy reduces the need of further dilation. The high rate of severe complications from dilation reported in early literature has not been reproduced in most recent series, with mild postprocedural chest pain as the most common side effect. Current data suggest that the risk of esophageal perforation is less than 1%. Mucosal tears after dilation should no longer be considered a complication, but rather a marker of procedural success. SUMMARY Esophageal dilation should be considered in EoE patients with esophageal strictures or narrow caliber esophagus who have persistent dysphagia/food impaction despite an effective anti-inflammatory treatment.
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Practice Differences in the Diagnosis and Management of Eosinophilic Esophagitis Among Adult and Pediatric Gastroenterologists in Israel. J Pediatr Gastroenterol Nutr 2018; 67:34-39. [PMID: 29394215 DOI: 10.1097/mpg.0000000000001909] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Eosinophilic esophagitis (EoE) guidelines call for similar practices in adults and children with EoE. We compared the diagnostic and management practices of gastroenterologists treating adult and pediatric patients suspected of having, or diagnosed with, EoE. METHODS A 19-question multiple-choice questionnaire was given to gastroenterologists treating either adults or children. Questions explored 4 areas of interest: physician demographics, diagnosis and tissue sampling practices, management, and the need for societal publications on EoE. RESULTS Completed questionnaires were returned by 85/180 adult and 30/40 pediatric gastroenterologists (PGs). Compared to PGs, adult gastroenterologists (AGs) took esophageal biopsies significantly less frequently in the following scenarios: endoscopy without esophageal symptoms or macroscopic endoscopic findings (10% vs 57%; P < 0.001), dysphagia without macroscopic findings (83% vs 100%; P = 0.019), and gastroesophageal reflux symptoms with distal esophageal erythema (44% vs 100%; P < 0.001). Significantly fewer AGs reported taking gastric and duodenal biopsies when EoE was suspected (29% vs 90%; P < 0.001). AGs more often followed patients clinically (30% vs 0%; P < 0.001) rather than endoscopically, and were far less inclined to implement elimination diets compared to PGs (23% vs 68%; P < 0.001). CONCLUSIONS Significant disparities exist between gastroenterologists treating adult and pediatric patients with EoE. These findings may impact rates of diagnosis, appropriate treatment, monitoring, long-term outcomes, and may affect negatively transition from pediatric to adult care.
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Eosinophilic esophagitis: an underdiagnosed cause of dysphagia and food impaction to be recognized by otolaryngologists. HNO 2018; 66:534-542. [DOI: 10.1007/s00106-018-0516-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Lucendo AJ, Arias Á, Molina-Infante J, Arias-González L. The role of endoscopy in eosinophilic esophagitis: from diagnosis to therapy. Expert Rev Gastroenterol Hepatol 2017; 11:1135-1149. [PMID: 28803528 DOI: 10.1080/17474124.2017.1367664] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Eosinophilic esophagitis (EoE) has arisen as a common disorder in current clinical and endoscopic gastroenterology practice. Areas covered: A comprehensive review of the literature to summarize and update different aspects related with the use of endoscopy in the diagnostic workout and treatment of pediatric and adult EoE patients is conducted. Expert commentary: Endoscopic features in EoE are frequently subtle, so were inadverted in some initial reports of the disease. Literature has described a wide number of EoE-associated features, systematized in the EREFS classification, which standardized the grade and severity of exudates, rings, edema, furrows, and strictures. The insufficient reliability of these features to predict eosinophilic inflammation still makes biopsies essential in diagnosing or monitoring EoE. EoE causes half of the food impactions requiring endoscopy; food impaction leads to EoE diagnosis in up to half of cases. Long term consequences of EoE include esophageal remodeling leading to strictures and narrowing, thus impairing symptoms and needs dilation. Recognizing the risks from dilation in EoE required carrying out a safe technique to avoid the high complication rate reported in the early literature. Endoscopic dilation should be considered in patients with esophageal narrowing and dysphagia/food impaction unresponsive to diet or drugs-based anti-inflammatory treatment.
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Affiliation(s)
- Alfredo J Lucendo
- a Department of Gastroenterology , Hospital General de Tomelloso , Tomelloso , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
| | - Ángel Arias
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,c Research Support Unit , Hospital General Mancha Centro , Alcázar de San Juan , Spain
| | - Javier Molina-Infante
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,d Department of Gastroenterology , Hospital San Pedro de Alcántara , Cáceres , Spain
| | - Laura Arias-González
- a Department of Gastroenterology , Hospital General de Tomelloso , Tomelloso , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
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Lucendo AJ, Arias-González L, Molina-Infante J, Arias Á. Determinant factors of quality of life in adult patients with eosinophilic esophagitis. United European Gastroenterol J 2017; 6:38-45. [PMID: 29435312 DOI: 10.1177/2050640617707095] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/03/2017] [Indexed: 12/23/2022] Open
Abstract
Background Eosinophilic esophagitis (EoE) affects health-related quality of life (HRQoL). Data on determinant factors and the influence of dietary interventions are scarce. Objective The objective of this article is to evaluate factors influencing HRQoL in adult EoE patients. Methods We conducted a multicenter observational, cross-sectional study. A validated Spanish version of the self-administered Adult Eosinophilic Esophagitis Quality of Life (EoE-QoL-A) questionnaire and specific surveys were used. Multiple linear regression was used to identify and quantify determinant factors of HRQoL. Results Responses provided by 170 patients were assessed (73.5% male; mean age 33.5 ± 11.4 years). Overall mean score for the EoE-QoL-A index was 1.4 ± 0.8, with no differences between patients on dietary or pharmacological therapy (1.82 ± 0.8 vs. 1.62 ± 0.8; p = 0.132). Disease anxiety showed the highest mean score (2.13 ± 0.9 points), followed by choking anxiety (1.97 ± 1.1); social impact (1.77 ± 1.1), and diet/eating impact (1.68 ± 0.9). Emotional impact had the lowest rating (1.15 ± 0.9), and only with a significantly worse score in patients under dietary restrictions. Recurrent food impaction, a higher educational level, dietary interventions and symptom duration were all independent determinant factors significantly impairing HRQoL. Female gender and empiric elimination diets negatively influenced on diet/eating impact. Conclusion Recurrent food impaction, dietary interventions and symptom duration are the most important factors influencing the perception of HRQoL in adults with 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), Madrid, Spain
| | - Laura Arias-González
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier Molina-Infante
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology, Hospital Universitario San Pedro de Alcántara, Cáceres, Spain
| | - Ángel Arias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Research Support Unit, Complejo Hospitalario La Mancha Centro, Alcázar de San Juan, Spain
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Lucendo AJ, Arias Á, Redondo-González O, Molina-Infante J. Quality assessment of clinical practice guidelines for eosinophilic esophagitis using the AGREE II instrument. Expert Rev Gastroenterol Hepatol 2017; 11:383-390. [PMID: 28117605 DOI: 10.1080/17474124.2017.1285696] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND High-quality evidence-based clinical practice guidelines can guide diagnosis and treatment to optimize outcomes. We aimed to systematically review the quality of international guidelines on eosinophilic esophagitis (EoE). METHODS MEDLINE and Scopus databases were searched for appropriate guidelines up to 2016. Two gastroenterologists and two methodologists independently evaluated the documents using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. RESULTS Amongst the 25 records initially retrieved, four guidelines developed by recognized scientific organizations met inclusion criteria. AGREE II results varied widely across domains, but none achieved an overall assessment score of over 60%. Scope and purpose (61.82 ± 19.24%), clarity of presentation (57.13 ± 40.56%) and editorial independence (93.75 ± 1.69%) showed the highest mean rating, whereas stakeholder involvement (28.82 ± 11.19%), rigor of development (32.29 ± 12.02%) and applicability (21.62 ± 7.14%) did not reach quality thresholds. Intraclass correlation coefficients for agreement was excellent among appraisers (0.903), between gastroenterologists and methodologists (0.878) and for each individual guideline (0.838 to 0.955). CONCLUSION Clinical practice guidelines for EoE vary significantly in quality, are invariably limited and currently, none can be 'strongly recommended'.
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Affiliation(s)
- Alfredo J Lucendo
- a Department of Gastroenterology , Hospital General de Tomelloso , Tomelloso , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
| | - Ángel Arias
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,c Research Support Unit , Hospital General La Mancha-Centro , Alcázar de San Juan , Spain
| | - Olga Redondo-González
- c Research Support Unit , Hospital General La Mancha-Centro , Alcázar de San Juan , Spain
| | - Javier Molina-Infante
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,d Department of Gastroenterology , Hospital San Pedro de Alcántara , Cáceres , Spain
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Role of Endoscopy in Diagnosis and Management of Pediatric Eosinophilic Esophagitis. Gastrointest Endosc Clin N Am 2016; 26:187-200. [PMID: 26616904 PMCID: PMC5000297 DOI: 10.1016/j.giec.2015.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergic (immune-mediated) disease that leads to esophageal dysfunction and feeding disorders in children. Foods, and possibly environmental triggers, cause an inflammatory response in the esophagus, leading to esophageal inflammation, eosinophilic infiltration, and esophageal dysmotility, which may progress to dysphagia, food impaction, and esophageal stricture. Endoscopy with biopsy and histologic evaluation is currently the only method to diagnose EoE. Once diagnosed with EoE, children undergo follow-up endoscopy after therapy initiation and adjustments to ensure remission. Furthermore, children with food impactions or strictures may require endoscopic intervention such as foreign body removal and/or esophageal dilation.
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Lucendo AJ, Arias Á, Redondo-González O, González-Cervera J. Seasonal distribution of initial diagnosis and clinical recrudescence of eosinophilic esophagitis: a systematic review and meta-analysis. Allergy 2015; 70:1640-50. [PMID: 26392117 DOI: 10.1111/all.12767] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND The association between seasonality and diagnosis and/or recrudescence of eosinophilic esophagitis (EoE) remains unclear, with some studies demonstrating a higher diagnostic rate in those months with a higher aeroallergen load while others rule out this association. METHODS We performed a systematic search of the MEDLINE, EMBASE, and SCOPUS databases for studies on the seasonality of the initial diagnosis or recrudescence (i.e., food bolus impaction) of EoE. Summary estimates, including 95% confidence intervals, were calculated for seasonal variation in diagnosis or incidence of food bolus impaction. A random-effects meta-regression model was made using aggregate-level data to compare seasonality in EoE diagnosis and recrudescence. Publication bias risks were assessed by means of funnel plot analysis. RESULTS Of 1078 references found, data were finally collected from 18 studies which included a total of 16,846 EoE patients. Of all new cases of EoE diagnosed per year, 27.1% were diagnosed in spring and 21.5% in winter. No overall statistical differences in the annual seasonal distribution of newly diagnosed EoE cases were observed in the random-effects meta-regression model (P = 0.132). Similarly, a homogenous distribution of episodes of EoE recrudescence throughout the year was noted, with no significant differences between seasons (P = 0.699). No significant publication bias was found. CONCLUSIONS This systematic review found no significant variations in the seasonal distribution of either the diagnosis or clinical recrudescence of EoE throughout the year.
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Affiliation(s)
- A. J. Lucendo
- Department of Gastroenterology; Hospital General de Tomelloso; Tomelloso Spain
| | - Á. Arias
- Research Unit; Complejo Hospitalario La Mancha Centro; Alcázar de San Juan Spain
| | - O. Redondo-González
- Research Unit; Complejo Hospitalario La Mancha Centro; Alcázar de San Juan Spain
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Eosinophilic oesophagitis: a systematic review for otolaryngologists. The Journal of Laryngology & Otology 2015; 129:1156-66. [PMID: 26467493 DOI: 10.1017/s0022215115002777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis is a chronic, immune/antigen-mediated oesophageal disease, only recently, but increasingly, recognised in the world literature. It is diagnosed and managed primarily by medical gastroenterologists and allergy specialists, and is a distinct disease entity, affecting both children and adults. Few studies have been published in otolaryngology journals, although otolaryngologists will encounter patients with undiagnosed eosinophilic oesophagitis. Patients may present with dysphagia, bolus obstruction or with other ENT disorders, such as atopic rhinitis, reflecting the underlying systemic allergic disorder. OBJECTIVE This paper systematically reviews the evidence base published on the epidemiology, clinical presentation, diagnosis, treatment and prognosis of eosinophilic oesophagitis, particularly as it relates to otolaryngology practice.
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Lucendo AJ. Cellular and molecular immunological mechanisms in eosinophilic esophagitis: an updated overview of their clinical implications. Expert Rev Gastroenterol Hepatol 2014; 8:669-85. [PMID: 24742298 DOI: 10.1586/17474124.2014.909727] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a pathophysiologically complex disorder driven by distinct, multiple mechanisms involving a large number of cells, molecules, and genes. Associated with food allergy from its initial descriptions, a key role for the Th2-type cytokines IL-5 and IL-13 in recruiting and activating eosinophils has been described. Epithelial cells have been recognized as major effectors in initiating EoE, both through their recruitment of iNKT cells towards the esophageal epithelium, which constitutes a major cytokine source, and through the release of eotaxin-3 and other chemoattractants. Epithelial and mesenchymal-released TSLP is a key regulator for which a connecting role between the adaptive and innate mucosal-associated immune response has been suggested. Finally, activated eosinophil- and mast cell-derived TGF β1 secretion is crucial in EoE-associated tissue remodeling.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
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Arias A, González-Cervera J, Tenias JM, Lucendo AJ. Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: a systematic review and meta-analysis. Gastroenterology 2014; 146:1639-48. [PMID: 24534634 DOI: 10.1053/j.gastro.2014.02.006] [Citation(s) in RCA: 356] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/24/2014] [Accepted: 02/12/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Various dietary interventions have been used to treat patients with eosinophilic esophagitis (EoE), yielding varied results. This systematic review assesses the efficacy of different dietary therapies in inducing disease remission. METHODS We performed a systematic search of the MEDLINE, EMBASE, and SCOPUS databases for studies investigating the efficacy of dietary interventions (reducing infiltration by immune cells <15 eosinophils/high-power field in esophageal biopsies) for pediatric and adult patients with EoE. Summary estimates, including 95% confidence intervals (CI), were calculated for exclusive feeding with amino acid-based elemental formulas, allergy test result-directed food elimination diets, and 6-food elimination diets (SFED). A fixed- or random-effects model was used depending on heterogeneity (I(2)); publication bias risks were assessed by means of funnel plot analysis. RESULTS The search yielded 581 references; of these, 33 were included in the quantitative summary. We analyzed data on a total of 1317 patients with EoE (1128 children and 189 adults) who received different dietary treatments. Elemental diets were effective for 90.8% of cases (95% CI, 84.7%-95.5%; I(2) = 52.3%), SFED for 72.1% (95% CI, 65.8%-78.1%; I(2) = 0), and allergy test result-directed food elimination for 45.5% of cases (95% CI, 35.4%-55.7%; I(2) = 75.1%). Additional strategies (elimination of cow's milk, gluten-free diets, and 4-food elimination diet) were also evaluated. Adults vs children had no significant differences in remission after dietary interventions (67.2% vs 63.3%). CONCLUSIONS Dietary interventions are effective in producing histologic remission in patients with EoE. Elemental diets and SFEDs were the most effective, achieving <15 eosinophils/high-power field in 90.8% and 72.1% of patients, respectively.
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Affiliation(s)
- Angel Arias
- Research Unit, Complejo Hospitalario La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | | | - José M Tenias
- Research Unit, Complejo Hospitalario La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain.
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Abstract
BACKGROUND/AIMS A growing body of research indicates that dietary therapy is an effective treatment option for children with eosinophilic esophagitis (EoE). Its ability to achieve sustained symptomatic and histological responses is comparable to that of topical steroids, but avoids their use and side effects. Recent studies also support dietary therapy as a preferred treatment option for adult patients. METHODS A comprehensive literature review was carried out to assess the efficacy of the most commonly used dietary interventions in inducing and maintaining disease remission in adult EoE patients as compared with results from pediatric studies. RESULTS The only available study assessing exclusive feeding with an elemental diet carried out in adults demonstrated a 94% disease remission rate, comparable to the high efficacy reported in pediatric studies. The major drawbacks of this therapy are poor adherence and a rapid disease recurrence after resumption of a normal diet. Although there is limited data on skin allergy testing-directed food elimination in adult patients, the highest efficacy rates observed do not exceed 26% histological remission. Prospective studies on empirical six-food elimination diets in adults provided efficacy rates comparable to those reported in children, achieving disease remission in approximately 75% of patients. However, specific food triggers can only be identified after documented recurrence of eosinophilic inflammation as determined with repeated endoscopic biopsies. Prolonged avoidance of the offending food(s) produces sustained remission of adult EoE. CONCLUSIONS Diet is a feasible therapeutic option for adult EoE patients, providing them with the same effective drug-free alternative as in pediatric patients.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
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Lucendo AJ, Molina-Infante J. Emerging therapeutic strategies for eosinophilic esophagitis. ACTA ACUST UNITED AC 2014; 12:1-17. [PMID: 24370990 DOI: 10.1007/s11938-013-0001-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Eosinophilic esophagitis (EoE) is recognized as an increasingly common cause of chronic and recurrent esophageal symptoms that significantly impact quality of life and may occasionally result in severe complications in both pediatric and adult patients. The disease is triggered and maintained by exposure to food antigens in most patients, with an additional role proposed for airborne allergens. Different diet-based approaches focused on restricting potentially offending foods have proven to be effective long-term therapies for EoE. Dietary therapy is thus an attractive, yet challenging treatment option that should be considered for all pediatric and adult EoE patients. However, limitations related to food restriction, patient willingness to undergo repeated endoscopies and biopsies, and the variable results of allergy testing imply that dietary management is for the most part currently restricted to highly motivated healthcare providers treating highly motivated patients reluctant to utilize drug-based therapy on a chronic basis. Pharmacological therapies for EoE mainly comprise swallowed topical steroids, especially fluticasone propionate and budesonide, which were originally developed to treat bronchial asthma and are now extensively used "off label" in EoE patients. In fact, topical steroids currently constitute the prevailing therapeutic option and will probably continue to do so in the near future; indeed, several randomized clinical trials are currently underway to test these drugs for approval as the first pharmacological agents for EoE patients. Immunomodulators and several anti-allergic agents must be further assessed as therapeutic alternatives for refractory cases or patients with complications. Endoscopic dilation represents the third pillar in the therapeutic management of EoE patients, since they frequently present reductions in the esophageal caliber as a result of collagen deposition and a progressive fibrous remodeling process promoted by chronic eosinophilic infiltration. Dilation provides at least temporary symptom relief with similar complication rates to esophageal strictures from a different origin. However, although repeated endoscopic dilation has sometimes been used as the sole therapy for EoE, it best constitutes an adjuvant therapy along with dietary or pharmacological-based interventions, especially since dilation has no effect on the underlying esophageal inflammation. Current therapeutic management of EoE varies widely, with physician experience being a major explanatory factor. New evidence from ongoing research on EoE should thus seek to define a common treatment algorithm to optimize EoE patient management.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n, 13700, Tomelloso, Ciudad Real, Spain,
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Lucendo AJ, Arias Á. Dietary Management of Patients with Eosinophilic Esophagitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-014-0012-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
Eosinophilic esophagitis (EoE) represents a prevalent chronic esophageal disorder. Since the condition was first described, its pathophysiology has been known to have an immune-allergic origin, but the high response rate to dietary therapies based on feeding patients exclusively with amino acid-based elemental formulas (with complete elimination of table foods) has clearly established EoE as a particular form of food allergy. Nevertheless, the management of EoE in clinical practice remains widely heterogeneous, with topical steroids being a therapeutic mainstay. However, a growing body of evidence points to dietary therapy as an effective treatment option for both children and adults with EoE, as this approach is capable of achieving a sustained symptomatic and histological response without resorting to drugs. This article reviews the available data on the major types of dietary therapy for EoE, including elemental formula diets, skin allergy testing-directed elimination diets and empirical elimination diets based on common food allergens.
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Affiliation(s)
- Angel Arias
- Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
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