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McCann E, Peterson KA, Whalley D, Qin S, Tilton ST, Kamat S, Sun X, Dellon ES. Psychometric evaluation of the Dysphagia Symptom Questionnaire for adults and adolescents with eosinophilic esophagitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100302. [PMID: 39228895 PMCID: PMC11369371 DOI: 10.1016/j.jacig.2024.100302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 03/27/2024] [Accepted: 04/28/2024] [Indexed: 09/05/2024]
Abstract
Background Eosinophilic esophagitis (EoE) is a chronic, inflammatory disease of the esophagus leading to symptoms of esophageal dysfunction; dysphagia is the most common symptom experienced by adults and adolescents. Objective We sought to perform a psychometric evaluation of the Dysphagia Symptom Questionnaire (DSQ), a patient-reported outcome measure for patients with EoE. Methods Using baseline and week 24 data from the randomized, interventional, multinational phase 3 R668-EE-1774 trial (NCT03633617), the measurement properties of the DSQ-including reliability, construct and known-groups validity, responsiveness, and interpretation of change-were evaluated. Results The analysis population comprised 239 patients with EoE (age [mean ± SD], 28.1 ± 13.14 years; 63.6% male; 90.4% White). Intraclass correlation coefficients of 0.92 and 0.97 exceeded the acceptable reliability threshold (≥0.70). Construct validity correlations with EoE symptom and impact measures were moderate at baseline (|r| = 0.44-0.55) and week 24 (|r| = 0.55-0.69), and the DSQ biweekly total score discriminated among groups defined by disease severity. Analyses exploring interpretation of change from baseline on the DSQ biweekly total score indicated thresholds for within-patient improvement ranging from 9 to 23 points; a within-patient improvement from baseline of 13 points or greater could be considered clinically meaningful. Conclusions This analysis confirmed that the DSQ has acceptable distributional properties, test-retest reliability, construct validity, and ability to detect change. Therefore, the DSQ is a valid and reliable measure to assess the patient-reported symptom of dysphagia among adult and adolescent patients with EoE in the context of a clinical trial setting.
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Affiliation(s)
| | | | | | - Shanshan Qin
- RTI Health Solutions, Research Triangle Park, NC
| | | | | | - Xian Sun
- Regeneron Pharmaceuticals, Inc, Sleepy Hollow, NY
| | - Evan S. Dellon
- University of North Carolina School of Medicine, Chapel Hill, NC
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Strauss Starling A, Ren Y, Li H, Spergel JM, Muir AB, Lynch KL, Liacouras CA, Falk GW. Reducing Eosinophil Counts in Eosinophilic Esophagitis in Children Is Associated With Reduction in Later Stricture Development. Am J Gastroenterol 2024; 119:2002-2009. [PMID: 38661151 DOI: 10.14309/ajg.0000000000002830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/04/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION There are limited longitudinal data on the impact of chronic therapy on the natural history of eosinophilic esophagitis (EoE), a chronic allergic disease of the esophagus. The purpose of this study was to evaluate if patients with well-controlled EoE were less likely to develop fibrostenotic complications. METHODS Subjects were identified from a database of pediatric patients with EoE at the Children's Hospital of Philadelphia started in 2000. Patients were then searched in adult medical records to identify patients who transitioned care. All office visits, emergency department visits, and endoscopic, histologic, and imaging reports were reviewed for the primary outcome of strictures and the secondary outcomes of food impactions and dysphagia. Cox proportional hazard regression was performed for outcomes. RESULTS One hundred five patients were identified with the mean follow-up of 11.4 ± 4.9 years. 52.3% (n = 55) had a period of histologic disease control defined as ≥2 consecutive endoscopies with histologic remission. These patients were less likely to develop strictures compared with patients who did not have a period of histologic control (HR 0.232; 95% CI 0.084-0.64, P = 0.005). Patients who were diagnosed at younger ages were less likely to develop strictures. Presentation with dysphagia or impaction was associated with higher rate of stricture development. DISCUSSION In this cohort study with > 10 years of follow-up, children with EoE with a period of histologic disease control and diagnosed at younger ages were less likely to develop esophageal strictures. While this suggests histologic remission is associated with reduction of remodeling complications, additional prospective data with long-term follow-up are needed.
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Affiliation(s)
- Alexandra Strauss Starling
- Division of Gastroenterology & Hepatology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yue Ren
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hongzhe Li
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amanda B Muir
- Division of Gastroenterology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kristle L Lynch
- Division of Gastroenterology & Hepatology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chris A Liacouras
- Division of Gastroenterology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gary W Falk
- Division of Gastroenterology & Hepatology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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S2k guideline Gastroesophageal reflux disease and eosinophilic esophagitis of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1786-1852. [PMID: 39389106 DOI: 10.1055/a-2344-6282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
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Chehade M, Dellon ES, Spergel JM, Collins MH, Rothenberg ME, Pesek RD, Hirano I, Liu R, Laws E, Mortensen E, Martincova R, Shabbir A, McCann E, Kamal MA, Kosloski MP, Hamilton JD, Samuely C, Lim WK, Wipperman MF, Farrell A, Patel N, Yancopoulos GD, Glotfelty L, Maloney J. Dupilumab for Eosinophilic Esophagitis in Patients 1 to 11 Years of Age. N Engl J Med 2024; 390:2239-2251. [PMID: 38924731 DOI: 10.1056/nejmoa2312282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
BACKGROUND Dupilumab is a human monoclonal antibody that blocks interleukin-4 and interleukin-13 pathways and has shown efficacy in five different atopic diseases marked by type 2 inflammation, including eosinophilic esophagitis in adults and adolescents. METHODS In this phase 3 trial, we randomly assigned, in a 2:2:1:1 ratio, patients 1 to 11 years of age with active eosinophilic esophagitis who had had no response to proton-pump inhibitors to 16 weeks of a higher-exposure or lower-exposure subcutaneous dupilumab regimen or to placebo (two groups) (Part A). At the end of Part A, eligible patients in each dupilumab group continued the same regimen and those in the placebo groups were assigned to higher-exposure or lower-exposure dupilumab for 36 weeks (Part B). At each level of exposure, dupilumab was administered in one of four doses tiered according to baseline body weight. The primary end point was histologic remission (peak esophageal intraepithelial eosinophil count, ≤6 per high-power field) at week 16. Key secondary end points were tested hierarchically. RESULTS In Part A, histologic remission occurred in 25 of the 37 patients (68%) in the higher-exposure group, in 18 of the 31 patients (58%) in the lower-exposure group, and in 1 of the 34 patients (3%) in the placebo group (difference between the higher-exposure regimen and placebo, 65 percentage points [95% confidence interval {CI}, 48 to 81; P<0.001]; difference between the lower-exposure regimen and placebo, 55 percentage points [95% CI, 37 to 73; P<0.001]). The higher-exposure dupilumab regimen led to significant improvements in histologic, endoscopic, and transcriptomic measures as compared with placebo. The improvements in histologic, endoscopic, and transcriptomic measures between baseline and week 52 in all the patients were generally similar to the improvements between baseline and week 16 in the patients who received dupilumab in Part A. In Part A, the incidence of coronavirus disease 2019, nausea, injection-site pain, and headache was at least 10 percentage points higher among the patients who received dupilumab (at either dose) than among those who received placebo. Serious adverse events were reported in 3 patients who received dupilumab during Part A and in 6 patients overall during Part B. CONCLUSIONS Dupilumab resulted in histologic remission in a significantly higher percentage of children with eosinophilic esophagitis than placebo. The higher-exposure dupilumab regimen also led to improvements in measures of key secondary end points as compared with placebo. (Funded by Sanofi and Regeneron Pharmaceuticals; EoE KIDS ClinicalTrials.gov number, NCT04394351.).
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Affiliation(s)
- Mirna Chehade
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Evan S Dellon
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Jonathan M Spergel
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Margaret H Collins
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Marc E Rothenberg
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Robert D Pesek
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Ikuo Hirano
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Ruiqi Liu
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Elizabeth Laws
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Eric Mortensen
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Renata Martincova
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Arsalan Shabbir
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Eilish McCann
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Mohamed A Kamal
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Matthew P Kosloski
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Jennifer D Hamilton
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Carin Samuely
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Wei Keat Lim
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Matthew F Wipperman
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Annamaria Farrell
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Naimish Patel
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - George D Yancopoulos
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Lila Glotfelty
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Jennifer Maloney
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
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5
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Correia AA, Weber MA, Krishnan U. Prevalence, Predictive Factors, and Clinical Manifestations of Fungal Esophagitis in Children. J Pediatr Gastroenterol Nutr 2023; 77:610-617. [PMID: 37608450 DOI: 10.1097/mpg.0000000000003927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES Fungal esophagitis (FE) is the most common cause of esophageal infection and its prevalence in immunocompetent adults is rising. However, there is minimal data on FE in children without human immunodeficiency virus. Therefore, the objective of this study was to determine the prevalence, symptoms, endoscopic appearances, and predictive factors of FE in children, regardless of immune status. METHODS A 2010-2020 retrospective case-control study was conducted on 1823 children presenting to Sydney Children's Hospital for elective endoscopy with esophageal biopsy. Histopathology reports were reviewed to identify FE cases and determine prevalence rates. Thirty-two patients with FE were age- and sex-matched (1:2) to 64 controls. Significant symptoms and risk factors of FE were identified via univariate and multivariate logistic regression analysis. RESULTS The prevalence of FE in children was 1.76%. Common symptoms included dysphagia (25%), heartburn (25%), poor oral intake (21.9%), vomiting (18.8%), cough (15.6%), nausea (12.5%), and weight loss (9.4%). No significant differences in symptoms were found between cases and controls. On endoscopy, although white plaques were associated with FE ( P < 0.001), visually normal findings were reported in 28.1% of cases. Topical swallowed corticosteroids were a significant independent risk factor for FE (adjusted odds ratio = 10.740, 95% confidence interval: 1.213-95.101, P = 0.033). CONCLUSIONS The prevalence of FE in this pediatric cohort reflects rates among immunocompetent adults. Given that many of these children presented with a wide range of gastrointestinal symptoms, esophageal biopsy is required to accurately diagnose FE. Pediatricians should consider the risk of FE when prescribing topical swallowed corticosteroids.
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Affiliation(s)
- Alison A Correia
- From the Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Martin A Weber
- School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- the Department of Anatomical Pathology, New South Wales Health Pathology East (Randwick Campus), Randwick, New South Wales, Australia
| | - Usha Krishnan
- the Department of Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
- the School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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7
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Disease Burden and Unmet Need in Eosinophilic Esophagitis. Am J Gastroenterol 2022; 117:1231-1241. [PMID: 35417421 DOI: 10.14309/ajg.0000000000001777] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/04/2022] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory disease of increasing prevalence, characterized by symptoms of dysphagia and reduced quality of life. A dysregulated type 2 immune response to food and aeroallergen leads to barrier dysfunction, chronic esophageal inflammation, remodeling, and fibrosis. Patients with EoE have impaired quality of life because of dysphagia and other symptoms. They may also suffer social and psychological implications of food-related illness and expensive out-of-pocket costs associated with treatment. Disease burden in EoE is often compounded by the presence of comorbid type 2 inflammatory diseases. Current conventional treatments include elimination diet, proton pump inhibitors, and swallowed topical corticosteroids, as well as esophageal dilation in patients who have developed strictures. These treatments demonstrate variable response rates and may not always provide long-term disease control. There is an unmet need for long-term histologic, endoscopic, and symptomatic disease control; for targeted therapies that can normalize the immune response to triggers, reduce chronic inflammation, and limit or prevent remodeling and fibrosis; and for earlier diagnosis, defined treatment outcomes, and a greater understanding of patient perspectives on treatment. In addition, healthcare professionals need a better understanding of the patient perspective on disease burden, the disconnect between symptoms and disease activity, and the progressive nature of EoE and the need for continuous monitoring and maintenance treatment. In this review, we explore the progression of disease over the patient's lifespan, highlight the patient perspective on disease, and discuss the unmet need for effective long-term treatments.
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8
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Rossi CM, Lenti MV, Merli S, Licari A, Votto M, Marseglia GL, Di Sabatino A. Primary eosinophilic gastrointestinal disorders and allergy: Clinical and therapeutic implications. Clin Transl Allergy 2022; 12:e12146. [PMID: 35620572 PMCID: PMC9125508 DOI: 10.1002/clt2.12146] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 12/14/2022] Open
Abstract
Primary eosinophilic gastrointestinal disorders (EGID) are increasingly prevalent, immune‐mediated, chronic conditions which primarily affect pediatric and young adult patients, leading to substantial disease burden, and poor quality of life. EGID may either involve single portions of the gastrointestinal tract (i.e., esophagus, stomach, small bowel, and colon) or a combination. Their strong association with allergic disorders has been recently recognized, and although their shared pathophysiological basis remains partly elusive, this feature greatly impacts the diagnostic and treatment work‐up. We herein critically discuss the current knowledge on the association of EGID and allergic disorders, including atopic dermatitis, allergic rhinitis, allergic asthma, and food or drug allergy. In particular, we reviewed the literature focusing on their epidemiology, pathophysiological basis and mechanisms, and diagnostic strategies. Finally, we discuss the currently ongoing clinical trials targeting EGID and allergic diseases, including, among others the monoclonal antibodies dupilumab, mepolizumab, benralizumab, and lirentelimab.
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Affiliation(s)
- Carlo Maria Rossi
- First Department of Internal Medicine IRCCS Fondazione Policlinico San Matteo University of Pavia Pavia Italy
| | - Marco Vincenzo Lenti
- First Department of Internal Medicine IRCCS Fondazione Policlinico San Matteo University of Pavia Pavia Italy
| | - Stefania Merli
- First Department of Internal Medicine IRCCS Fondazione Policlinico San Matteo University of Pavia Pavia Italy
| | - Amelia Licari
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences University of Pavia Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Martina Votto
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences University of Pavia Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Gian Luigi Marseglia
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences University of Pavia Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Antonio Di Sabatino
- First Department of Internal Medicine IRCCS Fondazione Policlinico San Matteo University of Pavia Pavia Italy
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Chehade M, Falk GW, Aceves S, Lee JK, Mehta V, Leung J, Shumel B, Jacob-Nara JA, Deniz Y, Rowe PJ, Cunoosamy D, Khodzhayev A. Examining the Role of Type 2 Inflammation in Eosinophilic Esophagitis. GASTRO HEP ADVANCES 2022; 1:720-732. [PMID: 39131849 PMCID: PMC11307682 DOI: 10.1016/j.gastha.2022.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/06/2022] [Indexed: 08/13/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic type 2 inflammatory disease characterized by an eosinophilic inflammatory infiltrate in the esophagus, leading to remodeling, stricture formation, and fibrosis. Triggered by food and aeroallergens, type 2 cytokines interleukin (IL)-4, IL-13, IL-5 produced by CD4+ T helper 2 cells (Th2), eosinophils, mast cells, basophils, and type 2 innate lymphoid cells alter the esophageal epithelial barrier and increase inflammatory cell tissue infiltration. Clustering analysis based on the expression of type 2 inflammatory genes demonstrated the diversity of EoE endotypes. Despite the availability of treatment options for patients with EoE, which include dietary restriction, proton pump inhibitors, swallowed topical steroids, and esophageal dilation, there are still no Food and Drug Administration-approved medications for this disease; as such, there are clear unmet medical needs for these patients. A number of novel biologic therapies currently in clinical trials represent a promising avenue for targeted therapeutic approaches in EoE. This review summarizes our current knowledge on the role of type 2 inflammatory cells and mediators in EoE disease pathogenesis, as well as the future treatment landscape targeting underlying inflammation in EoE.
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Affiliation(s)
- Mirna Chehade
- Deparment of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gary W. Falk
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Seema Aceves
- Deparment of Pediatrics and Medicine, University of California, San Diego, California
| | - Jason K. Lee
- Deparment of Clinical Immunology and Allergy and Internal Medicine, Toronto Allergy and Asthma Clinic, Toronto, Ontario, Canada
| | - Vinay Mehta
- Allergy, Asthma & Immunology Associates, P.C., Lincoln, Nebraska
| | - John Leung
- Boston Specialists, Boston, Massachusetts
| | - Brad Shumel
- Regeneron Pharmaceuticals, Inc, Tarrytown, New York
| | | | - Yamo Deniz
- Regeneron Pharmaceuticals, Inc, Tarrytown, New York
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Reed CC, Ketchem CJ, Miller TL, Dellon ES. Psychiatric Comorbidities Are Highly Prevalent in Nonesophageal Eosinophilic Gastrointestinal Diseases. Clin Gastroenterol Hepatol 2022; 20:e664-e670. [PMID: 34058413 PMCID: PMC8627515 DOI: 10.1016/j.cgh.2021.05.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/07/2021] [Accepted: 05/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The prevalence of psychiatric comorbidity in nonesophageal eosinophilic gastrointestinal disorders (EGIDs) has not been studied. We aimed to ascertain the prevalence of psychiatric diagnoses and psychiatric medication use in children, adolescents, and adults with EGIDs and to assess whether psychiatric comorbidity affects clinical presentation. METHODS This was a retrospective cohort study of newly diagnosed patients with a nonesophageal EGID at the University of North Carolina from 2008 to 2020. Psychiatric diagnoses and medications were extracted from medical records. We compared the clinical and demographic features of EGID patients with and without psychiatric diagnoses. RESULTS Of 79 patients (mean 23.3 years of age, 53% male, 78% White) with a nonesophageal EGID diagnosis, 40 (51%) were diagnosed with a comorbid psychiatric disease. Anxiety (37%) and depression (28%) were most common. There were also 40 (51%) patients treated medically for a psychiatric diagnosis. Patients with a psychiatric diagnosis were more commonly ≥18 years of age at the time of EGID diagnosis (odds ratio [OR], 3.95, 95% confidence interval [CI], 1.20-13.02) and had endorsed symptoms of nausea (OR, 5.31; 95% CI, 1.33-21.22) and dysphagia (OR, 4.24; 95% CI, 1.18-15.26). CONCLUSION Psychiatric diagnoses were very common in nonesophageal EGID patients with approximately 7 in 10 adults and one-third of children diagnosed. Similar proportions were found for psychiatric medication use. We also found that psychiatric illness may influence age of clinical presentation and symptoms. Providers should assess for concomitant psychiatric comorbidities in EGID patients.
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Affiliation(s)
- Craig C. Reed
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Corey J. Ketchem
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Talya L. Miller
- Division of Pediatric Gastroenterology, Department of Pediatrics; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
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11
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Wong S, Ellison S, Haj Ali S, Hawkes J, Collinson J, O'Neill T, Ruszkiewicz A, Moore D, Holloway RH, Nguyen NQ. Characteristics and progression of childhood-onset and adult-onset eosinophilic esophagitis. J Gastroenterol Hepatol 2022; 37:69-74. [PMID: 34374118 DOI: 10.1111/jgh.15660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/27/2021] [Accepted: 08/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM The prevalence and incidence of eosinophilic esophagitis (EoE) has been increasing over recent years. However, the natural history remains incompletely understood particularly the differences in disease characteristics and progression of childhood-onset and adult-onset EoE. The aim of this study was to evaluate the disease characteristics and progression of childhood-onset and adult-onset EoE. METHODS A cross-sectional, questionnaire-based study, on 87 adults and 67 children from 2 major tertiary hospitals in South Australia was conducted. Data of those who were diagnosed with EoE between 1999 and 2018 were collected and correlated with medical records. RESULTS Of the 87 adults with EoE, 34 (39%) were diagnosed at the age of < 18 years (childhood-onset EoE). Reflux symptoms were more common in childhood-onset EoE, whereas asthma was more common in adult-onset EoE. The median duration of symptoms prior to diagnosis of EoE was > 1-4 years in childhood-onset disease (44%) and ≥ 10 years in adult-onset disease (34%). Food impaction was significantly more common on initial presentation in those with adult-onset EoE, whereas weight loss was more common in childhood-onset EoE. At the time of questionnaire, regurgitation, abdominal pain, and bloating were more common in childhood-onset EoE. Those with childhood-onset EoE were more likely to have multiple symptoms at questionnaire when compared with their adult-onset counterparts. In both groups, 15% (5/34 childhood-onset EoE and 8/53 adult-onset EoE) were asymptomatic at the time of questionnaire. CONCLUSION Childhood-onset EoE appears to be a progressive disease from childhood to adulthood, however with more inflammatory-type symptoms post transition compared to those with adult-onset EoE.
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Affiliation(s)
- Stephanie Wong
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Samuel Ellison
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Sara Haj Ali
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medicine, Al-Balqa Applied University, Salt, Jordan
| | - Joanna Hawkes
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Jane Collinson
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Thomas O'Neill
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Andrew Ruszkiewicz
- Department of Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David Moore
- Department of Gastroenterology and Hepatology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Richard H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia
| | - Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia
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12
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Review of eosinophilic oesophagitis in children and young people. Eur J Pediatr 2021; 180:3471-3475. [PMID: 34173043 DOI: 10.1007/s00431-021-04174-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/12/2021] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
Abstract
Eosinophilic oesophagitis is a relapsing inflammatory disorder involving oesophagus identified over 30 years ago. Diagnosis is made by upper gastrointestinal endoscopy and oesophageal biopsies. There is huge variation in management practices across the globe. Therapeutic options include the use of proton pump inhibitors, topical steroids, and elimination diet. Biologics and immunomodulator drugs are being explored but not yet recommended in children. Long-term treatment may be required to control symptoms and to prevent complications such as fibrosis/stricture.Conclusion: Even though clinicians have better understanding of eosinophilic oesophagitis, further research is warranted in exploring the unmet needs of developing a highly sensitive non-invasive biomarker for its diagnosis and response to treatment along with a robust and easily deliverable therapeutic option. What is Known: •Incidence of eosinophilic oesophagitis has increased over the recent years. •Diagnostic confirmation requires upper gastrointestinal endoscopy and therapeutic options include elimination diet and/or topical steroids. What is New: •There is a lack of consensus ion management strategy with wide variation across the globe. •There is a need to develop a highly reliable and non-invasive biomarker to diagnose eosinophilic oesophagitis and to monitor the response to treatment.
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13
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Dorsey YC, Song EJ, Leiman DA. Beyond the Eckardt Score: Patient-Reported Outcomes Measures in Esophageal Disorders. Curr Gastroenterol Rep 2021; 23:29. [PMID: 34850300 DOI: 10.1007/s11894-021-00831-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of patient reported outcome measures (PROMs) and summarize their role in assessing undifferentiated dysphagia and common esophageal disorders, including achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD). RECENT FINDINGS Given the subjective nature of swallowing disorders, accurate diagnoses often rely on capturing the patient experience. As a result, the number of PROMs used to characterize esophageal symptoms is increasing with a recent particular emphasis on EoE. Overall, esophageal-focused PROMs are used to interpret patient symptoms and quality of life, diagnosis, and symptom changes over time. There are limitations with each instrument, including factors affecting validity, reliability, accessibility, patient participation, and logistical implementation. PROM instruments can be helpful tools in the diagnosis and treatment of esophageal disorders. Instruments should be chosen based on factors such as target population and setting, including research, clinical, and quality improvement efforts. Future research should address how best to implement PROMs and integrate the obtained data with patient care.
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Affiliation(s)
- Y Claire Dorsey
- Division of Gastroenterology, Duke University School of Medicine, Duke Clinical Research Institute, 200 Morris Street, Durham, NC, 27701, USA
| | - Erin J Song
- Department of Medicine, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University School of Medicine, Duke Clinical Research Institute, 200 Morris Street, Durham, NC, 27701, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
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14
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Dunn JLM, Rothenberg ME. 2021 year in review: Spotlight on eosinophils. J Allergy Clin Immunol 2021; 149:517-524. [PMID: 34838883 DOI: 10.1016/j.jaci.2021.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 02/06/2023]
Abstract
This review highlights recent advances in the understanding of eosinophils and eosinophilic diseases, particularly eosinophilic gastrointestinal diseases during the last year. The increasing incidence of diseases marked by eosinophilia has been documented and highlighted the need to understand eosinophil biology and eosinophilic contributions to disease. Significant insight into the nature of eosinophilic diseases has been achieved using next-generation sequencing technologies, proteomic analysis, and machine learning to analyze tissue biopsies. These technologies have elucidated mechanistic underpinnings of eosinophilic inflammation, delineated patient endotypes, and identified patient responses to therapeutic intervention. Importantly, recent clinical studies using mAbs that interfere with type 2 cytokine signaling or deplete eosinophils point to multiple and complex roles of eosinophils in tissues. Several studies identified distinct activation features of eosinophils in different tissues and disease states. The confluence of these studies supports a new paradigm of tissue-resident eosinophils that have pro- and anti-inflammatory immunomodulatory roles in allergic disease. Improved understanding of unique eosinophil activation states is now poised to identify novel therapeutic targets for eosinophilic diseases.
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Affiliation(s)
- Julia L M Dunn
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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15
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Rosenwald K, Pan Z, Andrews R, Menard-Katcher C. Follow-up and symptom persistence after esophageal food impaction. Dis Esophagus 2021; 34:6276257. [PMID: 33993222 DOI: 10.1093/dote/doab029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/18/2021] [Accepted: 04/16/2021] [Indexed: 12/11/2022]
Abstract
Esophageal food impactions (EFI) are associated with esophageal pathology, most commonly eosinophilic esophagitis (EoE). Obtaining biopsies provides opportunity for diagnosis, which is important since treatment of EoE decreases the risk for future EFI. Outpatient follow-up rates remain suboptimal and outcomes of patients without timely follow-up are unknown. We aimed to identify the factors associated with pediatric subspecialty follow-up post-EFI and to determine the symptom burden in patients without follow-up. We performed a retrospective review of patients presenting with EFI at a tertiary children's hospital between 2010 and 2018. Patients without subspecialty follow-up within 1 year of EFI were included in a prospective telephone survey investigating the barriers to care, outcomes, and symptoms. Clinical characteristics were compared between groups. Multivariate analysis was used to control for multiple variables. There were 127 EFI identified in 123 individuals (73% male, mean age: 12.2 years). Esophageal biopsies were collected in 76% of cases, and 49% of patients had follow-up. Individuals with follow-up were more likely (P ≤ 0.05) to have had biopsies. In a multivariate analysis, written recommendation for follow-up (Odds Ratio: 6.9 [2.4-19.5], P = 0.001) as well as atopic history and identified stricture were associated with a higher likelihood of follow-up. Those without follow-up had subsequent stricture (35%), dilation (44%), or EFI (39%), and 55% (12/22) described ongoing esophageal symptoms. Identification of treatable findings at time of EFI and ongoing symptom burden after EFI support an imperative for follow-up after EFI. Clear recommendations are a modifiable factor that may improve follow-up in this population.
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Affiliation(s)
- Kent Rosenwald
- Randall Children's Hospital at Legacy Emanuel Medical Center, Portland, OR, USA
| | - Zhaoxing Pan
- Biostatistics Core of Children's Hospital Colorado Research Institute, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rachel Andrews
- Digestive Health Institute, Children's Hospital Colorado,, Aurora, CO, USA
| | - Calies Menard-Katcher
- Digestive Health Institute, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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16
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Arsiè E, Cantù P, Penagini R. The role of endoscopy in eosinophilic esophagitis: from diagnosis to therapy. Minerva Gastroenterol (Torino) 2020; 68:9-22. [PMID: 33267563 DOI: 10.23736/s2724-5985.20.02786-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endoscopy plays an important role in the management of eosinophilic esophagitis (EoE), since it is involved in the diagnosis, follow-up and treatment of this condition. In patients presenting with food impaction, dysphagia and other symptoms of suspected EoE, esophago-gastric-duodenoscopy (EGD) with multiple esophageal biopsies should be performed to confirm or rule out the diagnosis of EoE. The EREFS system, a validated instrument for assessment of the endoscopically-identified esophageal features in EoE (edema, rings, exudates, longitudinal furrows and strictures), is currently used in the clinical practice for the evaluation of the macroscopic aspects of esophageal mucosa during EGD. Multiple esophageal biopsies are mandatory to further confirm EoE diagnosis and subsequent response to treatment, since symptoms reported by patients do not always correlate with histological activity, and considering the low sensitivity of endoscopic assessment; a cut-off of ≥15 eosinophils in at least one high power field is the density threshold considered the standard for diagnosis (sensitivity 100%, specificity 96%). Other histological features, included in the EoE histologic scoring system (EoEHSS), are supportive for the diagnosis and for the assessment of inflammatory activity during follow-up. Esophageal dilation, performed either with Savary dilators/bougie or hydrostatic balloon, is an effective and safe treatment in both adult and pediatric EoE patients with fibrostenotic features, mainly in association with other therapeutic strategies which can control eosinophilic inflammation.
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Affiliation(s)
- Elena Arsiè
- Unit of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy - .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy -
| | - Paolo Cantù
- Unit of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberto Penagini
- Unit of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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17
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Frazzoni L, Tolone S. Eosinophilic esophagitis: definition, epidemiology and quality of life. Minerva Gastroenterol (Torino) 2020; 68:60-68. [PMID: 33267567 DOI: 10.23736/s2724-5985.20.02798-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Eosinophilic esophagitis (EoE) is a clinicopathological disease defined by symptoms of esophageal dysfunction and ≥15 eosinophils/HPF after excluding other causes of esophageal eosinophilia. Increasing attention has been paid by clinicians and researchers after its first description in 1978. Many consensuses and guidelines have been issued over the years, as gastroenterologists did not reach an agreement on EoE definition, especially regarding the controversial responsiveness to proton pump inhibitor (PPI) therapy. Of note, recent evidence suggests that the incidence and prevalence of EoE have been increasing through the years: many risk factors have been advocated as possible reasons for this, although further studies are needed. In this brief review, we will first cover the history of EoE in the literature, with a focus on its varying definition throughout the years. Then, we will discuss EoE epidemiology, emphasizing potential risk factors explaining its increasing incidence and prevalence. Last, we will deal with the quality of life of adult and pediatric patients with EoE.
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Affiliation(s)
- Leonardo Frazzoni
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy -
| | - Salvatore Tolone
- Unit of Mini-Invasive and Bariatric Surgery, Department of Surgery, Luigi Vanvitelli University of Campania, Naples, Italy
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18
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O'Shea KM, Rochman M, Shoda T, Zimmermann N, Caldwell J, Rothenberg ME. Eosinophilic esophagitis with extremely high esophageal eosinophil counts. J Allergy Clin Immunol 2020; 147:409-412.e5. [PMID: 32526311 DOI: 10.1016/j.jaci.2020.05.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/01/2020] [Accepted: 05/28/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Kelly M O'Shea
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark Rochman
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tetsuo Shoda
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nives Zimmermann
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Julie Caldwell
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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19
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Psychiatric Comorbidities and Psychiatric Medication Use Are Highly Prevalent in Patients With Eosinophilic Esophagitis and Associate With Clinical Presentation. Am J Gastroenterol 2020; 115:853-858. [PMID: 32195733 PMCID: PMC7274870 DOI: 10.14309/ajg.0000000000000597] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The prevalence of psychiatric disease in patients with eosinophilic esophagitis (EoE) is not fully characterized. We aimed to determine the prevalence of psychiatric disease and centrally acting medication use in a cohort of children and adults with EoE and evaluated whether psychiatric disease affects the EoE clinical presentation. METHODS We conducted a retrospective study of newly diagnosed cases with EoE at the University of North Carolina from 2002 to 2018. Psychiatric comorbidities and relevant treatments were extracted from the medical records. The demographic and clinical features of patients with EoE with and without psychiatric diagnoses, and those with and without psychiatric medication use, were compared. RESULTS Of 883 patients (mean age 26.6 years, 68% men, 79% white), 241 (28%) had a psychiatric comorbidity. The most common diagnosis was anxiety (23%) followed by depression (17%); 28% of patients were treated pharmacologically. There were 45 patients (5%) treated pharmacologically without a psychiatric diagnosis for chronic pain syndromes, insomnia, and/or epilepsy. Cases with EoE with a psychiatric diagnosis were more likely to be women, white, and 18 years or older and to have a longer symptom duration before diagnosis. DICUSSION Psychiatric comorbidities were common in EoE, seen in a third of adults and more than 1 in 7 children, and with similar proportions receiving a prescription medication. These illnesses affected the EoE presentation because psychiatric comorbidities were more likely in older, female, and white patients with a longer duration of symptoms preceding diagnosis.
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20
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Lieberman JA. Minimally symptomatic patients with eosinophilic esophagitis should still be actively treated-CON. Ann Allergy Asthma Immunol 2020; 122:574-575. [PMID: 31171239 DOI: 10.1016/j.anai.2018.11.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 11/08/2018] [Accepted: 11/19/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Jay Adam Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, LeBonheur Children's Hospital, Memphis, Tennessee.
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21
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Lynch MK, Dimmitt RA, Goodin BR. Evidence of Disturbed Sleep in Children With Eosinophilic Esophagitis and Persistent Epigastric Pain. J Pediatr Psychol 2019; 43:331-341. [PMID: 29048495 DOI: 10.1093/jpepsy/jsx117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/29/2017] [Indexed: 12/21/2022] Open
Abstract
Objective To determine whether the experience of persistent epigastric pain is associated with sleep disturbances in children with eosinophilic esophagitis (EoE). We hypothesized that children with EoE and persistent epigastric pain would (1) self-report greater current and worst pain severity, and (2) experience more disturbed sleep on objective and subjective measures in comparison with children with EoE but no persistent pain and healthy children. Methods Fifty children with EoE were recruited for this cross-sectional study, of which 24 (48%) reported experiencing persistent epigastric pain. The remaining 26 (52%) children with EoE denied experiencing persistent pain. An additional 25 healthy children without EoE or persistent pain were included. All children provided severity ratings of current pain and worst pain experienced over the past week. Children then completed 12 consecutive nights of ambulatory sleep monitoring via actigraphy in the home. Caregivers provided information regarding their child's sleep patterns and internalizing symptoms. Results Children with EoE and persistent pain reported significantly greater severity of current pain (p < .001) and worst pain over the past week (p < .001) compared with EoE without persistent pain and healthy children. Compared with the other groups, children with EoE and persistent pain also demonstrated greater actigraphic sleep disturbances, lower sleep efficiency (p = .004) and greater wake after sleep onset (p = .034). Conclusions This study provides novel evidence that a significant proportion of children with EoE experience persistent symptoms of epigastric pain. Persistent pain was associated with significant sleep disturbances in children with EoE.
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Affiliation(s)
| | - Reed A Dimmitt
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics
| | - Burel R Goodin
- Department of Psychology.,Division of Pain Medicine, Department of Anesthesiology & Perioperative Medicine, University of Alabama at Birmingham
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22
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Lynch MK, Barnes MJ, Dimmitt RA, Martin L, Rothenberg ME, Goodin BR. Disease-Related Predictors of Health-Related Quality of Life in Youth With Eosinophilic Esophagitis. J Pediatr Psychol 2019; 43:464-471. [PMID: 29048518 DOI: 10.1093/jpepsy/jsx128] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 09/30/2017] [Indexed: 01/07/2023] Open
Abstract
Objective To evaluate relations between health-related quality of life (HRQoL) and clinical symptom presentation in youth with eosinophilic esophagitis (EoE). We hypothesized that presence of dysphagia, reflux, nausea/vomiting, and epigastric pain would be related to poorer HRQoL. In predictive models, it was hypothesized that dysphagia, reflux, nausea/vomiting, and epigastric pain would each significantly and uniquely predict poorer HRQoL. Methods This cross-sectional, two-study design included 91 dyads comprised children with EoE and their respective caregivers across two tertiary children's hospitals, Site 1 in the Midwest (N = 47) and Site 2 in the Deep South (N = 44). Youth and their caregivers both completed questionnaires addressing HRQoL and EoE symptoms during clinic visits. Results Per youth self-report, epigastric pain was found to be a significant predictor of poor physical and psychosocial HRQoL. Per caregiver-proxy reports, epigastric pain was found to be a significant predictor of poor physical HRQoL. Conclusions The clinical symptoms of EoE, specifically epigastric pain, were found to be predictive of the youth's HRQoL. Targeted interventions to help youth with EoE better manage their specific symptom experiences could ultimately improve HRQoL.
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Affiliation(s)
| | | | - Reed A Dimmitt
- Department of Pediatrics, University of Alabama at Birmingham
| | - Lisa Martin
- Department of Pediatrics, University of Cincinnati School of Medicine.,Division of Human Genetics
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center
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23
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Capucilli P, Hill DA. Allergic Comorbidity in Eosinophilic Esophagitis: Mechanistic Relevance and Clinical Implications. Clin Rev Allergy Immunol 2019; 57:111-127. [PMID: 30903437 PMCID: PMC6626558 DOI: 10.1007/s12016-019-08733-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Allergic eosinophilic esophagitis (EoE) is a chronic, allergen-mediated inflammatory disease of the esophagus, and the most common cause of prolonged dysphagia in children and young adults in the developed world. While initially undistinguished from gastroesophageal reflux disease-associated esophageal eosinophilia, EoE is now recognized as a clinically distinct entity that shares fundamental inflammatory features of other allergic conditions and is similarly increasing in incidence and prevalence. The clinical and epidemiologic associations between EoE and other allergic manifestations are well established. In addition to exaggerated rates of atopic dermatitis, IgE-mediated food allergy, asthma, and allergic rhinitis in EoE patients, each of these allergic manifestations imparts individual and cumulative risk for subsequent EoE diagnosis. As such, EoE may be a member of the "allergic march"-the natural history of allergic manifestations during childhood. Several determinants likely contribute to the relationship between these conditions, including shared genetic, environmental, and immunologic factors. Herein, we present a comprehensive review of allergic comorbidity in EoE. We discuss areas of the genome associated with both EoE and other allergic diseases, including the well-studied variants encoding thymic stromal lymphopoietin and calpain 14, among other "atopic" regions. We summarize ways that environmental factors (such as microbiome-altering pressures and aeroallergen exposure) may predispose to multiple allergic conditions including EoE. Finally, we touch on some fundamental features of type 2 inflammation, and the resulting implications for the development of multiple allergic manifestations. We conclude with an analysis of the "type 2" biologics, and how mechanistic similarities between EoE and the other allergic manifestations have important implications for screening and treatment of the allergic patient.
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Affiliation(s)
- Peter Capucilli
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Building, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - David A Hill
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Abramson Research Building, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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24
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Meyer R, Fox AT, Chebar Lozinsky A, Michaelis LJ, Shah N. Non-IgE-mediated gastrointestinal allergies-Do they have a place in a new model of the Allergic March. Pediatr Allergy Immunol 2019; 30:149-158. [PMID: 30403301 DOI: 10.1111/pai.13000] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 10/08/2018] [Accepted: 10/23/2018] [Indexed: 12/18/2022]
Abstract
The rise in food allergy has been described as the "second wave" of the allergy epidemic, with some developed countries reporting a prevalence of 10% of challenge-proven food allergies. Recognition of the Allergic March has played a crucial role in identifying causality in allergic conditions, linking atopic dermatitis to food allergy and food allergy to other atopic disorders, thereby highlighting opportunities in prevention and the importance of early intervention. This publication will establish the value of weaving the less well-understood, non-IgE-mediated food allergy into the Allergic March and mapping its progression through childhood and its associated co-morbidities. The proposed non-IgE-mediated Allergic March highlights the concomitant presentation of gastrointestinal symptoms and atopic dermatitis as early presenting symptoms in confirmed non-IgE-mediated allergies and the later development of atopic co-morbidities, including asthma and allergic rhinitis, similar to the IgE-mediated Allergic March. This publication highlights recent observations of a link between non-IgE-mediated food allergy in early childhood and functional gastrointestinal disorders in later life and also the reported occurrence of extra-intestinal manifestations at later ages. Although significant limitations exist in regard to the proposed evolution of the Allergic March model, the authors hope that this publication will influence the management of non-IgE-mediated gastrointestinal allergies and inform future research and interventions.
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Affiliation(s)
- Rosan Meyer
- Department Paediatrics, Imperial College, London, UK
| | - Adam T Fox
- Department of Paediatric Allergy, Evelina London Children's Hospital, London, UK
| | | | - Louise J Michaelis
- Department of Allergy and Immunology, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Neil Shah
- Department Gastroenterology, Great Ormond Street Hospital, London, UK
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25
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Sallis BF, Acar U, Hawthorne K, Babcock SJ, Kanagaratham C, Goldsmith JD, Rosen R, Vanderhoof JA, Nurko S, Fiebiger E. A Distinct Esophageal mRNA Pattern Identifies Eosinophilic Esophagitis Patients With Food Impactions. Front Immunol 2018; 9:2059. [PMID: 30455683 PMCID: PMC6230678 DOI: 10.3389/fimmu.2018.02059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/21/2018] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic esophagitis (EoE), a Th2-type allergic immune disorder characterized by an eosinophil-rich esophageal immune infiltrate, is often associated with food impaction (FI) in pediatric patients but the molecular mechanisms underlying the development of this complication are not well understood. We aim to identify molecular pathways involved in the development of FI. Due to large variations in disease presentation, our analysis was further geared to find markers capable of distinguishing EoE patients that are prone to develop food impactions and thus expand an established medical algorithm for EoE by developing a secondary analysis that allows for the identification of patients with food impactions as a distinct patient population. To this end, mRNA patterns from esophageal biopsies of pediatric EoE patients presenting with and without food impactions were compared and machine learning techniques were employed to establish a diagnostic probability score to identify patients with food impactions (EoE+FI). Our analysis showed that EoE patients with food impaction were indistinguishable from other EoE patients based on their tissue eosinophil count, serum IgE levels, or the mRNA transcriptome-based p(EoE). Irrespectively, an additional analysis loop of the medical algorithm was able to separate EoE+FI patients and a composite FI-score was established that identified such patients with a sensitivity of 93% and a specificity of 100%. The esophageal mRNA pattern of EoE+FI patients was typified by lower expression levels of mast cell markers and Th2 associated transcripts, such as FCERIB, CPA3, CCL2, IL4, and IL5. Furthermore, lower expression levels of regulators of esophageal motility (NOS2 and HIF1A) were detected in EoE+FI. The EoE+FI -specific mRNA pattern indicates that impaired motility may be one underlying factor for the development of food impactions in pediatric patients. The availability of improved diagnostic tools such as a medical algorithm for EoE subpopulations will have a direct impact on clinical practice because such strategies can identify molecular inflammatory characteristics of individual EoE patients, which, in turn, will facilitate the development of individualized therapeutic approaches that target the relevant pathways affected in each patient.
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Affiliation(s)
- Benjamin F. Sallis
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Utkucan Acar
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Kelsey Hawthorne
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
- Center for Motility and Functional Gastrointestinal Disorders Boston Children's Hospital, Boston, MA, United States
| | - Stephen J. Babcock
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Cynthia Kanagaratham
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | | | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
- Center for Motility and Functional Gastrointestinal Disorders Boston Children's Hospital, Boston, MA, United States
- Department of Pathology, Boston Children's Hospital, Boston, MA, United States
| | - Jon A. Vanderhoof
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Samuel Nurko
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
- Center for Motility and Functional Gastrointestinal Disorders Boston Children's Hospital, Boston, MA, United States
| | - Edda Fiebiger
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
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26
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Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus associated with an atopic predisposition which appears to be increasing in prevalence over the last few decades. Symptoms stem from fibrosis, swelling, and smooth muscle dysfunction. In the past two decades, the etiology of EoE has been and is continuing to be revealed. This review provides an overview of the effects of genetics, environment, and immune function including discussions that touch on microbiome, the role of diet, food allergy, and aeroallergy. The review further concentrates on the pathophysiology of the disease with particular focus on the important concepts of the molecular etiology of EoE including barrier dysfunction and allergic hypersensitivity.
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Affiliation(s)
- Benjamin P Davis
- Department of Internal Medicine, Division of Immunology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52246, USA.
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Hommeida S, Grothe RM, Hafed Y, Lennon RJ, Schleck CD, Alexander JA, Katzka DA, Absah I. Assessing the incidence trend and characteristics of eosinophilic esophagitis in children in Olmsted County, Minnesota. Dis Esophagus 2018; 31:5049295. [PMID: 29982568 PMCID: PMC6279968 DOI: 10.1093/dote/doy062] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Previous studies reported increased eosinophilic esophagitis (EoE) incidence in children. It is unclear whether this reported increased EoE incidence is true or due to increased recognition and diagnostic endoscopy among children. A population-based study that evaluated EoE incidence in OC, Minnesota, from 1976 to 2005 concluded that EoE incidence increased significantly over the past three 5-year intervals (from 0.35 [range: 0-0.87] per 100,000 person-years for 1991-1995 to 9.45 [range: 7.13-11.77] per 100,000 person-years for 2001-2005). The aim of this study is to assess the change of incidence and characteristics of EoE in children in the same population between 2005 and 2015 and compare the findings to those reported in the previous study. We retrospectively reviewed the electronic medical records from Olmsted Medical Center and Mayo Clinic between 2005 and 2015, using Rochester Epidemiology Project (REP) resources. All children with EoE diagnosis based on the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines were included. The incidence and characteristics of children with EoE during the study period were compared to those diagnosed between 1995 and 2005. The incidence of EoE in children adjusted for age and sex was 5.31 per 100,000 population person-years in 1995, 15.2 in 2005, and 19.2 in 2015. Change in annual incidence and seasonal variation were not significant, (P = .48) and (P = .32), respectively. Between 2005 and 2015, 73 children received an EoE diagnosis (boys 49; 67%) compared to 16 children (boys 10; 62.5) between 1995 and 2005. Mean (SD) age at diagnosis was 7.5 (5.2) and 12.8 (4.3) years, respectively. Symptoms differed by age of presentation, with vomiting the most common in children younger than 5 years (41.1% and 43.5%) and dysphagia in those older than 5 years (35.6% and 60.9%). The incidence of EoE was not increased for any specific age-group during the study period (P = .49). This study showed increased incidence of EoE in children in Olmsted County between 2005 and 2015 compared to the incidence between 1995 and 2005 (5.31 per 100,000 population person-years in 1995, 15.2 in 2005, and 19.2 in 2015). However, between 2005 and 2015, the change of incidence was not statically significant, (P = .48) despite the steady increase of EGD performed during the same time frame (64 in 2005 to 144 in 2015). By comparing children diagnosed between 2005 and 2015 to those diagnosed between 1995 and 2005, the mean age at diagnosis was younger in the former group, 7.5 versus 12.8 years. Vomiting replaced dysphagia as the most common clinical presentation. Otherwise, the presenting symptom of EoE in children remained consistent across specific age groups.
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Affiliation(s)
- S Hommeida
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA,Address correspondence to: Salim Hommeida, M.D., Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail:
| | - R M Grothe
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA,Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Y Hafed
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - R J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - C D Schleck
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - J A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - I Absah
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA,Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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Hill DA, Grundmeier RW, Ramos M, Spergel JM. Eosinophilic Esophagitis Is a Late Manifestation of the Allergic March. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1528-1533. [PMID: 29954692 DOI: 10.1016/j.jaip.2018.05.010] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/08/2018] [Accepted: 05/14/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The allergic march describes the natural history of allergic conditions as they develop during childhood. Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease that can be triggered by specific foods. Despite its allergic pathophysiology, the epidemiologic relationship between EoE and established members of the allergic march is unknown. OBJECTIVE We sought to determine whether EoE meets epidemiologic criteria for being considered a member of the allergic march. METHODS Using a primary care birth cohort of 130,435 children, we determined the natural histories of atopic dermatitis (AD), IgE-mediated food allergy (IgE-FA), asthma, EoE, and allergic rhinitis (AR) in individual patients. We then performed case-control analyses to establish the extent that existing allergic conditions influence the rate of subsequent EoE diagnosis. RESULTS A total of 139 children developed EoE during the observation period (prevalence of 0.11%). The peak age of EoE diagnosis was 2.6 years, as compared with 0.3 years, 1 year, 1.1 years, and 2.1 years for AD, IgE-FA, asthma, and AR, respectively. The presence of AD (hazard ratio [HR] 3.2, 95% confidence interval [CI] 2.2-4.6), IgE-FA (HR 9.1, 95% CI 6.5-12.6), and asthma (HR 1.9, 95% CI 1.3-2.7) was independently and cumulatively associated with subsequent EoE diagnosis. The presence of AR was associated with subsequent EoE diagnosis (HR 2.8, 95% CI 2.0-3.9), and the presence of EoE was associated with subsequent AR diagnosis (HR 2.5, 95% CI 1.7-3.5). CONCLUSIONS Allergic comorbidities are positively associated with EoE diagnosis. Together, our findings suggest that EoE is a late manifestation of the allergic march.
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Affiliation(s)
- David A Hill
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Mark Ramos
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jonathan M Spergel
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
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Mukkada V, Falk GW, Eichinger CS, King D, Todorova L, Shaheen NJ. Health-Related Quality of Life and Costs Associated With Eosinophilic Esophagitis: A Systematic Review. Clin Gastroenterol Hepatol 2018; 16:495-503.e8. [PMID: 28655543 DOI: 10.1016/j.cgh.2017.06.036] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/02/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease characterized by esophageal inflammation and dysfunction. Little is known about the humanistic and economic burden of the disease on patients, their caregivers, and the health care system. A systematic review was conducted to evaluate the existing literature on the disease burden of EoE for patients and their caregivers. METHODS The MEDLINE, Embase, and Evidence-Based Medicine Reviews databases and recent congresses were searched on March 23, 2017, for English-language publications describing the impact of EoE on health-related quality of life (HRQoL) in children and adults, and the economic burden associated with the disease. RESULTS Of 676 articles identified, 22 met the inclusion criteria and were included in this analysis (HRQoL, 13; economic burden, 7; cost effectiveness, 2). The included studies showed that EoE is associated with a significant impact on HRQoL, resulting in disruption to and restrictions on daily life for patients, their caregivers, and, in some instances, their families. Treatment with topical corticosteroids, the 6-food elimination diet, or the cow's milk elimination diet significantly improved the HRQoL of patients with EoE. Symptom severity was associated strongly with the impact of EoE on HRQoL. Medical resource utilization costs for patients with EoE were significantly higher than those for healthy controls. CONCLUSIONS EoE negatively impacts the HRQoL of patients and their families, and is a burden to the health care system. Although data are sparse, currently available treatments appear to improve HRQoL.
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Affiliation(s)
- Vincent Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Denise King
- PharmaGenesis London, London, United Kingdom
| | | | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Shaheen NJ, Mukkada V, Eichinger CS, Schofield H, Todorova L, Falk GW. Natural history of eosinophilic esophagitis: a systematic review of epidemiology and disease course. Dis Esophagus 2018; 31:4958126. [PMID: 29617744 PMCID: PMC6102800 DOI: 10.1093/dote/doy015] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/03/2018] [Indexed: 12/14/2022]
Abstract
Eosinophilic esophagitis is a chronic immune-mediated esophageal disorder. For its timely diagnosis, clinicians must recognize common symptoms, and understand differences in symptoms across patient groups. The aim of this study is to systematically review the epidemiology and natural history of eosinophilic esophagitis. The MEDLINE, Embase, and Cochrane databases were searched from 1974 to February 2017 for studies describing the epidemiology and natural history of eosinophilic esophagitis. Congress abstracts from 2014 to 2016 were also searched. Search results were screened against predetermined inclusion/exclusion criteria by two independent reviewers, and data extraction was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 1376 articles identified, 47 met the inclusion criteria: 20 on epidemiology and 27 on natural history. Incidence and prevalence of eosinophilic esophagitis varied widely across North America and Europe, and increased over time. Incidence increased 131-fold in the Netherlands (1996-2010), 20-fold in Denmark (1997-2006), and 5.1-fold in Calgary, Canada (2004-2008). The most commonly reported symptoms were emesis and abdominal pain in children, and dysphagia and food impaction in adults. Age at diagnosis was 5.9-12.0 years in children, and approximately 30 years in adults. Time between symptom onset and diagnosis was 1.2-3.5 years in children and 3.0-8.0 years in adults. Diagnostic delay was associated with an increased risk of endoscopic features of fibrostenosis. Symptoms of eosinophilic esophagitis differed significantly by age and race. In conclusion, there is an increasing incidence and prevalence of eosinophilic esophagitis. The considerable delay between symptom onset and diagnosis suggests that clinicians do not readily recognize the disease, which may have important clinical ramifications.
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Affiliation(s)
- N J Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina,Address correspondence to: Nicholas J. Shaheen, MD, MPH, Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, CB#7080, 130 Mason Farm Road, Suite 4150, Chapel Hill, NC 27599-7080, USA.
| | - V Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | | | - G W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Lieberman JA, Zhang J, Whitworth J, Cavender C. A randomized, double-blinded, placebo-controlled study of the use of viscous oral cromolyn sodium for the treatment of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2018; 120:527-531. [PMID: 29544738 DOI: 10.1016/j.anai.2018.03.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/12/2018] [Accepted: 03/06/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is a need for effective, nonsteroid pharmacologic therapies for eosinophilic esophagitis (EoE). Cromolyn sodium offers an option because mast cells have been implicated in the symptomatology of EoE and cromolyn has been shown to have some anti-eosinophilic properties. OBJECTIVE To evaluate the efficacy of cromolyn in decreasing esophageal eosinophilia in patients with EoE. Secondary outcomes included symptom improvement and adverse effects. METHODS We conducted a randomized, double-blinded, placebo-controlled trial of viscous oral cromolyn for EoE in pediatric patients. Subjects were randomized to 100 mg (2-11 years of age) or 200 mg (12-17 years of age) of cromolyn or placebo 4 times daily. The medications were mixed with powdered sugar at home to make them viscous. RESULTS Sixteen subjects (50% boys, median age 11.4 years) were enrolled. Nine were randomized to cromolyn and 7 were randomized to placebo. Cromolyn decreased the peak eosinophil count from 62.1 to 57.3 eosinophils per high-powered field (P = .78) and placebo decreased the peak eosinophil count from 87.0 to 71.3 eosinophils per high-powered field (P = .62) One subject randomized to cromolyn and none in the placebo arm had complete resolution of eosinophilia. Cromolyn decreased symptoms scores from a mean baseline score of 37.8 to a mean post-therapy score of 17.5, which was a 54% decrease (P = .04). Placebo decreased the symptom scores from a baseline score of 32.2 to a post-therapy score of 23.3, which was a 28% decrease (P = .05). CONCLUSION Cromolyn, when mixed into a viscous preparation, did not significantly decrease esophageal eosinophilia. However, it did decrease symptom scores (although not significantly more than placebo) and led to complete resolution in 1 subject.
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Affiliation(s)
- Jay Adam Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Jie Zhang
- Department of Pathology, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Whitworth
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Cary Cavender
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee
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Reed CC, Wolf WA, Cotton CC, Rusin S, Perjar I, Hollyfield J, Woosley JT, Shaheen NJ, Dellon ES. Optimal Histologic Cutpoints for Treatment Response in Patients With Eosinophilic Esophagitis: Analysis of Data From a Prospective Cohort Study. Clin Gastroenterol Hepatol 2018; 16:226-233.e2. [PMID: 28987502 PMCID: PMC6582220 DOI: 10.1016/j.cgh.2017.09.046] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/22/2017] [Accepted: 09/27/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS No prospective studies substantiate 15 eos/hpf as an appropriate endpoint for treatment of eosinophilic esophagitis (EoE). We aimed to determine a histologic cutpoint that identifies successful treatment of EoE by assessing symptomatic and endoscopic improvement. METHODS We performed a prospective cohort study of 62 consecutive adult patients undergoing outpatient esophagogastroduodenoscopy at the University of North Carolina from 2009 through 2014. At diagnosis of EoE and after 8 weeks of standard treatment, symptom and endoscopic responses were measured using a visual analogue scale and an endoscopic severity score (ESS), and eosinophil counts were assessed. Receiver operator curves and logistic regression models evaluated the histologic threshold that best predicted symptomatic and endoscopic response. For symptoms, analysis was limited to patients without baseline esophageal dilation. RESULTS The mean eosinophil count at diagnosis was 124 eos/hpf, falling to 35 eos/hpf after treatment. The mean visual analogue scale decreased from 3.4 at baseline to 1.7 after treatment, and the mean ESS decreased from 3 to 1.6. Twenty-nine patients had symptom responses (47%) and 34 had endoscopic responses (55%). Post-treatment eosinophil count thresholds of 8, 15, and 5 eos/hpf best predicted symptom, endoscopic and combined responses, respectively. On logistic regression, decreasing eosinophil count was significantly associated with the probability of symptomatic (P = .01) and endoscopic response (P < .001). CONCLUSIONS In a prospective study of patients with EoE, we found that a cutpoint of <15 eos/hpf identifies most patients with symptom and endoscopic improvements, providing support for the current diagnostic threshold. A lower threshold (<5 eos/hpf) identifies most patients with a combination of symptom and endoscopic responses; this cutpoint might be used in situations that require a stringent histologic threshold.
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Affiliation(s)
- Craig C. Reed
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - W. Asher Wolf
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Cary C. Cotton
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Spencer Rusin
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Irina Perjar
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Johnathan Hollyfield
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - John T. Woosley
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nicholas J. Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Collins MH, Capocelli K, Yang GY. Eosinophilic Gastrointestinal Disorders Pathology. Front Med (Lausanne) 2018; 4:261. [PMID: 29379785 PMCID: PMC5775510 DOI: 10.3389/fmed.2017.00261] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/26/2017] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic gastrointestinal disorders (EGID) are characterized pathologically by excess eosinophils in mucosal biopsies of one or multiple sites in the gastrointestinal (GI) tract, simultaneously or sequentially. Eosinophilic esophagitis (EoE) is the best characterized EGID, and in most patients it is an abnormal immune-mediated response to food antigens. Current recommendations for diagnosis include signs and symptoms of esophageal dysfunction that do not respond to proton-pump inhibitor therapy, and esophageal biopsies that exhibit at least 15 intraepithelial eosinophils in at least one high power field (HPF). Therapy consists of swallowed glucocorticoids or dietary elimination. Eosinophilic gastritis (EG) is the second most common form of EGID, but like all forms of EGID except EoE consensus recommendations for either clinical or pathological diagnosis do not exist. EG may be associated clinically with peripheral blood eosinophilia, hypoalbuminemia, and anemia, and pathologically with marked expansion of lamina propria by dense eosinophilic infiltrates. Eosinophilic enteritis (EE) may be subdivided into eosinophilic duodenitis, eosinophilic jejunitis, and eosinophilic ileitis. Most investigators believe that EE rarely, if ever, exists as a solitary form of EGID and is encountered only in patients who have at least one other affected portion of the GI tract. Eosinophilic colitis (EC) is perhaps the most enigmatic EGID. Distinction of EC from inflammatory bowel disease may be problematic especially in children. Multiple possible etiologies for EGID include hypereosinophilic syndrome, drug reactions, etc. Currently, the only etiology that can be identified histologically is parasitic infestation, if a portion of an invasive parasite is found in mucosal biopsies. This review will provide guidelines for the pathologic diagnosis of the various forms of EGID.
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Affiliation(s)
- Margaret H Collins
- Division of Pathology and Laboratory Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Kelley Capocelli
- Department of Pathology, Children's Hospital Colorado, Aurora, CO, United States.,Department of Pathology, University of Colorado, Denver, CO, United States
| | - Guang-Yu Yang
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Muñoz-Mendoza D, Chapa-Rodríguez A, Bahna SL. Eosinophilic Esophagitis Clinical Manifestations and Differential Diagnosis. Clin Rev Allergy Immunol 2018; 55:7-18. [PMID: 29290036 DOI: 10.1007/s12016-017-8663-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
As a chronic inflammatory disease with eosinophilic infiltrate of the esophagus, eosinophilic esophagitis (EoE) causes a variety of gastrointestinal (GI) clinical manifestations. None of the symptoms, endoscopic features, or biopsy findings is pathognomonic of the disease, even with high degrees of esophageal eosinophilia. The pathogenesis has been explored by several studies, yet it still far from being completely understood. Evidence supports a role of allergen-driven Th2 lymphocyte mechanism, though not in every patient. This article addresses the disease's clinical manifestations, endoscopic findings, diagnosis, and differential diagnoses. In addition to the current diagnostic criteria, we summarize some recently emerging procedures that promise of enhancing more precise diagnosis and institution of early appropriate management, with consequent better quality of life and reduction of complications.
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Affiliation(s)
- Diana Muñoz-Mendoza
- Department of Pediatrics, Allergy and Immunology Section, Louisiana State University Health Sciences Center in Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA
| | - Adrián Chapa-Rodríguez
- Department of Pediatrics, Gastroenterology and Nutrition Section, Louisiana State University Health Sciences Center in Shreveport, Shreveport, LA, USA
| | - Sami L Bahna
- Department of Pediatrics, Allergy and Immunology Section, Louisiana State University Health Sciences Center in Shreveport, 1501 Kings Highway, Shreveport, LA, 71130-3932, USA.
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Dellon ES, Hirano I. Epidemiology and Natural History of Eosinophilic Esophagitis. Gastroenterology 2018; 154:319-332.e3. [PMID: 28774845 PMCID: PMC5794619 DOI: 10.1053/j.gastro.2017.06.067] [Citation(s) in RCA: 464] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) has emerged over the past 2 decades as a major cause of upper gastrointestinal morbidity. Over this time, the epidemiology of EoE has also rapidly evolved. EoE has transformed from a rare case-reportable condition to disease that is commonly encountered in the gastroenterology clinic, hospital emergency room, and endoscopy suite. The incidence and prevalence are increasing at rates that outpace increased disease recognition. Current incidence estimates range from 5 to 10 cases per 100,000, and current prevalence estimates range from 0.5 to 1 case per 1000. We review the data and potential reasons behind this increase, examine risk factors, and identify important areas for research into disease etiology. The article also discusses the progression of EoE from an inflammatory to fibrostenotic phenotype. An accurate view of the natural history of EoE is central to discussions with patients regarding disease prognosis and decisions about long-term use of medical, endoscopic, and diet therapies. Progressive remodelling appears to be gradual, but not universal, and the duration of untreated disease is the best predictor of stricture risk. Ultimately, prospective, long-term outcome studies focusing on multiple aspects of disease activity are needed to fully understand the natural history of EoE.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Ikuo Hirano
- Divsion of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Abstract
Adults and children with eosinophilic esophagitis (EoE) have distinct clinical and endoscopic presentations. Recognition of clinical signs, along with laboratory and endoscopic findings, is critical for the identification of patients with EoE because delay in diagnosis has been associated with esophageal remodeling and stricture formation. Clinical presentation varies considerably between adults and children. This is less due to differences in the disease and more due to patient differences. This article describes the similarities and differences in clinical presentation of children and adults with EoE, including areas of epidemiology, clinical and endoscopic presentation, pathophysiology, and treatment.
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37
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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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Martin LJ, He H, Collins MH, Abonia JP, Biagini Myers JM, Eby M, Johansson H, Kottyan LC, Khurana Hershey GK, Rothenberg ME. Eosinophilic esophagitis (EoE) genetic susceptibility is mediated by synergistic interactions between EoE-specific and general atopic disease loci. J Allergy Clin Immunol 2017; 141:1690-1698. [PMID: 29129581 DOI: 10.1016/j.jaci.2017.09.046] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/26/2017] [Accepted: 09/27/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is an esophageal inflammatory disease associated with atopic diseases. Thymic stromal lymphopoietin (TSLP) and calpain 14 (CAPN14) genetic variations contribute to EoE, but how this relates to atopy is unclear. OBJECTIVE The purpose of this study was to explore the relationship between EoE, atopy, and genetic risk. METHODS EoE-atopy enrichment was tested by using 700 patients with EoE and 801 community control subjects. Probing 372 single nucleotide polymorphisms (SNPs) in 63 atopy genes, we evaluated EoE associations using 412 nonatopic and 868 atopic disease control subjects. Interaction and stratified analyses of EoE-specific and atopy-related SNPs were performed. RESULTS Atopic disease was enriched in patients with EoE (P < .0001). Comparing patients with EoE and nonatopic control subjects, EoE associated strongly with IL-4/kinesin family member 3A (IL4/KIF3A) (P = 2.8 × 10-6; odds ratio [OR], 1.87), moderately with TSLP (P = 1.5 × 10-4; OR, 1.43), and nominally with CAPN14 (P = .029; OR, 1.35). Comparing patients with EoE with atopic disease control subjects, EoE associated strongly with ST2 (P = 3.5 × 10-6; OR, 1.77) and nominally with IL4/KIF3A (P = .019; OR, 1.25); TSLP's association persisted (P = 4.7 × 10-5; OR, 1.37), and CAPN14's association strengthened (P = .0001; OR, 1.71). Notably, there was gene-gene interaction between TSLP and IL4 SNPs (P = .0074). Children with risk alleles for both genes were at higher risk for EoE (P = 2.0 × 10-10; OR, 3.67). CONCLUSIONS EoE genetic susceptibility is mediated by EoE-specific and general atopic disease loci, which can have synergistic effects. These results might aid in identifying potential therapeutics and predicting EoE susceptibility.
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Affiliation(s)
- Lisa J Martin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati Medical School, Cincinnati, Ohio
| | - Hua He
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margaret H Collins
- Department of Pediatrics, University of Cincinnati Medical School, Cincinnati, Ohio; Division of Pathology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - J Pablo Abonia
- Department of Pediatrics, University of Cincinnati Medical School, Cincinnati, Ohio; Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joceyln M Biagini Myers
- Department of Pediatrics, University of Cincinnati Medical School, Cincinnati, Ohio; Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael Eby
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hanna Johansson
- Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leah C Kottyan
- Department of Pediatrics, University of Cincinnati Medical School, Cincinnati, Ohio; Center for Autoimmune Genomics and Etiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gurjit K Khurana Hershey
- Department of Pediatrics, University of Cincinnati Medical School, Cincinnati, Ohio; Division of Asthma Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marc E Rothenberg
- Department of Pediatrics, University of Cincinnati Medical School, Cincinnati, Ohio; Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Hudgens S, Evans C, Phillips E, Hill M. Psychometric validation of the Dysphagia Symptom Questionnaire in patients with eosinophilic esophagitis treated with budesonide oral suspension. J Patient Rep Outcomes 2017; 1:3. [PMID: 29757322 PMCID: PMC5934937 DOI: 10.1186/s41687-017-0006-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/27/2017] [Indexed: 02/07/2023] Open
Abstract
Background Eosinophilic esophagitis (EoE) is characterized by high levels of eosinophils in the esophageal mucosa. Patients with the disease present with a range of symptoms, including dysphagia (difficulty swallowing). The aim of this analysis was to assess the psychometric properties of the Dysphagia Symptom Questionnaire (DSQ), a patient-reported outcome (PRO) measure of dysphagia associated with EoE. Psychometric properties of the DSQ were assessed using data collected from a 12-week, phase 2, multicenter, randomized, double-blind, placebo-controlled trial of budesonide oral suspension in adolescents and adults (11–40 years old) with EoE. Results The study population comprised 93 patients with EoE; 94.6% of whom were white, 68.8% were male and the mean age (standard deviation) was 21.6 (7.7) years. Patients had been diagnosed with EoE for a mean of 37.6 months before study initiation. The DSQ was feasible to implement with few item-level data missing at baseline. Item discrimination was high, with floor and ceiling effects below the predefined threshold (≤9%). Higher DSQ scores corresponded with presence and increased severity of dysphagia, indicative of strong item discrimination among patients at baseline (threshold >50%). The DSQ was able to detect changes in symptoms over time and produced similar outcomes to those from physician- and other patient-rated measures, supportive of construct validity. The DSQ had strong test–retest reliability (intraclass correlation coefficient, r = 0.82); and was also responsive to disease-level changes, with higher DSQ scores corresponding to increased esophageal eosinophilic burden. Lastly, the percentage changes in the minimal clinically important difference and clinically important difference in DSQ score were estimated at −27.4% and −55.4%, respectively. Conclusions These analyses support the DSQ as a valid and reliable measure of dysphagia in patients with EoE. Changes in DSQ scores suggest a level of agreement between clinician, patient and histologic response. The DSQ should therefore be considered a viable PRO measure of dysphagia for use in future therapeutic studies of EoE.
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Affiliation(s)
- Stacie Hudgens
- Clinical Outcome Solutions, 3709 North Campbell, Tucson, AZ 85719 USA
| | - Christopher Evans
- Endpoint Outcomes, 11 Beacon Street, Suite 910, Boston, MA 02108 USA
| | - Elaine Phillips
- Formerly at Meritage Pharma, Inc., 12555 High Bluff Drive #385, San Diego, CA 92130 USA
| | - Malcolm Hill
- Formerly at Meritage Pharma, Inc., 12555 High Bluff Drive #385, San Diego, CA 92130 USA
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Tavares M, Dias JA. Eosinophilic Oesophagitis in Children: Disease Modulation by Topical Steroids. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0142-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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41
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Lucendo AJ, Arias-González L, Molina-Infante J, Arias Á. Systematic review: health-related quality of life in children and adults with eosinophilic oesophagitis-instruments for measurement and determinant factors. Aliment Pharmacol Ther 2017. [PMID: 28639700 DOI: 10.1111/apt.14194] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several measures have been used to assess the health-related quality of life (HRQoL) of patients with eosinophilic oesophagitis (EoE). AIMS To systematically review these HRQoL measures, to appraise measurement properties of specific instruments and to evaluate determinant factors influencing HRQoL in paediatric and adult EoE patients. METHODS We searched the PubMed, Embase, Scopus, Web of Science (WOS) and PsycINFO databases for documents providing original information on the development of measurement tools and/or evaluation of HRQoL outcomes in EoE patients of all ages. RESULTS Of the 596 references identified, data was collected from 34 studies (with only 16 of them being published as full papers) including a total of 1,689 individual patients. Three disease-specific HRQoL measures in EoE covering different aspects of patients' lives and developed in English, were scored positive regarding measurement properties. The PedsQL inventory (including parent and child report forms) and the Peds-QoL EoE module were the generic and specific instruments respectively used in children, while the SF-36 and EoE-QoL-A were the most used questionnaires in adults. Patients with EoE show an impaired HRQoL compared to controls, which greatly depends on symptom severity and disease duration. Severity of endoscopic features and female gender may also determine an impaired HRQoL. The effect of treatments on HRQoL requires further assessment. CONCLUSIONS HRQoL is a relevant outcome that should be considered in clinical practice and research of EoE. Further validation studies in several languages and populations are required to support the use of disease-specific HRQoL measures.
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Affiliation(s)
- A J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - L Arias-González
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - J Molina-Infante
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.,Department of Gastroenterology, Hospital Universitario San Pedro de Alcántara, Cáceres, Spain
| | - Á Arias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.,Research Support Unit, Complejo Hospitalario La Mancha Centro, Alcázar de San Juan, Spain
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Abstract
OBJECTIVES Eosinophilic esophagitis (EoE) is a clinicopathologic disorder characterized by infiltration of eosinophils into the esophagus. Primary treatment approaches include topical corticosteroids and/or food elimination. The aim of the present study was to compare the effectiveness of combination therapy (topical corticosteroid plus test-based food elimination [FS]) with single therapy (topical corticosteroid [S] or test-based food elimination [F]). METHODS Chart review of patients with EoE at Texas Children's Hospital (age <21 years) was performed. Clinical and histological statuses were evaluated after a 3-month treatment with either single or combination therapy. Comparisons were analyzed using Fisher exact test, Kruskal-Wallis tests, and multiple logistic regression models. RESULTS Among 670 charts, 63 patients (1-21 years, median 10.3 years) with clinicopathologic diagnoses of EoE were identified. Combination FS therapy was provided to 51% (n = 32) and single treatment (S, F) to 27% (n = 17) or 22% (n = 14) of patients, respectively. Clinical responses were noted in 91% (n = 29), 71% (n = 12), and 64% (n = 14) of patients in the FS, S, and F groups, respectively. The odds of clinically improving were 4.6 times greater (95% confidence interval: 1.1-18.8) with combination versus single therapy. The median peak number of eosinophils per high-power field after 3-month therapy was not significantly different in the S, F, and FS groups. CONCLUSIONS The combination of topical corticosteroids with specific food elimination is as effective in achieving clinical and histological remissions as the single-treatment approaches. Responses were achieved with the combination in patients who had previously failed single-agent therapy. Prospective research of this combination approach in young patients with EoE is needed.
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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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44
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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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González-Cervera J, Arias Á, Redondo-González O, Cano-Mollinedo MM, Terreehorst I, Lucendo AJ. Association between atopic manifestations and eosinophilic esophagitis: A systematic review and meta-analysis. Ann Allergy Asthma Immunol 2017; 118:582-590.e2. [PMID: 28366582 DOI: 10.1016/j.anai.2017.02.006] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/13/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) has repeatedly been associated with atopic manifestations, which are reported more frequently in these patients than in the general population. OBJECTIVE To systematically assess the evidence and strength of the associations between EoE and atopy. METHODS We performed a systematic search of the MEDLINE, EMBASE, and SCOPUS databases for case-control studies comparing the frequency of atopic diatheses among patients with EoE and control subjects representing the general population without EoE. Using random-effects meta-analyses, we calculated summary estimates, including 95% confidence intervals (CIs), for bronchial asthma, atopic rhinitis, and eczema. Publication bias risks were assessed by means of funnel plot analysis and specific statistical tests. RESULTS Of the 2,954 references identified, data were collected from 21 studies, including a total of 53,542 patients with EoE and 54,759 controls. The criteria for defining a diagnosis of atopy in patients with EoE or controls was not structurally considered in most of the studies. Overall, allergic rhinitis was significantly more common among patients with EoE compared with control subjects (odds ratio [OR], 5.09; 95% CI, 2.91-8.90; I2 = 86.7%) as were bronchial asthma (OR, 3.01; 95% CI, 1.96-4.62; I2 = 84.5%) and eczema (OR, 2.85; 95% CI, 1.87-4.34; I2 = 57.1%). Food allergies and other atopic conditions were also assessed. No significant publication bias was found for studies dealing with allergic rhinitis and eczema in EoE. CONCLUSION Despite pointing to a significant association between atopy and EoE, most of the studies provided no normalized diagnostic criteria for atopy. Further research should provide clear and standardized definitions of such conditions. TRIAL REGISTRATION www.crd.york.ac.uk/PROSPERO Trial Identifier: CRD42016036161.
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Affiliation(s)
- Jesús González-Cervera
- Department of Allergy, Hospital General de Tomelloso, Tomelloso, Spain; Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Ángel Arias
- Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Spain
| | | | | | - Ingrid Terreehorst
- Department of ENT and Pediatrics, Academisch Medisch Centrum, Amsterdam, the Netherlands
| | - Alfredo J Lucendo
- Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.
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de Bortoli N, Penagini R, Savarino E, Marchi S. Eosinophilic esophagitis: Update in diagnosis and management. Position paper by the Italian Society of Gastroenterology and Gastrointestinal Endoscopy (SIGE). Dig Liver Dis 2017; 49:254-260. [PMID: 27979389 DOI: 10.1016/j.dld.2016.11.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/21/2016] [Accepted: 11/24/2016] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus characterized by symptoms related to esophageal dysfunction, as well as significant esophageal eosinophilia. The entity exists worldwide but has been most extensively studied in Western countries. However, a wide range of symptoms has been noticed such as chest pain or gastro-esophageal reflux disease-like symptoms. Upper gastro-intestinal endoscopy and esophageal biopsies are crucial for the diagnosis. Endoscopy might be normal or reveal typical patterns such as rings, furrows, exudates, edema, and stricture. Two to four biopsies should be performed both in the distal and in the proximal esophagus, and 15 eosinophils per high power field within the esophageal epithelium are the minimal threshold to diagnose eosinophilic esophagitis. Allergy testing is recommended, although its impact to orient treatment remains to be demonstrated. Eosinophilic esophagitis treatment includes medical treatment, diet and endoscopic dilation. Proton pump inhibitors are the first-line therapy as up to 50% of patients respond well to proton pump inhibitors irrespective of objective evidence of GERD. Topical viscous corticosteroids or elimination diet are the treatment of choice in case of unresponsiveness to proton pump inhibitors.
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Affiliation(s)
- Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
| | - Roberto Penagini
- Gastroenterology Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore, Policlinic, Department of Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Santino Marchi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Dellon ES, Katzka DA, Collins MH, Hamdani M, Gupta SK, Hirano I, Lewis J, Markowitz J, Nurko S, Wo J, Dellon E, Gunasekaran TS, Hirano I, Gupta S, Pasternak B, Ellis M, Peterson K, Falk G, Leung J, Prestridge L, Hart M, Leleiko N, Vaezi M, Cherry R, Katzka D, Friedenberg K, Assouline-Dayan Y, Mukkada V. Budesonide Oral Suspension Improves Symptomatic, Endoscopic, and Histologic Parameters Compared With Placebo in Patients With Eosinophilic Esophagitis. Gastroenterology 2017; 152:776-786.e5. [PMID: 27889574 DOI: 10.1053/j.gastro.2016.11.021] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/14/2016] [Accepted: 11/16/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Pharmacologic treatment of eosinophilic esophagitis (EoE) is limited to off-label use of corticosteroids not optimized for esophageal delivery. We performed a randomized, controlled phase 2 trial to assess the ability of budesonide oral suspension (BOS), a novel muco-adherent topical steroid formulation, to reduce symptoms and esophageal eosinophilia in adolescents and adults with EoE. METHODS In this multicenter, randomized, double-blind, placebo-controlled, parallel-group trial, 93 EoE patients between the ages of 11 and 40 years with dysphagia and active esophageal eosinophilia were randomized to receive either BOS 2 mg or placebo twice daily for 12 weeks. Co-primary outcomes were change in Dysphagia Symptom Questionnaire (DSQ) score from baseline, and proportion of patients with a histologic response (≤6 eosinophils/high-power field) after treatment. Endoscopic severity scores and safety parameters were assessed. RESULTS At baseline, mean DSQ scores were 29.3 and 29.0, and mean peak eosinophil counts were 156 and 130 per hpf in the BOS and placebo groups, respectively. After treatment, DSQ scores were 15.0 and 21.5, and mean peak eosinophil counts were 39 and 113 per high-power field, respectively (P < .05 for all). For BOS vs placebo, change in DSQ score was -14.3 vs -7.5 (P = .0096), histologic response rates were 39% vs 3% (P < .0001), and change in endoscopic severity score was -3.8 vs 0.4 (P < .0001). Adverse events were similar between groups. CONCLUSIONS Treatment with BOS was well tolerated in adolescent and young adult patients with EoE and resulted in improvement in symptomatic, endoscopic, and histologic parameters using validated outcome instruments. ClinicalTrials.gov ID NCT01642212.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Sandeep K Gupta
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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Hewett R, Alexakis C, Farmer AD, Ainley J, Chhaya V, Hayat JO, Poullis A, Kang JY. Effects of eosinophilic oesophagitis on quality of life in an adult UK population: a case control study. Dis Esophagus 2017; 30:1-7. [PMID: 27868307 DOI: 10.1111/dote.12524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Eosinophilic oesophagitis (EoE) is a chronic immune-mediated esophageal disease, characterized by symptoms related to esophageal dysfunction and histologically by eosinophil predominant inflammation. Current evidence for an adverse impact on quality of life (QoL) is conflicting and there are no data from a UK population regarding QoL. We conducted a prospective cross-sectional observational study using the Short Form-36 Health Survey, Hospital Dysphagia/Odynophagia Questionnaire, and the EoE Adult Quality of Life Questionnaire to assess QoL and severity of dysphagia in EoE patients, compared to age and gender matched healthy control subjects. Data were also collected on comorbidity and medication use. Eighty-eight subjects were recruited (44 patients). Patients had higher rates of antihistamine and topical (swallowed) corticosteroid use. Physical QoL did not differ between patients and controls, although patients did report a statistically significant lower mental QoL, with small absolute magnitude of difference. Patients reported higher dysphagia scores and these were negatively correlated with both physical and mental QoL. Higher rates of dysphagia and medication use in patients may among other things account for lower mental QoL. However, a higher rate of dysphagia in patients is not associated with a reduced physical QoL. Our findings are of clinical value, particularly when a new diagnosis of EoE is made, as clinicians can reassure patients that their general physical health should not be greatly affected by the diagnosis. Moreover, it may also be useful for patients to be aware that EoE may have an impact on their mental health, but this effect is likely to be small. We therefore advocate education and reassurance in this respect for all patients at diagnosis.
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Affiliation(s)
- R Hewett
- Department of Gastroenterology, St George's Hospital NHS Trust, Tooting, London, UK
| | - C Alexakis
- Department of Gastroenterology, St George's Hospital NHS Trust, Tooting, London, UK
| | - A D Farmer
- Centre for Digestive Diseases, Blizard Institute of Cell & Molecular Science, Queen Mary University of London, London, UK.,Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke on Trent, Staffordshire, UK
| | - J Ainley
- Gastroenterology, Emerson's Green NHS Treatment Centre, Bristol, UK
| | - V Chhaya
- Department of Gastroenterology, St George's Hospital NHS Trust, Tooting, London, UK
| | - J O Hayat
- Department of Gastroenterology, St George's Hospital NHS Trust, Tooting, London, UK
| | - A Poullis
- Department of Gastroenterology, St George's Hospital NHS Trust, Tooting, London, UK
| | - J-Y Kang
- Department of Gastroenterology, St George's Hospital NHS Trust, Tooting, London, UK
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Bohm M, Jacobs JW, Gupta A, Gupta S, Wo JM. Most children with eosinophilic esophagitis have a favorable outcome as young adults. Dis Esophagus 2017; 30:1-6. [PMID: 26822685 DOI: 10.1111/dote.12454] [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: 12/11/2022]
Abstract
The disease progression of eosinophilic esophagitis (EoE) from childhood into adulthood is unclear. To determine the clinical outcome of patients who were diagnosed with EoE as children, and who now are young adults. Children (<18 years old) diagnosed with EoE were enrolled in a prospective registry on demographics, presenting symptoms, and endoscopic/histologic findings. Subjects who now are adults (≥18 years old) were identified, and a structured telephone interview was conducted to obtain follow-up data on symptom prevalence (dysphagia to solids and liquids, nausea/vomiting, abdominal pain, and heartburn/regurgitation), food impaction, medication usage, health-care utilization, and resolution of atopy/food allergies. A favorable outcome was defined if EoE symptoms were resolved or improved by subjects' assessment. Unfavorable outcomes was defined as symptoms same or worse. Clinical variables that predicted a favorable outcome as an adult were examined. Mayo Dysphagia Scale (MDQ-30: scored 0-100) was administered to validate the outcome assessment. Mantel-Haenszel odds ratio and unpaired t-test were used. Fifty-eight subjects (64% male) who met study criteria were enrolled. Mean age at diagnosis was 12 years (range 4-17) and mean duration of follow-up was 8.3 years (2-16). As children, the most common presenting symptoms were abdominal pain (54%), dysphagia (33%), and vomiting (24%). As young adults, 47 subjects (81%) had a favorable outcome. Total MDQ-30 scores were 4.6 (0-30) and 14.1 (0-50) in subjects with favorable outcome and unfavorable outcome, respectively (P = 0.015). Two-thirds of subjects did not use steroids or proton pump inhibitors in the preceeding 12 months. Male children with EoE were four times more likely to have a favorable outcome as young adults compared with female children. Females were more likely to report nausea/vomiting as young adults (odds ratio 3.23, CI 0.97-10.60). Of all presenting symptoms in EoE children, dysphagia was the most likely to persist into adulthood (odds ratio 6.29, CI 1.85-21.38). Eighty one percent of EoE children had a favorable outcome as young adults. Most patients with symptom resolution did not require any form of steroid therapy or seek healthcare.
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Affiliation(s)
- M Bohm
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - J W Jacobs
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - A Gupta
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - S Gupta
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - J M Wo
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
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50
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Natural History of Eosinophilic Oesophagitis in Childhood. CURRENT PEDIATRICS REPORTS 2016. [DOI: 10.1007/s40124-016-0102-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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