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Haas AM, Doidge RJ, Hiremath G. Recognition and Management of Feeding Dysfunction in the Pediatric Patient with Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:173-184. [PMID: 38575216 DOI: 10.1016/j.iac.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Feeding is a complex skill requiring coordination of multiple body systems. Multiple factors are considered in feeding dysfunction in pediatric patients with eosinophilic gastrointestinal disorders, including overall development, nutritional status, mealtime behaviors, and medical comorbidities. Symptoms of feeding dysfunction vary by age, with maladaptive learned feeding behaviors spanning all age ranges. Knowledge of the normal acquisition of feeding skills is critical to interpret the impact of the disease and plan appropriate intervention. Assessment and treatment from a feeding and swallowing disorders specialist can dramatically impact successful outcomes in nutrition, growth, mealtime dynamics and ultimatly quality of life for children and their caregivers in home and social settings.
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Affiliation(s)
- Angela M Haas
- Department of Speech Language Pathology, Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, B030, Aurora, CO 80045, USA.
| | - Rebecca J Doidge
- Department of Speech Language Pathology, Children's Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, B030, Aurora, CO 80045, USA
| | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, Gastroenterology, Hepatology and Nutrition, 2200 Children's Way, Nashville, TN 37232, USA
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2
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Thomas J, Deb C, Bittar K, Bornstein J, Mehta D, Smadi Y. Monitoring pediatric eosinophilic esophagitis disease activity using an unsedated blind esophageal brushing model: A pilot study. J Pediatr Gastroenterol Nutr 2024; 78:878-885. [PMID: 38591709 DOI: 10.1002/jpn3.12127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 04/10/2024]
Abstract
BACKGROUND Recurrent upper endoscopies are essential for monitoring therapy response and disease activity in patients with eosinophilic esophagitis (EoE), leading to increased costs, procedural complications, and anesthesia exposure. The aim of this study was to examine an office-based model using serial sedation-free blind esophageal epithelial brushing (BEEB) to monitor therapy response through eosinophil-derived neurotoxin (EDN) levels and guide therapy plans in pediatric EoE patients. METHODS EoE patients (≤21 years of age) were enrolled in this prospective study. Subjects were placed on dietary, pharmacologic, or combination therapy with the goal of inducing or maintaining remission. To assess response to sequential interventions, subjects underwent sequential sedation-free BEEBs through nasogastric tubes to measure EDN levels. Based on serial brushings, an individual plan of diet, medications, or a combination of both was created for each subject, and a final endoscopy was then performed to validate the accuracy of the individual plans. RESULTS Twenty-four subjects completed the study. The average peak eosinophil count in patients with active EoE was 58.1 ± 30.8 eosinophils per high-power field and mean EDN level was 165.2 ± 191.3 μg/mL. A total of 42 BEEBs were completed. Individual therapy plans based on sequential BEEB were accurate in 19 out of the 24 patients (79%) and specifically nine out of 10 patients (90%) treated with elimination diets. CONCLUSION This study suggests that office-based sedation-free BEEBs can be used to monitor therapy response and disease activity in pediatric EoE patients.
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Affiliation(s)
- Jessina Thomas
- Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children at Orlando Health, Orlando, Florida, USA
| | - Chirajyoti Deb
- Pediatric Specialty Diagnostic Gastroenterology Translational Lab, Arnold Palmer Hospital for Children at Orlando Health, Orlando, Florida, USA
| | - Khaled Bittar
- Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children at Orlando Health, Orlando, Florida, USA
| | - Jeffrey Bornstein
- Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children at Orlando Health, Orlando, Florida, USA
| | - Devendra Mehta
- Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children at Orlando Health, Orlando, Florida, USA
| | - Yamen Smadi
- Eosinophilic Esophagitis Center, Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children at Orlando Health, Orlando, Florida, USA
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3
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Yousef E, Korotkaya Y, Simpson AB. Eosinophilic esophagitis in children: Updates and practical aspects of management for allergists in a non-tertiary care private practice setup. Allergy Asthma Proc 2022; 43:5-11. [PMID: 34983704 DOI: 10.2500/aap.2022.43.210084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Eosinophilic esophagitis (EoE) is a chronic immune and/or antigen-mediated disease characterized by eosinophilic infiltration of mucosa (≥15 eosinophils per high power field) without any secondary etiology. Non-immunoglobulin E mediated mechanisms predominate in EoE. Objective: This review concentrated on a stepwise approach for the allergist working in non-tertiary care private practice. Methods: A medical literature search that focused on several areas of the latest developments in the diagnosis and management of EoE was conducted. Results: There has been a steady increase in the prevalence and incidence of EoE. Clinical symptoms can vary from dysphagia to failure to thrive, depending on the age at presentation; some children develop adaptive behaviors to compensate for dysphagia, such as food preferences and slow eating. The diagnosis is based on a high index of clinical suspicion and is confirmed with endoscopy with biopsies after ruling out other causes of esophageal eosinophilia. Treatment options may include dietary therapy, pharmacologic therapies, or combination therapy. Therapeutic options may also include endoscopic dilation for stricturing disease. Conclusion: Providers should be aware of recent recommendation changes in the diagnostic workup, the role of skin-prick testing, and role of the proton-pump inhibitor as first-line therapy for EoE. Also, clinicians should be aware of the emerging role of empiric dietary therapy as a preferable therapeutic option when compared with the testing-directed diet and the elemental diet. Furthermore, topical glucocorticoid therapies are available, and new developing therapies are being investigated. Reevaluation of esophageal mucosa with biopsies is required approximately 2 months after therapy for a response and after a change in therapies to confirm continued resolution.
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Affiliation(s)
- Ejaz Yousef
- From the Divisions of Allergy/Immunology and Pediatric Gastroentrology, Nemours Children Specialty Care, Jacksonville, Florida; and
| | - Yelena Korotkaya
- From the Divisions of Allergy/Immunology and Pediatric Gastroentrology, Nemours Children Specialty Care, Jacksonville, Florida; and
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Tabatabaei N, Kang D, Kim M, Wu T, Grant CN, Rosenberg M, Nishioka NS, Hesterberg PE, Garber J, Yuan Q, Katz AJ, Tearney GJ. Clinical Translation of Tethered Confocal Microscopy Capsule for Unsedated Diagnosis of Eosinophilic Esophagitis. Sci Rep 2018; 8:2631. [PMID: 29422678 PMCID: PMC5805683 DOI: 10.1038/s41598-018-20668-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/19/2018] [Indexed: 12/27/2022] Open
Abstract
Esophagogastroduodenoscopy (EGD) is a widely used procedure, posing significant financial burden on both healthcare systems and patients. Moreover, EGD is time consuming, sometimes difficult to tolerate, and suffers from an imperfect diagnostic yield as the limited number of collected biopsies does not represent the whole organ. In this paper, we report on technological and clinical feasibility of a swallowable tethered endomicroscopy capsule, which is administered without sedation, to image large regions of esophageal and gastric mucosa at the cellular level. To demonstrate imaging capabilities, we conducted a human pilot study (n = 17) on Eosinophilic Esophagitis (EoE) patients and healthy volunteers from which representative cases are presented and discussed. Results indicate that, compared to endoscopic biopsy, unsedated tethered capsule endomicroscopy obtains orders of magnitude more cellular information while successfully resolving characteristic tissue microscopic features such as stratified squamous epithelium, lamina propria papillae, intraepithelial eosinophils, and gastric cardia and body/fundic mucosa epithelia. Based on the major import of whole organ, cellular-level microscopy to obviate sampling error and the clear cost and convenience advantages of unsedated procedure, we believe that this tool has the potential to become a simpler and more effective device for diagnosing and monitoring the therapeutic response of EoE and other esophageal diseases.
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Affiliation(s)
- Nima Tabatabaei
- Department of Mechanical Engineering, Lassonde School of Engineering, York University, Toronto, ON M3J 1P3, Canada
| | - DongKyun Kang
- Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - Minkyu Kim
- Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - Tao Wu
- Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - Catriona N Grant
- Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - Mireille Rosenberg
- Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - Norman S Nishioka
- Department of Medicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - Paul E Hesterberg
- Department of Medicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - John Garber
- Department of Medicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - Qian Yuan
- Department of Medicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - Aubrey J Katz
- Department of Medicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA
| | - Guillermo J Tearney
- Department of Medicine, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA. .,Department of Pathology, Massachusetts General Hospital Harvard Medical School, Boston, MA, 02114, USA. .,Harvard-MIT Division of Health Science and Technology, Cambridge, MA, 02139, USA.
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5
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Park H. An overview of eosinophilic esophagitis. Gut Liver 2014; 8:590-7. [PMID: 25368745 PMCID: PMC4215443 DOI: 10.5009/gnl14081] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/12/2014] [Accepted: 07/10/2014] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease affecting both children and adults. The condition is characterized by an eosinophilic infiltration of the esophageal epithelium. Symptoms of esophageal dysfunction include dysphagia, food impaction and symptoms mimicking gastroesophageal reflux disease. Endoscopic examination typically reveals mucosal fragility, ring or corrugated mucosa, longitudinal furrows, whitish plaques or a small caliber esophagus. Histologic findings of >15 eosinophils per high-power field is the diagnostic hallmark of EoE. An elimination diet, topical corticosteroids or endoscopic dilation for fibrostenotic disease serve as effective therapeutic option.
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Affiliation(s)
- Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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6
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Health-related quality of life over time in children with eosinophilic esophagitis and their families. J Pediatr Gastroenterol Nutr 2014; 59:308-16. [PMID: 24897164 PMCID: PMC4141021 DOI: 10.1097/mpg.0000000000000451] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Existing treatments for pediatric eosinophilic esophagitis (EoE) effectively reduce inflammation. The impact of treatment on health-related quality of life (HRQoL) over time for pediatric patients with EoE and their families, however, has not been systematically assessed. We hypothesized that individualized multidisciplinary treatment would improve both child and family HRQoL over time, with improvements associated with decreased symptom severity. METHODS Children with EoE treated in 4 tertiary care centers were enrolled. Baseline assessments occurred at the time of patients' first evaluation; follow-up assessments occurred at 2 and 6 months after baseline. Presence and severity of 8 EoE symptoms were measured. HRQoL was measured with the Pediatric Quality of Life Inventory parent proxy report, child self-report (CR), and Family Impact Module (FIM). Statistical analyses used mixed-effects modeling to test changes over time for child and family HRQoL. RESULTS Ninety-seven children were enrolled (ages 2-18 years, mean age 7.7 years ± 4.8, 78% boys, 80% white). Baseline mean symptom number was 3.5 (standard deviation 2.3), and symptom severity was 5.5 (standard deviation, 4.5). HRQoL scores were significantly related to symptom scores (P < 0.001). EoE symptom severity decreased during the study (P = 0.03). Pediatric Quality of Life Inventory parent proxy Total and FIM Total scores improved from baseline to 6 months (respectively, adjusted means 78.4 vs 81.0, P = 0.0006; 68.9 vs 70.1, P = 0.03). Interactions with baseline symptom severity revealed that subjects with lowest symptom severity showed the most improved HRQoL scores (P = 0.0013). CONCLUSIONS HRQoL improved during the course of evaluation and treatment, with positive changes being strongest for patients with less symptom severity at baseline.
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Liacouras CA, Spergel J, Gober LM. Eosinophilic esophagitis: clinical presentation in children. Gastroenterol Clin North Am 2014; 43:219-29. [PMID: 24813511 DOI: 10.1016/j.gtc.2014.02.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Eosinophilic esophagitis (EoE) is increasing in western nations. Symptoms in infants and young children include feeding difficulties, failure to thrive, and gastroesophageal reflux. School-aged children may present with vomiting, abdominal pain, and regurgitation; adolescents and adults with dysphagia and food impaction. Delayed diagnosis increases risk of stricture formation. Children with untreated EoE have tissue changes resembling airway remodeling. Endoscopy does not always correlate. Management centers on food elimination. Approaches include skin prick and patch testing, removal of foods, or an amino acid formula diet. Long-term elimination diets can produce nutritional deficiencies and have poor adherence.
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Affiliation(s)
- Chris A Liacouras
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Jonathan Spergel
- Division of Allergy, Immunology, and Infectious Diseases, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Laura M Gober
- Division of Allergy, Immunology, and Infectious Diseases, Center for Pediatric Eosinophilic Disorders, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Lucendo AJ, Sánchez-Cazalilla M. Adult versus pediatric eosinophilic esophagitis: important differences and similarities for the clinician to understand. Expert Rev Clin Immunol 2013; 8:733-45. [PMID: 23167685 DOI: 10.1586/eci.12.68] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) is recognized as a common, allergy-associated cause of chronic esophageal symptoms affecting both children and adults. Research has begun to shed light on its epidemiology with consistent results from various geographical areas. Differences in clinical presentation, endoscopic aspects and response to treatment have all been reported for patients of different ages, and the question as to whether adult and pediatric EoE are manifestations of a single entity or in fact two distinct disorders has been posed. The most relevant differences between pediatric and adult EoE come from evolutionary changes in the consequences of the disease, including fibrous remodeling, and the ability to express symptoms. However, most studies support a common pathogenesis and similar histopathological features for adult and pediatric patients, being the same diagnostic criteria applied to them. This article comprehensively reviews the most recently published information and addresses important questions about the natural history of EoE.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain.
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9
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Yoo H, Kang D, Katz AJ, Lauwers GY, Nishioka NS, Yagi Y, Tanpowpong P, Namati J, Bouma BE, Tearney GJ. Reflectance confocal microscopy for the diagnosis of eosinophilic esophagitis: a pilot study conducted on biopsy specimens. Gastrointest Endosc 2011; 74:992-1000. [PMID: 21944314 PMCID: PMC3425354 DOI: 10.1016/j.gie.2011.07.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 07/14/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Diagnosis of eosinophilic esophagitis (EoE) currently requires endoscopic biopsy and histopathologic analysis of the biopsy specimens to count intraepithelial eosinophils. Reflectance confocal microscopy (RCM) is an endomicroscopy technology that is capable of obtaining high-resolution, optically sectioned images of esophageal mucosa without the administration of exogenous contrast. OBJECTIVE In this study, we investigated the capability of a high-speed form of RCM, termed spectrally encoded confocal microscopy (SECM), to count intraepithelial esophageal eosinophils and characterize other microscopic findings of EoE. DESIGN A total of 43 biopsy samples from 35 pediatric patients and 8 biopsy samples from 8 adult patients undergoing EGD for EoE were imaged by SECM immediately after their removal and then processed for routine histopathology. Two SECM readers, trained on adult cases, prospectively counted intraepithelial eosinophils and detected the presence of abscess, degranulation, and basal cell hyperplasia on SECM images from the pediatric patients. A pathologist blinded to the SECM data analyzed the same from corresponding slides. SETTING The Gastrointestinal Unit, Massachusetts General Hospital. RESULTS Eosinophils by SECM demonstrated a higher reflectance than the surrounding cells and other inflammatory cells. There was good correlation between SECM and histology maximum eosinophil counts/high-power field (R = 0.76, P < .0001). Intra- and interobserver correlations for SECM counts were very good (R = 0.93 and R = 0.92, respectively; P < .0001). For the commonly used eosinophil count cutoff of 15 per high-power field, the sensitivity and specificity of SECM for EoE were 100%. The sensitivity and specificity for abscess, degranulation, and basal cell hyperplasia were 100% and 82%, 91% and 60%, and 94% and 80%, respectively. Intra- and interobserver agreements for these microscopic features of EoE were very good (κ = 0.9/0.9, 0.84/1.0, 0.91/0.81, respectively). LIMITATION Ex vivo study. CONCLUSIONS This study demonstrates that RCM can be used to accurately count intraepithelial eosinophils and identify other microscopic abnormalities associated with EoE on freshly excised biopsy samples. These findings suggest that RCM may be developed into a tool for assessing eosinophilic infiltration in the esophagus in vivo.
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Affiliation(s)
- Hongki Yoo
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Dermatology Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - DongKyun Kang
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Dermatology Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aubrey J. Katz
- Department of Gastrointestinal Unit, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA,Food Allergy Center, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gregory Y. Lauwers
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Norman S. Nishioka
- Department of Gastrointestinal Unit, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yukako Yagi
- Department of Pathology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pornthep Tanpowpong
- Department of Gastrointestinal Unit, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA,Food Allergy Center, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jacqueline Namati
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Dermatology Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brett E. Bouma
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard-MIT Health Sciences and Technology, Cambridge, Massachusetts, USA
| | - Guillermo J. Tearney
- Wellman Center for Photomedicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Dermatology Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard-MIT Health Sciences and Technology, Cambridge, Massachusetts, USA
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Schroeder S, Atkins D, Furuta GT. Recent advances in the treatment of eosinophilic esophagitis. Expert Rev Clin Immunol 2011; 6:929-37. [PMID: 20979557 DOI: 10.1586/eci.10.65] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
First described nearly 20 years ago, eosinophilic esophagitis (EoE) is an inflammatory disease of the esophagus characterized by eosinophilic infiltration of the esophageal epithelium. Over 50% of the current literature on EoE has been published in the last 3 years, signaling both a rising incidence and increased recognition of this disorder. Treatment options available for patients with EoE include dietary management and/or pharmacologic therapy. An individualized approach to treatment is preferred, with an emphasis on patient-parental preference. The objective of this article is to discuss the current and future treatment options for EoE.
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Affiliation(s)
- Shauna Schroeder
- University of Colorado Denver School of Medicine, Denver, CO, USA; The Children's Hospital Denver, 13123 East 16th Avenue, B290, Aurora, CO 80016, USA
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Mukkada VA, Haas A, Maune NC, Capocelli KE, Henry M, Gilman N, Petersburg S, Moore W, Lovell MA, Fleischer DM, Furuta GT, Atkins D. Feeding dysfunction in children with eosinophilic gastrointestinal diseases. Pediatrics 2010; 126:e672-7. [PMID: 20696733 DOI: 10.1542/peds.2009-2227] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Feeding dysfunction (FD) seen in younger children with eosinophilic gastrointestinal disease (EGID) has not been well described. Thus, our aim was to further characterize FD in children with EGIDs. METHODS A retrospective medical record analysis of 200 children seen over 12 months in a multidisciplinary Gastrointestinal Eosinophilic Diseases Program was performed. The clinical data of 33 children identified as also having FD were examined, including information obtained by history, physical examination, feeding evaluation, review of nutritional data, allergy testing and histologic assessment of mucosal biopsies. RESULTS Of 200 children with EGIDs, 16.5% had significant FD. The median age of this group was 34 months (range: 14-113 months). A variety of learned maladaptive feeding behaviors were reported in 93.9%. Frequent gagging or vomiting occurred in 84.8%. Food sensitivity was documented in 88% while 52% had other allergic disease. Twenty one percent were diagnosed with failure to thrive and 69.7% required individual or group feeding therapy. Forty-two percent had residual eosinophilia of >15 per HPF on esophageal biopsies performed at the time of symptoms. CONCLUSIONS FD is prevalent in children with EGIDs often presenting as maladaptive learned feeding behaviors with altered mealtime dynamics and physical difficulties in eating mechanics. FD can persist even after eosinophilic inflammation is successfully treated. Awareness of the increased prevalence of FD in children with EGIDs with enable earlier recognition of this problem, resulting in a comprehensive, individualized treatment plan with the desired outcome of improving the development, feeding, and nutrition of these children.
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Affiliation(s)
- Vincent A Mukkada
- Gastrointestinal Eosinophilic Diseases Program, Department of Pathology, Children's Hospital, Aurora, CO, USA
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A systematic review of the risk of perforation during esophageal dilation for patients with eosinophilic esophagitis. Dig Dis Sci 2010; 55:1512-5. [PMID: 20238250 PMCID: PMC3121144 DOI: 10.1007/s10620-010-1165-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 02/11/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is associated with tissue remodeling that can result in esophageal mucosal fragility, and esophageal dilation for patients with EoE is known to cause painful mucosal lacerations. Clinicians have been admonished that patients with EoE may be exceptionally predisposed to perforation with esophageal dilation, a notion supported primarily by case reports. We have conducted a systematic review of literature on esophageal dilation in EoE in an attempt to better define the risk of perforation. METHODS We searched PubMed and abstracts presented at the annual scientific meetings of the American Gastroenterological Association and the American College of Gastroenterology to identify reports on esophageal dilation in EoE. We analyzed reports meeting the following criteria: (1) the diagnosis was established from esophageal biopsy specimens revealing >or=15 eosinophils/hpf, (2) esophageal dilation was described, (3) esophageal perforations described were the result of esophageal dilation. RESULTS We identified 18 reports for inclusion in our systematic review. The studies comprised 468 patients who underwent a total of 671 endoscopic dilations. Esophageal mucosal tears were described in most cases, but there was only one perforation among the 671 dilations (0.1%). CONCLUSIONS Our systematic review does not reveal an inordinate frequency of esophageal perforation from dilation in patients with EoE, and it is not clear that dilation is any more hazardous for patients with EoE than for patients with other causes of esophageal stricture. Although esophageal dilation must be performed with caution in all patients, the risk of perforation in EoE appears to have been exaggerated.
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13
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Brown-Whitehorn TF, Spergel JM. The link between allergies and eosinophilic esophagitis: implications for management strategies. Expert Rev Clin Immunol 2010; 6:101-9. [PMID: 20161677 DOI: 10.1586/eci.09.74] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Eosinophilic esophagitis (EE) has an increased incidence of diagnosis similar to other atopic diseases. We present a recent literature review of the common features between atopic diseases (i.e., asthma, allergic rhinitis and atopic dermatitis) and EE. All of the disorders have allergen triggers and evidence of a possible Th2 inflammation at the site of disease. Murine models have also shown similar features with the importance of T cells and Th2 cytokines for the development of disease. The diseases share underlying inflammation with the potential for remodeling with an increase in TGF-beta expression in asthma and EE. However, differences do exist between the diseases in treatment and pathogenesis. For EE, there are two basic treatment options: avoidance of the food triggers or treatment of the eosinophilic inflammation with corticosteroids.
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Affiliation(s)
- Terri F Brown-Whitehorn
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania School of Medicine, 3550 Market Street, Philadelphia, PA 19104, USA.
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14
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Aceves SS, Newbury RO, Dohil MA, Bastian JF, Dohil R. A symptom scoring tool for identifying pediatric patients with eosinophilic esophagitis and correlating symptoms with inflammation. Ann Allergy Asthma Immunol 2009; 103:401-6. [PMID: 19927538 DOI: 10.1016/s1081-1206(10)60359-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EE) is an increasingly recognized allergic disease entity that is difficult to distinguish clinically from other causes of esophagitis, especially gastroesophageal reflux disease (GERD). To our knowledge, there are no prospectively analyzed or validated symptom scoring tools for pediatric patients with EE and no prospective evaluation correlating symptoms with tissue inflammation. OBJECTIVES To prospectively analyze a symptom scoring tool's ability to distinguish pediatric patients with EE from those with GERD and from control patients with and without allergies and to correlate symptoms with tissue inflammation. METHODS A prospective study of a symptom scoring tool given to patients with EE (n = 35 not receiving EE targeted therapy), patients with GERD (n = 27 not undergoing acid suppression), allergic control patients (n = 24), and nonallergic control patients (n = 14) at an academic pediatric hospital. Histology and endoscopy scores were correlated with symptom complaints. RESULTS The total symptom score was higher among patients with EE (mean, 6.51; 95% confidence interval [CI], 5.50-7.53) and GERD (mean, 5.44; 95% CI, 4.64-6.25) than in allergic (mean, 0.92; 95% CI, 0.28-1.55) and nonallergic (mean, 1.00; 95% CI, 0.40-1.60) patients (P < .001). Patients with EE and GERD complained of more nausea/vomiting, abdominal pain, heartburn/regurgitation, and nocturnal awakening than control groups (P < .001). Only dysphagia (mean, 0.9 [95% CI, 0.7-1.2] in EE patients vs 0.4 [95% CI, 0.2-0.7] in GERD patients) and anorexia/early satiety (mean, 1.4 [95% CI, 1.2-1.6] in EE patients vs 0.8 [95% CI, 0.5-1.1] in GERD patients) discriminate EE from GERD (P < .01). These symptoms also correlated with the severity of histologic and endoscopic findings (P < .05). CONCLUSION Dysphagia and anorexia/early satiety identify pediatric patients with EE and correlate symptoms with tissue inflammation.
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Affiliation(s)
- Seema S Aceves
- Division of Allergy and Immunology, Rady Children's Hospital and University of California, San Diego 92123, USA.
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Esofagitis eosinofílica: algoritmo secuencial de opciones terapéuticas. Med Clin (Barc) 2009; 133:798-801. [DOI: 10.1016/j.medcli.2009.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 04/14/2009] [Indexed: 12/17/2022]
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Kedika RR, Souza RF, Spechler SJ. Potential anti-inflammatory effects of proton pump inhibitors: a review and discussion of the clinical implications. Dig Dis Sci 2009; 54:2312-7. [PMID: 19714466 PMCID: PMC3035917 DOI: 10.1007/s10620-009-0951-9] [Citation(s) in RCA: 234] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 08/10/2009] [Indexed: 12/19/2022]
Abstract
Proton pump inhibitors (PPIs) are potent blockers of gastric acid secretion, and are widely regarded as the agents of choice for the treatment of acid-peptic disorders. For patients with upper gastrointestinal symptoms of uncertain etiology, improvement with PPI therapy is considered prima facie evidence of a pathogenetic role for acid-peptic disease. In addition to anti-secretory effects, however, PPIs have been found to have anti-oxidant properties and direct effects on neutrophils, monocytes, endothelial, and epithelial cells that might prevent inflammation. Those anti-inflammatory effects of the PPIs might influence a variety of inflammatory disorders, both peptic and non-peptic, within and outside of the gastrointestinal tract. The purpose of this report is to review the mechanisms whereby PPIs might exert anti-inflammatory effects exclusive of gastric acid inhibition, to discuss the clinical implications of those effects, and to emphasize that a clinical response to PPIs should not be construed as proof for an underlying acid-peptic disorder.
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Affiliation(s)
- Ramalinga R. Kedika
- VA North Texas Healthcare System, Dallas, TX, USA,The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rhonda F. Souza
- VA North Texas Healthcare System, Dallas, TX, USA,The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stuart Jon Spechler
- VA North Texas Healthcare System, Dallas, TX, USA,The University of Texas Southwestern Medical Center, Dallas, TX, USA,Division of Gastroenterology, Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216, USA
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Aceves SS, Ackerman SJ. Relationships between eosinophilic inflammation, tissue remodeling, and fibrosis in eosinophilic esophagitis. Immunol Allergy Clin North Am 2009; 29:197-211, xiii-xiv. [PMID: 19141355 DOI: 10.1016/j.iac.2008.10.003] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The clinical and pathologic features of eosinophilic esophagitis (EE) include extensive tissue remodeling. Increasing evidence supports a key role for the eosinophil in multiple aspects of the esophageal remodeling and fibrosis seen in this allergic disease. This article reviews the clinical implications of esophageal remodeling and fibrosis in EE and discusses the possible pathogenic mechanisms inducing and regulating these responses. The focus is specifically on eosinophil and cytokine interactions with the esophageal epithelium, vascular endothelium, resident fibroblasts, and smooth muscle. Current and potential therapeutic interventions are discussed that may impact the development or resolution of chronic esophageal remodeling and fibrosis in EE.
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Affiliation(s)
- Seema S Aceves
- Division of Allergy and Immunology, Rady Children's Hospital, 3020 Children's Way, MC 5114, San Diego, CA 92123-6791, USA
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Merwat SN, Spechler SJ. Might the use of acid-suppressive medications predispose to the development of eosinophilic esophagitis? Am J Gastroenterol 2009; 104:1897-902. [PMID: 19661930 DOI: 10.1038/ajg.2009.87] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The prevalence of eosinophilic esophagitis, a manifestation of food allergy, has increased in recent years for reasons that are not clear. The gastrointestinal mucosa is regularly exposed to food antigens with the potential to evoke immunological reactions. Studies have shown that some food allergens that ordinarily would be degraded by peptic digestion are not degraded when the pH of gastric fluid is raised to levels commonly found in the stomachs of patients treated with proton pump inhibitors (PPIs). Other studies have shown that PPIs increase gastrointestinal mucosal permeability, which might facilitate the uptake of undegraded peptide allergens. Mice treated with antisecretory medications while being fed a diet of caviar have been found to develop caviar-specific immunoglobulin E (IgE) antibodies, T-cell reactivity, and gastric eosinophilia. Adult patients treated with antisecretory medications for 3 months have been found to develop a rise in their IgE antibody levels and new, food-specific IgE antibodies. These data establish a plausible mechanism whereby acid-suppressive medications, by interfering with the peptic digestion of food allergens and increasing mucosal permeability, might lead to the development of food allergy. The time course of the introduction and subsequent widespread usage of PPIs with the emergence of eosinophilic esophagitis fits well with the hypothesis that PPIs may play an etiological role. Although the mere demonstration of a plausible association does not establish cause and effect, further studies on the role of acid suppression in the development of eosinophilic esophagitis clearly are warranted.
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Affiliation(s)
- Shehzad Nawaz Merwat
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Abstract
Eosinophilic esophagitis (EoE) is a chronic esophageal inflammatory disease of undetermined pathophysiology that results in dense mucosal eosinophilia and esophageal dysfunction. In childhood, vague symptoms associated with GERD and feeding difficulties are the first manifestations of EoE. Adults typically present with dysphagia and food impaction. No pathognomonic features have been identified for EoE and, therefore, its diagnosis must be made on both clinical and histological grounds. Effective treatments rely on steroids and dietary exclusions.
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A case of herpes esophagitis after fluticasone propionate for eosinophilic esophagitis. ACTA ACUST UNITED AC 2009; 5:527-30. [PMID: 18758471 DOI: 10.1038/ncpgasthep1225] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Accepted: 07/10/2008] [Indexed: 11/08/2022]
Abstract
BACKGROUND A 19-year-old white woman presented with a 6-month history of progressively worsening dysphagia. INVESTIGATIONS Esophagogastroduodenoscopy, esophageal biopsies followed by histological evaluation of biopsy samples including immunohistochemical staining for herpes simplex virus. DIAGNOSIS Herpes esophagitis with concurrent eosinophilic esophagitis. MANAGEMENT Valaciclovir and fluconazole.
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Clinical Presentation of Feeding Dysfunction in Children with Eosinophilic Gastrointestinal Disease. Immunol Allergy Clin North Am 2009; 29:65-75, ix. [DOI: 10.1016/j.iac.2008.09.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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