Eosinophilic esophagitis in adults

Recurrent blood eosinophilia in ulcerative colitis is associated with severe disease and primary sclerosing cholangitis

BACKGROUND AND AIMS

Eosinophils are implicated in the pathogenesis of inflammatory bowel disease (IBD). A subset of IBD patients develops blood eosinophilia, and the clinical profile of these patients is undefined. We sought to characterize IBD patients with and without eosinophilia.

METHODS

We studied a prospective registry of 1,176 IBD patients followed in a tertiary referral center. Patients who developed eosinophilia at any time were identified by electronic medical record query. We performed a chart review case-control study comparing patients with recurrent eosinophilia versus randomly selected disease-matched patients with no history of eosinophilia. Histological analysis was performed on selected cases and controls.

RESULTS

Eosinophilia at any time was more prevalent in ulcerative colitis (UC) patients than Crohn's disease patients (22.2 versus 12.7%), as was recurrent eosinophilia (3.4 versus 0.7%). UC patients with recurrent eosinophilia were predominantly male compared with the control UC population (81.3 versus 46.9%) and had higher rates of colectomy for either medically refractory disease or dysplasia/cancer than control UC patients (56.3 versus 15.6%). Primary sclerosing cholangitis (PSC) occurred in 37.5% of UC patients with recurrent eosinophilia compared with only 3.1% in the UC controls. Histological analysis of random diagnostic samples from UC patients with recurrent eosinophilia demonstrated a normal eosinophil pattern as seen in the control UC population.

CONCLUSIONS

Eosinophilia-associated UC is a subgroup of IBD associated with severe colitis and PSC. Further studies are warranted to characterize molecular mechanisms underlying eosinophilia-associated UC and to determine optimal approaches for therapy.

Inverse association of esophageal eosinophilia and Barrett esophagus

BACKGROUND

The high frequency of gastroesophageal reflux symptoms reported in patients with eosinophilic esophagitis has suggested that the two disorders may be associated; however, few studies have systematically addressed this issue.

GOALS

To determine the frequency of the simultaneous occurrence of esophageal eosinophilia and Barrett esophagus and define the clinical characteristics of patients with both conditions.

STUDY

From a national pathology database of patients who had esophagogastroduodenoscopy with mucosal biopsies we extracted patients with a diagnosis of Barrett mucosa, eosinophilic esophagitis pattern of injury [(≥15 eosinophils/high-power field (HPF)], or both. We then evaluated their respective clinicopathologic associations.

RESULTS

Among 233,662 unique patients evaluated during the study period, Barrett mucosa without increased eosinophils was diagnosed in 29,733 patients (12.7%; median age 63 y; 67.6% male); eosinophil counts of ≥15/HPF were recorded in 9509 patients without Barrett mucosa (4.1%; median age 44 y; 63.9% male). A simultaneous diagnosis of Barrett mucosa and ≥15 eosinophils/HPF in the squamous epithelium and was made in 404 unique patients (0.17%; median age 56 y; 79.5% male). The observed prevalence of the simultaneous occurrence of the two conditions was one third of that expected if they occurred independently (odds ratio 0.29; 95% confidence interval, 0.27-0.33; P<0.0001).

CONCLUSIONS

These data suggest a strong inverse relationship between Barrett metaplasia and eosinophilic infiltrates in the esophageal mucosa. Although the influence of diagnostic bias cannot be excluded, the possibility that eosinophilic infiltrates in the esophageal mucosa prevent subsequent metaplastic changes may deserve to be explored.

Eosinophilic esophagitis in children: frequency, clinical manifestations, endoscopic findings, and seasonal distribution

PURPOSE

Eosinophilic esophagitis (EoE) is a chronic disease characterized by eosinophilic infiltration of the esophageal mucosa, which is associated with clinical and endoscopic manifestations. The objective of our study was to determine the frequency of EoE and to outline the clinical manifestations of EoE in Polish children.

MATERIAL/METHODS

Ten large regional pediatric gastroenterology centers participated in the study. A database of endoscopy reports from January 2004 till December 2009 was reviewed. A total of 35,631 esophagogastroduodenal endoscopy studies in children, aged from 4 months to 18 years, were performed. Data pertaining to the children's age, gender, indications for endoscopy, clinical findings and histopathology diagnosis were made.

RESULTS

In 84 children (20 girls and 64 boys), aged between 4 months and 18 years, EoE was diagnosed. This constituted one case per 424 endoscopic studies. In children with changes in the esophageal mucosa the frequency of EoE was higher and reached one case per 73 children. The most frequent symptoms of EoE differed between the younger (1-6 years old) and older children (aged 13-18 years old). Feeding aversion, vomiting and/or regurgitation were most frequently observed in the younger children, while in older children: abdominal pain, dysphagia and chest pain. Granular mucosa, longitudinal furrows, and mucosal rings belong to the findings most often observed in endoscopic studies. EoE was more frequently diagnosed in the spring (45.2%) and summer (28.5%).

CONCLUSIONS

EoE was diagnosed in every age, with frequency of 1/424 gastrointestinal endoscopies, more frequently in boys than in girls.

Reflectance confocal microscopy for the diagnosis of eosinophilic esophagitis: a pilot study conducted on biopsy specimens

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.

Eosinophilic esophagitis: clinical features, endoscopic findings and response to treatment

Eosinophilic esophagitis (EE) is a motility disorder of the esophagus that typically presents with dysphagia. The objective of the present study was to explore patient characteristics, clinical and endoscopic features, and response to treatment of patients with EE. Patients were selected retrospectively based on a review of biopsy results from previous endoscopies performed between 2004 and 2008. A total of 54 patients (41 men and 13 women) with biopsy-proven EE were included in the study. Further information regarding the patients' clinical and endoscopic features, and response to treatment were obtained through chart reviews and patient telephone interviews. The mean age of the patients at symptom onset was 30 years. All patients complained of dysphagia, 81% had a history of bolus obstruction, 43% had a history of asthma and 70% had a history of environmental allergies. Thirty-three per cent had a family history of asthma, while 52% had a family history of food or seasonal allergies. The most common endoscopic findings were rings and⁄or corrugations, which were found in 63% of patients. Swallowed fluticasone therapy resulted in symptom resolution in 74% of patients; however, 79% of these patients relapsed after discontinuing fluticasone therapy and required repeat treatments. Esophageal dilation was complication free and resulted in improvement in 80% of patients. However, 83% of those reporting improvement relapsed within one year. The clinical and endoscopic findings were similar to those found in the literature, with most patients requiring ongoing, repeated therapies. Further studies are needed to assess the safety and efficacy of treatment modalities ideally suited to patients with EE.

Longstanding eosinophilic gastroenteritis of more than 20 years

Eosinophilic gastroenteritis (EGE) is an eosinophil-predominant inflammatory process that may be detected in endoscopic gastric or intestinal biopsies. The long-term natural history and effects of EGE treatment are not known. A 44-year-old man with abdominal pain was treated with oral ketotifen and followed for more than 20 years. Ketotifen provided symptomatic benefit, with prompt clinical relapse if the drug was discontinued. However, despite the use of ketotifen, the endoscopic abnormalities persisted and appeared to progress. Gastric body and antral mucosal folds appeared thickened, erythematous and friable, with minimal erosive change. Later, even during long asymptomatic periods suggesting clinical 'remission', inflammatory polypoid change, previously described in children with EGE, developed with mucosal 'pock-marking' and apparent scarring. Ketotifen treatment does not appear to prohibit or reverse the inflammatory process in the gastric mucosa in EGE, although long-term effects of steroids may be avoided. In the future, treatment of EGE may involve monoclonal antibody agents that target the specific biological effects of the eosinophil, apparently central to this unusual inflammatory process.

The Case of the Infection that Wasn't !

Eosinophilic esophagitis is an under-recognized inflammatory disorder of the esophagus. It has been frequently diagnosed in pediatric patients; however, over the last few years, there has been an increase in the number of cases recognized in adults as well. Despite this fact, eosinophilic esophagitis (EE) is often a delayed diagnosis in the primary care setting due to the overlapping symptoms it shares with other esophageal and gastrointestinal disorders such as gastroesophageal reflux disease and gastroenteritis, as well as a lack of awareness among physicians who see adult patients. We performed an exhaustive search of the literature, which revealed over 400 articles on EE; however, most were reported in gastroenterology or autoimmune specialty journals. We report a case of eosinophilic esophagitis in a 39-year-old man who presented with persistent epigastric abdominal pain and who was diagnosed via endoscopy and biopsy.

Eosinophilic esophagitis: the newest esophageal inflammatory disease

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.