Eosinophilic esophagitis -- a mimic of GERD

Prevalence of esophageal eosinophilia and eosinophilic esophagitis in adults: a population-based endoscopic study in Shanghai, China

BACKGROUND AND AIM

Population-based endoscopic studies of esophageal eosinophilia and eosinophilic esophagitis are limited in the world. This study was aiming to describe features of esophageal eosinophilia and eosinophilic esophagitis in a representative sample of the adult in Shanghai, China.

METHODS

As part of a large epidemiological study, 3,600 individuals (aged 18-80 years) were randomly selected in Shanghai, China. They were asked to undergo endoscopy and have at least four esophageal biopsies taken from 0.5 cm above the Z-line and any abnormal areas. Any eosinophil infiltration of the epithelium was defined as esophageal eosinophilia. Eosinophilic esophagitis was defined as ≥15 eosinophils/high-power field in esophageal biopsies.

RESULTS

A total of 1,030 individuals accepted to have endoscopy and 1,021 individuals with biopsy results were suitable for analysis. Esophageal eosinophilia was present in 67 subjects (6.6 %). Eosinophilic esophagitis was present in four cases (0.4 %). No significant association was found between the presence of esophageal eosinophilia and reflux esophagitis, Barrett's esophagus, symptom-defined gastroesophageal reflux disease or H. pylori infection. Most individuals with esophageal eosinophilia (80.6 %) did not have any of the upper gastrointestinal symptoms.

CONCLUSIONS

Esophageal eosinophilia was present in nearly 6.6 % of the general adult population of China; 0.4 % had eosinophilic esophagitis. Most of individuals with esophageal eosinophilia were asymptomatic.

Diagnostic utility of major basic protein, eotaxin-3, and leukotriene enzyme staining in eosinophilic esophagitis

OBJECTIVES

Features of eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) overlap. We aimed to determine whether staining for tissue biomarkers would differentiate EoE from GERD, suggesting utility for diagnosis of EoE.

METHODS

In this case-control study, EoE patients defined by consensus guidelines were compared to GERD patients with eosinophils on esophageal biopsy. Immunohistochemistry was performed for major basic protein (MBP), eotaxin-3, leukotriene A4 hydrolase (LTA4H), and leukotriene C4 synthase (LTC4S). After masking, the maximum staining density (cells per mm(2)) was quantified for each marker and compared between groups. Receiver operator characteristic curves were constructed, and the area under the curve (AUC) calculated to assess the diagnostic utility of each of the biomarkers alone and in combination with eosinophil counts.

RESULTS

There were 51 EoE cases (mean age 24; mean 143 eosinophils per high-power field (eos per h.p.f.)) and 54 GERD controls (mean age 34; mean 20 eos per h.p.f.). The MBP density was higher in EoE than in GERD (1479 vs. 59 cells per mm(2); P<0.001), as was the eotaxin-3 density (2219 vs. 479; P<0.001). There were no differences for LTA4H and LTC4S. MBP density and eosinophil count correlated (R=0.81; P<0.001); correlation with eotaxin-3 was weaker (R=0.25; P=0.01). The AUC for diagnosis of EoE was 0.96 for MBP, 0.87 for eotaxin-3, 0.58 for LTA4H, 0.66 for LTC4S, and 0.99 for the combination of MBP, eotaxin-3, and eosinophil count.

CONCLUSIONS

Patients with EoE had substantially higher levels of MBP and eotaxin-3 staining than GERD patients. These markers may have utility as a diagnostic assay for EoE.

Transient PPI responsive esophageal eosinophilia may be a clinical sub-phenotype of pediatric eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) and gastroesophageal reflux (GERD) both cause esophageal eosinophilia. Reports show that esophageal eosinophilia meeting criteria for EoE may respond to acid suppression mono-therapy. Consensus guidelines have termed this entity "PPI-responsive esophageal eosinophilia" (PPIRee) and recommend a trial with proton-pump inhibitors (PPIs) prior to a definitive EoE diagnosis. The mechanisms of PPIRee and whether this represents a sub-phenotype of GERD, a sub-phenotype of EoE, or its own distinct entity remain unclear.

METHODS

A database search revealed children who had an initial histologic response to PPI monotherapy but had recurrence of esophageal eosinophilia and symptoms despite continued PPI therapy. In order to understand the patterns of esophageal inflammatory cells during PPI therapy we performed quantitative immunohistochemistry for mast cells, CD1a positive antigen presenting cells, and CD45RO memory T cells.

RESULTS

Four pediatric patients (mean age 9.5 years) had a mean peak eosinophil count of 52 eos/hpf which initially resolved completely during PPI mono-therapy. However, despite continued PPI therapy, endoscopic abnormalities and pan-esophageal eosinophilia recurred (mean peak eosinophil count of 64 eos/hpf). There was no seasonal variation or lack of PPI adherence that explained the return of eosinopihlia. Similar to eosinophilia, mastocytosis and CD45RO cells were transiently decreased during PPI therapy.

CONCLUSION

PPIs appear to be capable of transiently resolving multiple inflammatory cell subsets including eosinophils, mast cells, and CD45RO cells. Our data suggest that patients with PPIRee should have continued monitoring for EoE during PPI monotherapy. The numbers of patients in whom PPIRee is a transient phenomenon and whether PPIRee represents a sub-phenotype of EoE in children merits further investigation.

Tryptase staining of mast cells may differentiate eosinophilic esophagitis from gastroesophageal reflux disease

OBJECTIVES

Mast cells may contribute to the pathogenesis of eosinophilic esophagitis (EoE), but their role in diagnosis is unknown. Our aim was to determine whether tryptase staining of esophageal mast cells differentiates EoE from gastroesophageal reflux disease (GERD) and has utility for diagnosis of EoE.

METHODS

We performed a case-control study comparing patients with EoE, defined by consensus guidelines, to GERD patients with eosinophils on esophageal biopsy. Immunohistochemistry was performed with mast cell tryptase. The density (mast cells/mm2) and intensity (0-4 scale) of mast cell staining was compared between groups after masking the diagnosis. Receiver operating characteristic (ROC) curves were constructed, and the area under the curve (AUC) was calculated to assess mast cell staining as both a stand-alone diagnostic test and an adjunctive assay with eosinophil counts.

RESULTS

Fifty-four EoE (mean age 24 years; 69% male; mean 146 eosinophils per high-power field (eos/hpf)) and 55 GERD (mean age 34 years; 60% male; mean 20 eos/hpf) patients were analyzed. The maximum epithelial tryptase density was higher in EoE than in GERD (162±87 mast cells/mm2 vs. 67±54; P<0.001). Mast cells were diffusely distributed throughout the biopsy in more EoE than GERD patients (41 vs. 7%; P<0.001). Tryptase density and eosinophil count were only weakly correlated (R2=0.09; P=0.002). The AUC was 0.84 for tryptase staining alone, and 0.96 for the combination of mast cells and eosinophils.

CONCLUSIONS

Patients with EoE have higher levels of tryptase-positive mast cells compared with GERD patients, improving the diagnostic value of biopsies beyond eosinophil counts alone. Mast cell tryptase may have utility as a diagnostic assay for EoE.

Redefining the role of lymphocytes in gastroesophageal reflux disease and eosinophilic esophagitis

Eosinophilic esophagitis (EoE) and reflux esophagitis (RE) overlap clinically and histologically. RE is characterized by epithelial infiltration with small numbers of neutrophils and eosinophils, EoE by a prominent eosinophilic infiltrate. Lymphocytic esophagitis (LE), a new entity characterized by peripapillary lymphocytosis, questions the role lymphocytes play in esophageal inflammation. We test the hypothesis that lymphocyte infiltration in RE differs from EoE. One blinded pathologist read esophageal biopsies from 39 RE and 39 EoE patients. Both groups demonstrated significant numbers of lymphocytes (RE 22.7 +/- 2.2/HPF, EoE 19.8 +/- 1.8/HPF). Eosinophils/HPF in RE and EoE were 2.8 +/- 0.7 and 74.9 +/- 8.2, respectively (P < 0.001). Neutrophils were uncommon in RE (0.26 +/- 0.16/HPF) and EoE (0.09 +/- 0.04; P = 0.07). Eight of the 39 RE specimens had >or=50 lymphocytes in >or=1 HPF. Two were consistent with LE. There was an inverse correlation between numbers of eosinophils and lymphocytes in EoE (R = -0.47; P = 0.002), and no correlation between them in RE (R = 0.18; P = 0.36). The patients with EoE who used antireflux medications had fewer lymphocytes (16.3 +/- 1.3 vs 22.2 +/- 2.3/HPF; P = 0.030) and eosinophils (55.6 +/- 5.2 vs 76.0 +/- 8.7/HPF; P = 0.042) than those who did not. The pathological role of lymphocytes in RE and EoE may be underestimated. Our observation that 5% of the RE specimens meet histopathological criteria for LE potentially blurs the line between these entities. The observation that eosinophil counts are lower in EoE when antireflux meds are used supports the notion that reflux plays a role in the clinical expression of EoE.

Are pathologists accurately diagnosing eosinophilic esophagitis in children? A 9-year single academic institutional experience with interobserver observations

Our aims were to evaluate (a) whether the incidence of eosinophilic esophagitis (EE) in children has increased, (b) whether the histologic diagnosis of EE has been accurate, and (c) potential interobserver variability in the counting of intraepithelial eosinophils in esophageal biopsies. A total of 1215 pediatric endoscopic esophageal biopsies were performed. In total, 289 biopsies were reviewed by one pathologist based on one of the following original histologic diagnoses: EE, reflux esophagitis (RE), or acute/chronic inflammation. EE was diagnosed when at least one high-power field (HPF) contained > or = 20 intraepithelial eosinophils. According to the first pathologist, 104 biopsies had a histologic diagnosis of EE; the prevalence remained relatively stable, ranging from 5.5 to 11 per 100 biopsies annually. In 36 cases, the reporting pathologist correctly diagnosed EE, and in another 34, EE was included in the differential diagnosis. From January 1997 to December 1998, the pathologist either correctly diagnosed EE or included it in the differential diagnosis in 6/13 cases. In contrast, from January 2004 to December 2005, 32/37 cases were included. In 34/104 cases, EE was misdiagnosed as RE. No case of RE was misdiagnosed as EE.A total of 58 cases had pathology reports that quantified the densest number of eosinophils per HPF. The agreement rate was 94.8%, with a kappa value of 0.888. The incidence of EE in children has been stable from January 1997 to December 2005. Overall, pathologists recognized EE in two thirds of cases. The increased diagnostic accuracy over time suggests pathologists are more aware of EE.

Clinical, endoscopic, and histologic findings distinguish eosinophilic esophagitis from gastroesophageal reflux disease

BACKGROUND & AIMS

Features of eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) overlap; because they cannot be differentiated on the basis of eosinophil counts alone, it can be a challenge to distinguish these disorders. We aimed to characterize the clinical, endoscopic, and histologic features of EoE and GERD and to identify factors that might be used to differentiate them.

METHODS

We performed a retrospective case-control study on data collected from 2000 to 2007. Cases were patients of any age with EoE, as defined by recent consensus guidelines; controls were patients of any age with GERD. Clinical and endoscopic data were collected, and all esophageal biopsy specimens were reassessed by gastrointestinal pathologists. Cases and controls were compared, unconditional logistic regression was performed to develop a model to predict EoE, and receiver operator characteristic curves were constructed.

RESULTS

Data from 151 patients with EoE and 226 with GERD were analyzed. Compared with GERD, features that independently predicted EoE included younger age; symptoms of dysphagia; documented food allergies; observations of esophageal rings, linear furrows, white plaques, or exudates by upper endoscopy; an absence of a hiatal hernia, observed by upper endoscopy; a higher maximum eosinophil count; and the presence of eosinophil degranulation observed in biopsy specimens. The area under the curve for this model was 0.934.

CONCLUSIONS

We identified a set of readily available and routinely measured variables that differentiate EoE from GERD. Use of this type of analysis with patients suspected to have EoE might lead to more accurate diagnoses.

Otolaryngologists may not be doing enough to diagnose pediatric eosinophilic esophagitis

OBJECTIVE

To systematically evaluate the diagnosis of eosinophilic esophagitis (EE).

METHODS

A retrospective review of 657 patients seen at the EE center of a tertiary care children's hospital between 1994 and 2007 was performed. Charts were reviewed for the 144 patients who were also seen by the otolaryngology service.

RESULTS

One hundred forty-four patients received 193 otolaryngology-related diagnoses. Eustachian tube dysfunction (27.5%) and sleep disordered breathing (24.9%) were the most common, followed by dysphagia (13.0%), rhinosinusitis/nasal congestion (9.3%) and airway stenosis (5.2%). Seventy-nine patients (54.9%) had a pre-existing diagnosis of EE at the time of their otolaryngology consultation. Twenty-one patients (14.6%) were referred to the gastroenterology service for evaluation for EE. Forty-four patients (30.5%) remained undiagnosed. Twenty-five of these patients presented with dysphagia, 16 of whom were not previously diagnosed with EE; only 4 of these 16 patients were referred for evaluation for EE. In one case, a child with moderate sized tonsils underwent adenotonsillectomy for dysphagia and failure to thrive; this patient was diagnosed with EE 1 month post-operatively.

CONCLUSIONS

Twenty percent of patients with EE may require care by an otolaryngologist for a myriad of complaints. Even experienced pediatric otolaryngologists may not recognize this condition. Otolaryngologists should consider EE in patients presenting with dysphagia. A careful gastroenterology review of symptoms may also allow otolaryngologists to identify EE in patients with allergy mediated nasal complaints, or laryngeal/airway disorders.

Relationships between eosinophilic inflammation, tissue remodeling, and fibrosis in eosinophilic esophagitis

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.

Paediatric eosinophilic oesophagitis presenting to the otolaryngologist

Introduction:

The prevalence of eosinophilic oesophagitis is increasing. A Pubmed search for ‘eosinophilic oesophagitis’ and ‘eosinophilic esophagitis’ yielded 345 publications since 1976. Only seven were in otolaryngology journals.1–7Patients typically present with dysphagia, vomiting, dyspepsia or food impaction and are therefore usually referred to a paediatric gastroenterologist; otolaryngologists are not usually involved in management. A missed diagnosis may result in oesophageal stricture.

Methods:

Two patients, aged two and four years, were referred to the paediatric otolaryngology department with intermittent upper oesophageal food impaction. A paediatric gastroenterologist was involved in the investigation. Histological examination of oesophageal biopsies demonstrated changes consistent with eosinophilic oesophagitis.

Results:

Both patients were expediently diagnosed, investigated and managed.

Conclusion:

A diagnosis of eosinophilic oesophagitis must be considered in patients presenting with food bolus impaction. Early involvement of a paediatric gastroenterology team in the diagnosis is recommended in children presenting with oesophageal symptoms, in order to avoid delayed diagnosis.

The potential impact of contemporary developments in the management of patients with gastroesophageal reflux disease undergoing an initial gastroscopy

BACKGROUND

Recent developments may alter the approach to patients presenting with gastroesophageal reflux disease (GERD)-like symptoms. A newly proposed Montreal consensus definition of Barrett's esophagus includes all types of esophageal columnar metaplasia, with or without intestinal-type metaplasia. There is also increasing recognition of eosinophilic esophagitis (EE) in patients with GERD-like symptoms.

OBJECTIVE

To quantify the impact of these developments on a multiphysician general gastroenterology practice in a tertiary care medical centre.

METHODS

Medical charts of all patients having an initial gastroscopy for GERD-like symptoms over a one-year period were reviewed retrospectively, and audits of their endoscopic images and esophageal biopsies were performed.

RESULTS

Of the 353 study participants, typical symptoms of heartburn and acid reflux were present in 87.7% and 23.2%, respectively. Less commonly, patients presented with atypical symptoms (eg, dysphagia in 9.4%). At endoscopy, 26% were found to have erosive esophagitis and 12% had endoscopically suspected esophageal metaplasia. Histological evaluation was available for 65 patients. Ten of the 65 biopsied patients (15%) met traditional criteria for Barrett's esophagus (ie, exhibiting intestinal-type metaplasia), whereas 49 (75%) fulfilled the newly proposed consensus definition of Barrett's esophagus. Five patients (7.7%) met the study criteria for EE (more than 20 eosinophils per high-power field), four of whom had not been previously recognized.

CONCLUSIONS

Among patients presenting with GERD-like symptoms, the prevalence of Barrett's esophagus may increase markedly if the Montreal definition is adopted. In addition, growing awareness of EE may lead to an increase in the prevalence of this diagnosis. Prospective studies of the management implications of these findings are warranted.

Eosinophilic esophagitis in an asymptomatic Chinese

Eosinophilic esophagitis is a growing problem in adults in Western countries. It is characterized by nausea, vomiting, dysphagia, food impaction, epigastralgia, heart burn and chest pain. Histologic survey is the most potent diagnostic tool. The diagnostic hallmark is the presence of more than 20 eosinophils per high-powered field on esophageal specimen and the absence of mucosal eosinophilia in the stomach. We herein report an asymptomatic Chinese male with eosinophilic esophagitis, which to the best of our knowledge is the first reported case in Asia. The unusual feature of the current case was the lack of symptoms. This case confirms that a dense infiltration of esophageal eosinophils can occur asymptomatically.

Eosinophilic esophagitis: a case report. Effective treatment with systemic corticosteroids for the relapse of the disease

We report on a case of eosinophilic esophagitis in a 33-year-old Japanese woman who visited our hospital with dysphagia and esophageal food impaction in April 2006. She had had the same symptoms in May 2005, and, by endoscopic and histologic examination, she was diagnosed with eosinophilic esophagitis. Biopsy specimens from multiple locations in the esophageal mucosa had shown remarkable infiltration of eosinophils, more than 20 eosinophils per high-power field in squamous mucosa, and she had been treated with Th2 cytokine antagonist and proton pump inhibitor at the time. Her symptoms had not improved, but she had received no further medical treatment. In 2006, upper gastrointestinal endoscopy showed edematous whitish esophageal mucosa, multiple ulcerations with whitish exudates on their surfaces, and white plaques. Biopsy specimens showed the same change as before, and corticosteroid (prednisolone 20 mg/day) was administered orally. After 2 weeks of corticosteroid therapy, her symptom had effectively improved. Endoscopy after 15 weeks of the therapy revealed remarkable improvement, and biopsy specimens from esophageal mucosa revealed the disappearance of the eosinophil infiltrates. We report on a case of eosinophilic esophagitis effectively treated with systemic corticosteroids. Eosinophilic esophagitis has, as yet, no standardized treatment. However, wider recognition of its features on endoscopy may reveal more cases, thereby increasing our understanding of this disease, and will provide new therapeutic possibilities.

High intraepithelial eosinophil counts in esophageal squamous epithelium are not specific for eosinophilic esophagitis in adults

OBJECTIVES

The histologic criterion of >20 eosinophils per high power field (hpf) is presently believed to establish the diagnosis of idiopathic eosinophilic esophagitis (IEE). This is based on data that the number of intraepithelial eosinophils in gastroesophageal reflux disease (GERD) is less than 20/hpf. This study tests this belief.

METHODS

Pathology records were searched for patients who had an eosinophil count >20/hpf in an esophageal biopsy. This patient population was biased toward adults with GERD who had routine multilevel biopsies of the esophagus. The clinical, radiological, and manometric data and biopsies were studied.

RESULTS

Forty patients out of a total of 3,648 reports examined had an eosinophil count >20/hpf in squamous epithelium of an esophageal biopsy. Analysis of these 40 cases indicated that 6 (15%) patients had IEE, 2 (5%) had coincident IEE and GERD, 28 (70%) had GERD, and 2 (5%) each had achalasia and diverticulum. There was no significant difference among these groups in terms of maximum eosinophil number, biopsy levels with >20 esoinophils/hpf, presence of eosinophilic microabscesses, involvement of surface layers by eosinophils, and severity of basal cell hyperplasia and dilated intercellular spaces.

CONCLUSION

All histologic features presently ascribed to IEE can occur in other esophageal diseases, notably GERD. As such, the finding of intraepithelial eosinophilia in any number is not specific for IEE. When a patient with GERD has an esophageal biopsy with an eosinophil count >20/hpf, it does not mean that the patient has IEE.

Integrated approach to treatment of children and adults with eosinophilic esophagitis

Over the last decade, treatment plans for eosinophilic esophagitis included the use of elemental formula, elimination diets, systemic corticosteroids, and the gavage of aerosolized steroids. Except for one placebo-controlled blinded prospective study, most decision making has been based on retrospective or uncontrolled studies and clinical experience. In this article, three authors from diverse backgrounds combine their resources to propose treatment paths with justification based on their clinical experience and interpretation of the literature.

Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thoughts on the complex relationship between gastroesophageal reflux disease and eosinophilic esophagitis

Recent data suggest that the interaction between gastroesophageal reflux disease (GERD) and eosinophilic esophagitis can be complex, and that the notion of establishing a clear distinction between the two disorders may be too simplistic. There are at least four situations in which GERD might be associated with esophageal eosinophils: (a) GERD causes esophageal injury that results in a mild eosinophilic infiltration, (b) GERD and eosinophilic esophagitis coexist but are unrelated, (c) eosinophilic esophagitis contributes to or causes GERD, or (d) GERD contributes to or causes eosinophilic esophagitis. The high frequency of GERD described in adult patients with eosinophilic esophagitis suggests that there may be more than a chance association between the two disorders. This report discusses potential mechanisms for the complex interaction between GERD and eosinophilic esophagitis. We hope that this information will serve as a conceptual basis for future studies on the relationship between the two disorders. Whereas there are a number of plausible mechanisms whereby GERD might contribute to the accumulation of eosinophils in the esophageal epithelium, it seems prudent to recommend a clinical trial of proton pump inhibitor (PPI) therapy even when the diagnosis of eosinophilic esophagitis seems clear-cut. Furthermore, we suggest that a favorable response to PPI therapy does not preclude a diagnosis of eosinophilic esophagitis.