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Sato H, Dellon ES, Aceves SS, Arva NC, Chehade M, Collins MH, Davis CM, Falk GW, Furuta GT, Gonsalves NP, Gupta SK, Hirano I, Hiremath G, Katzka DA, Khoury P, Leung J, Menard-Katcher P, Pesek R, Peterson KA, Pletneva MA, Spergel JM, Wechsler JB, Yang GY, Rothenberg ME, Shoda T. Clinical and molecular correlates of the Index of Severity for Eosinophilic Esophagitis. J Allergy Clin Immunol 2024; 154:375-386.e4. [PMID: 38750825 PMCID: PMC11305930 DOI: 10.1016/j.jaci.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/02/2024] [Accepted: 04/25/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND The Index of Severity for Eosinophilic Esophagitis (I-SEE) is a new expert-defined clinical tool that classifies disease severity of eosinophilic esophagitis (EoE). OBJECTIVE We aimed to determine whether I-SEE is associated with patient characteristics, molecular features of EoE, or both. METHODS We analyzed a prospective cohort of patients with EoE from the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR). Associations between I-SEE and clinical and molecular features (assessed by an EoE diagnostic panel [EDP]) were assessed. RESULTS In 318 patients with chronic EoE (209 adults, 109 children), median total I-SEE score was 7.0, with a higher symptoms and complications score in children than adults (4.0 vs 1.0; P < .001) and higher inflammatory and fibrostenotic features scores in adults than children (3.0 vs 1.0 and 3.0 vs 0, respectively; both P < .001). Total I-SEE score had a bimodal distribution with the inactive to moderate categories and severe category. EDP score correlated with total I-SEE score (r = -0.352, P < .001) and both inflammatory and fibrostenotic features scores (r = -0.665, P < .001; r = -0.446, P < .001, respectively), but not with symptoms and complications scores (r = 0.047, P = .408). Molecular severity increased from inactive to mild and moderate, but not severe, categories. Longitudinal changes of modified I-SEE scores and inflammatory and fibrostenotic features scores reflected histologic and molecular activity. CONCLUSIONS I-SEE score is associated with select clinical features across severity categories and with EoE molecular features for nonsevere categories, warranting further validation.
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Affiliation(s)
- Hiroki Sato
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Seema S Aceves
- University of California San Diego School of Medicine, San Diego, Rady Children's Hospital, San Diego, Calif
| | | | - Mirna Chehade
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Carla M Davis
- Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | | | | | | | | | - Ikuo Hirano
- Northwestern University Feinberg School of Medicine, Chicago, Ill
| | | | | | | | | | | | - Robbie Pesek
- University of Arkansas for Medical Science, Little Rock, Ark
| | | | | | | | | | - Guang-Yu Yang
- Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Marc E Rothenberg
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tetsuo Shoda
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Amil-Dias J, Oliva S, Papadopoulou A, Thomson M, Gutiérrez-Junquera C, Kalach N, Orel R, Auth MKH, Nijenhuis-Hendriks D, Strisciuglio C, Bauraind O, Chong S, Ortega GD, Férnandez SF, Furman M, Garcia-Puig R, Gottrand F, Homan M, Huysentruyt K, Kostovski A, Otte S, Rea F, Roma E, Romano C, Tzivinikos C, Urbonas V, Velde SV, Zangen T, Zevit N. Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2024; 79:394-437. [PMID: 38923067 DOI: 10.1002/jpn3.12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus characterized by symptoms of esophageal dysfunction and histologically by predominantly eosinophilic infiltration of the squamous epithelium. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published a guideline in 2014; however, the rapid evolution of knowledge about pathophysiology, diagnostic criteria, and therapeutic options have made an update necessary. METHODS A consensus group of pediatric gastroenterologists from the ESPGHAN Working Group on Eosinophilic Gastrointestinal Diseases (ESPGHAN EGID WG) reviewed the recent literature and proposed statements and recommendations on 28 relevant questions about EoE. A comprehensive electronic literature search was performed in MEDLINE, EMBASE, and Cochrane databases from 2014 to 2022. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of evidence and formulate recommendations. RESULTS A total of 52 statements based on the available evidence and 44 consensus-based recommendations are available. A revision of the diagnostic protocol, options for initial drug treatment, and the new concept of simplified empiric elimination diets are now available. Biologics are becoming a part of the potential armamentarium for refractory EoE, and systemic steroids may be considered as the initial treatment for esophageal strictures before esophageal dilation. The importance and assessment of quality of life and a planned transition to adult medical care are new areas addressed in this guideline. CONCLUSION Research in recent years has led to a better understanding of childhood EoE. This guideline incorporates the new findings and provides a practical guide for clinicians treating children diagnosed with EoE.
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Affiliation(s)
- Jorge Amil-Dias
- Pediatric Gastroenterology, Hospital Lusíadas, Porto, Portugal
| | - Salvatore Oliva
- Maternal and Child Health Department, University Hospital - Umberto I, Sapienza - University of Rome, Rome, Italy
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, Children's hospital Agia Sofia, University of Athens, Athens, Greece
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, International Academy for Paediatric Endoscopy Training, Sheffield Children's Hospital, UK
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro Majadahonda, Universidad Autónoma de Madrid, Spain
| | - Nicolas Kalach
- Department of Pediatrics, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University, Lille, France
| | - Rok Orel
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialized Surgery of the University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Sonny Chong
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - Gloria Dominguez Ortega
- Pediatric Gastroenterology and Nutrition Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sonia Férnandez Férnandez
- Pediatric Gastroenterology Unit, Department of Pediatrics, Severo Ochoa University Hospital, Madrid, Spain
| | - Mark Furman
- Royal Free London NHS Foundation Trust, London, UK
| | - Roger Garcia-Puig
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Pediatrics Department, Hospital Universitari MútuaTerrassa, Universitat de Barcelona, Barcelona, Spain
| | | | - Matjaz Homan
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Koen Huysentruyt
- Kindergastro-enterologie, hepatologie en nutritie, Brussels Centre for Intestinal Rehabilitation in Children (BCIRC), Belgium
| | - Aco Kostovski
- University Children's Hospital Skopje, Faculty of Medicine, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Sebastian Otte
- Childrens' Hospital, Helios Mariahilf Hospital, Hamburg, Germany
| | - Francesca Rea
- Endoscopy and Surgey Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Eleftheria Roma
- First Department of Pediatrics, University of Athens and Pediatric Gastroenterology Unit Mitera Children's Hospital, Athens, Greece
| | - Claudio Romano
- Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Christos Tzivinikos
- Paediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Dubai, UAE
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Vaidotas Urbonas
- Vilnius University Medical Faculty Clinic of Children's Diseases, Vilnius, Lithuania
| | | | - Tsili Zangen
- Pediatric Gastroenterology Unit, Wolfson Medical Center, Holon, Israel
| | - Noam Zevit
- Eosinophilic Gastrointestinal Disease Clinic, Institute of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Israel
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Martin LJ, Zhang X, Chehade M, Davis CM, Dellon ES, Falk GW, Gupta SK, Hirano I, Hiremath GS, Katzka DA, Khoury P, Leung J, Menard-Katcher P, Gonsalves N, Pesek RD, Spergel JM, Wechsler JB, Kliewer K, Arva NC, Collins MH, Pletneva M, Yang GY, Furuta GT, Rothenberg ME, Aceves SS. Long-term durability between parent and child patient-reported outcomes in eosinophilic esophagitis. J Allergy Clin Immunol 2024:S0091-6749(24)00740-1. [PMID: 39059504 DOI: 10.1016/j.jaci.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/11/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Because young children cannot self-report symptoms, there is a need for parent surrogate reports. Although early work suggested parent-child alignment for eosinophil esophagitis (EoE) patient-reported outcomes (PROs), the longitudinal alignment is unclear. OBJECTIVE We sought to assess the agreement and longitudinal stability of PROs between children with EoE and their parents. METHODS A total of 292 parent-child respondents completed 723 questionnaires over 5 years in an observational trial in the Consortium of Eosinophilic Gastrointestinal Disease Researchers. The change in and agreement between parent and child Pediatric Eosinophilic Esophagitis Symptom Score version 2 (PEESSv2.0) and Pediatric Quality of Life Eosinophilic Esophagitis Module (PedsQL-EoE) PROs over time were assessed using Pearson correlation and Bland-Altman analyses. Clinical factors influencing PROs and their agreement were evaluated using linear mixed models. RESULTS The cohort had a median disease duration equaling 3.7 years and was predominantly male (73.6%) and White (85.3%). Child and parent PEESSv2.0 response groups were identified and were stable over time. There was strong correlation between child and parent reports (PEESSv2.0, 0.83;PedsQL-EoE, 0.74), with minimal pairwise differences for symptoms. Longitudinally, parent-reported PedsQL-EoE scores were stable (P ≥ .32), whereas child-reported PedsQL-EoE scores improved (P = .026). A larger difference in parent and child PedsQL-EoE reports was associated with younger age (P < .001), and differences were driven by psychosocial PRO domains. CONCLUSIONS There is strong longitudinal alignment between child and parent reports using EoE PROs. These data provide evidence that parent report is a stable proxy for objective EoE symptoms in their children.
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Affiliation(s)
- Lisa J Martin
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Xue Zhang
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carla M Davis
- Division of Immunology, Allergy, and Retrovirology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex; Food Allergy Program, Texas Children's Hospital, Houston, Tex
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, NC; Division of Gastroenterology and Hepatology, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Gary W Falk
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Sandeep K Gupta
- Children's of Alabama, University of Alabama at Birmingham, Birmingham, Ala
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Kenneth Griffin Esophageal Center, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Girish S Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY
| | - Paneez Khoury
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - John Leung
- Division of Allergy/Immunology, Tuft's Medical Center, Boston, Mass; Division of Gastroenterology, Tuft's Medical Center, Boston, Mass
| | - Paul Menard-Katcher
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Kenneth Griffin Esophageal Center, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark
| | - Jonathan M Spergel
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Kara Kliewer
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nicoleta C Arva
- Department of Pathology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Margaret H Collins
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Maria Pletneva
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Glenn T Furuta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital of Colorado, Aurora, Colo; Gastrointestinal Eosinophilic Disease Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colo
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Seema S Aceves
- University of California San Diego, Rady Children's Hospital of San Diego, San Diego, Calif.
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Collins MH, Arva NC, Bernieh A, Lopez-Nunez O, Pletneva M, Yang GY. Histopathology of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:205-221. [PMID: 38575219 DOI: 10.1016/j.iac.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Microscopic examination of esophageal biopsies is essential to diagnose eosinophilic esophagitis (EoE). Eosinophil inflammation is the basis for the diagnosis, but additional abnormalities may contribute to persistent symptoms and epithelial barrier dysfunction. Both peak eosinophil count and assessments of additional features should be included in pre-therapy and post-therapy pathology reports. Pathologic abnormalities identified in esophageal biopsies of EoE are reversible in contrast to esophageal strictures.
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Affiliation(s)
- Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Pathology ML1035, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Nicoleta C Arva
- Department of Pathology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Anas Bernieh
- Pathology ML1035, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave.nue Cincinnati, OH 45229, USA
| | - Oscar Lopez-Nunez
- Pathology ML1035, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave.nue Cincinnati, OH 45229, USA
| | - Maria Pletneva
- Department of Pathology, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132, USA
| | - Guang-Yu Yang
- Department of Pathology, Ward Building Ward 4-115, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL. 60611, USA
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Jensen ET, Chaiboonma K, Ayala O, Proia A, Aceves SS. Sleep, Anxiety, Somatization, Quality of Life, and Resilience in Pediatric Patients With Eosinophilic Esophagitis. Clin Transl Gastroenterol 2024; 15:e00672. [PMID: 38205930 PMCID: PMC10962877 DOI: 10.14309/ctg.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Emerging evidence suggests a high burden of psychosocial comorbidities in patients with eosinophilic esophagitis (EoE), although factors associated with this burden have not been explored. We aimed to increase understanding of the psychosocial burden of EoE and assess factors that are associated with disease burden. METHODS We conducted a cross-sectional study of patients with EoE (n = 87) recruited from a single-center, multidisciplinary pediatric eosinophilic gastrointestinal disorders clinic (2019-2021). Participants (aged 8-18 years) completed validated assessments during routine clinic visit to assess EoE symptoms (Pediatric Eosinophilic Esophagitis Symptom Score version 2.0), quality of life (Pediatric Quality of LIfe- Eosinophilic Esophagitis), anxiety state and trait (State-Trait Anxiety Score for Children), somatization (Child Somatic Symptoms Inventory 24), sleep disordered breathing (Pediatric Sleep Questionnaire) and, in a subset (n = 35), resilience (Connor Davidson Resilience Scale). Clinical and demographic data were collected. RESULTS Participants were at a mean (SD) age of 12.8 (3.1) years, and 26% (n = 23) were female. Shorter disease duration (6-12 months) was associated with higher symptom burden ( P = 0.03), somatization ( P < 0.01), and anxiety (State-Trait Anxiety Score for Children Trait P < 0.01) scores. Participants with neurodevelopmental comorbidities had higher anxiety trait, somatization, sleep disordered breathing, and lower quality of life ( P < 0.01 for all). Symptom burden was significantly associated with increased somatic symptoms (adjusted β [aβ] = 0.34; 95% confidence interval 0.23-0.45) and decreased quality of life (aβ = -0.42; 95% confidence interval -0.59 to -0.25) but not state anxiety, trait anxiety, or disordered sleep breathing. DISCUSSION Pediatric patients with a recent diagnosis of EoE can experience higher EoE symptoms, somatization, and anxiety when compared with those with a longer-standing diagnosis. Patients earlier in their diagnosis and with neurodevelopmental disorders may experience increased somatization and anxiety that may warrant additional support services.
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Affiliation(s)
- Elizabeth T. Jensen
- Departments of Epidemiology and Prevention and Internal Medicine, Gastroenterology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kira Chaiboonma
- Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, California, USA
| | - Oscar Ayala
- Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, California, USA
| | - Anthony Proia
- Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, California, USA
| | - Seema S. Aceves
- Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, California, USA
- Rady Children's Hospital, San Diego, California, USA
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Ocampo AA, Xue Z, Chang NC, Thakkar KP, Reddy SB, Greenberg SB, Lee CJ, Ketchem CJ, Redd WD, Eluri S, Reed CC, Dellon ES. Clinical Features and Treatment Response to Topical Steroids in Ethnic and Racial Minority Patients With Eosinophilic Esophagitis. Am J Gastroenterol 2024; 119:262-269. [PMID: 37782465 PMCID: PMC10872844 DOI: 10.14309/ajg.0000000000002532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Differences in eosinophilic esophagitis (EoE) presentation and outcomes by ethnicity or race remain understudied. We aimed to determine whether EoE patients of Hispanic/Latinx ethnicity or non-White race have differences in presentation at diagnosis or response to topical corticosteroid (tCS) treatment. METHODS This retrospective cohort study included subjects of any age with a new diagnosis of EoE and documentation of ethnicity or race. For those who had treatment with tCS and follow-up endoscopy/biopsy, we assessed histologic response (<15 eosinophils/hpf), global symptom response, and endoscopic response. Hispanic EoE patients were compared with non-Hispanics at baseline and before and after treatment. The same analyses were repeated for White vs non-Whites. RESULTS Of 1,026 EoE patients with ethnicity data, just 23 (2%) were Hispanic. Most clinical features at presentation were similar to non-Hispanic EoE patients but histologic response to tCS was numerically lower (38% vs 57%). Non-White EoE patients (13%) were younger at diagnosis and had less insurance, lower zip code-level income, shorter symptom duration, more vomiting, less dysphagia and food impaction, fewer typical endoscopic features, and less dilation. Of 475 patients with race data treated with tCS, non-Whites had a significantly lower histologic response rate (41% vs 59%; P = 0.01), and odds of histologic response remained lower after controlling for potential confounders (adjusted odds ratio 0.40, 95% confidence intervals: 0.19-0.87). DISCUSSION Few EoE patients at our center were Hispanic, and they had similar clinical presentations as non-Hispanics. The non-White EoE group was larger, and presentation was less dysphagia-specific. Non-White patients were also less than half as likely to respond to tCS.
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Affiliation(s)
- Adolfo A. Ocampo
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Zeyun Xue
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nicole C. Chang
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kisan P. Thakkar
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Sumana B. Reddy
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Sydney B. Greenberg
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Christopher J. Lee
- Center for Esophageal Diseases and Swallowing, 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, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Walker D. Redd
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Swathi Eluri
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Craig C. Reed
- Center for Esophageal Diseases and Swallowing, 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, Division of Gastroenterology and Hepatology, Department of Medicine; 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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Sharlin CS, Mukkada VA, Putnam PE, Bolton SM. Treatment of Pediatric Eosinophilic Esophagitis: Traditional and Novel Therapies. Curr Gastroenterol Rep 2023; 25:289-298. [PMID: 37658151 DOI: 10.1007/s11894-023-00893-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/03/2023]
Abstract
PURPOSE OF REVIEW This review presents and summarizes the existing studies on the treatment goals and options for pediatric eosinophilic esophagitis utilizing rigorous peer-reviewed literature. RECENT FINDINGS In addition to traditional treatments, emerging biologic therapies continue to evolve the approach to treating pediatric eosinophilic esophagitis. Well defined treatment goals will aid the continued development of new therapies. Further, innovative assessment tools have changed how the clinician is able to assess the effectiveness of therapies with a trend toward less invasive options. The management of pediatric eosinophilic esophagitis continues to evolve with the advent of both novel treatment options and assessment tools. Treatment choices, with benefits and risks involved, should be presented to families upon diagnosis and tailored towards the individual patient and likelihood of adherence and success. Biologic therapy for EoE presents an exciting option for both first line therapy and escalation for those with severe or unresponsive disease.
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Affiliation(s)
- Colby S Sharlin
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott M Bolton
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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Pokrzywinski RM, Goodwin B, Dellon ES, Kodroff E, Brooks A, Bailey A, Williams J, Desai NK. Qualitative assessment of the suitability of the Dysphagia Symptom Questionnaire to monitor dysphagia in children aged 7-10 years with eosinophilic esophagitis. J Patient Rep Outcomes 2023; 7:110. [PMID: 37906323 PMCID: PMC10618132 DOI: 10.1186/s41687-023-00646-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 10/10/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND The Dysphagia Symptom Questionnaire (DSQ) is a patient-reported outcome measure that assesses the frequency and severity of dysphagia in patients with eosinophilic esophagitis (EoE); however, it has only been validated for use in patients with EoE aged 11-40 years. This study examined the content validity of the DSQ and its usability on an electronic handheld device in children aged 7-10 years with EoE. METHODS In this qualitative, observational cohort study, participants were recruited to partake in two rounds of interviews. During visit 1, a cognitive interview examined EoE-associated concepts and the appropriateness of the DSQ for assessing dysphagia. Participants completed the DSQ daily for 2 weeks, and DSQ scores were calculated. After 2 weeks, a second interview assessed the usability of the DSQ on the electronic device and the burden associated with completing it daily. RESULTS Overall, 16 participants were included (aged 7-8 years: n = 8; aged 9-10 years: n = 8); most were male (75%) and white (81%), and the mean (standard deviation [SD]) age was 8.4 (1.3) years. The most commonly reported EoE-associated concept was 'trouble with swallowing' (63% [10/16]). Most participants reported that the questions were 'easy to complete' and 'relevant to someone with EoE and dysphagia'. Overall, participants reported understanding the questions and associated responses; however, further probing demonstrated inconsistent comprehension. Key challenging concepts included 'solid food', 'trouble swallowing', 'vomit', and 'relief'; some participants also reported difficulty differentiating between pain levels (31% [4/13]). Most caregivers reported that their child had experienced dysphagia (94% [15/16]); however, mean (SD) DSQ scores over the study period were low (7.3 [7.4]), suggesting infrequent and mild dysphagia, or a lack of comprehension of the questions. Most participants reported that completing the DSQ on the electronic device was easy (93% [14/15]) and they would be willing to complete it for longer than 2 weeks (73% [11/15]). CONCLUSIONS Difficulties with comprehension and comprehensiveness suggest that the DSQ may not be sufficiently comprehensive for use in all patients in this population, and wording/phrasing changes are required before use in a clinical trial setting.
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Grants
- This study was funded by Shire Human Genetic Therapies Inc., a member of the Takeda Group of companies
- Medical writing support was provided by Iona MacKillop, MSc, Natasha Molle, MSc, and Tsvetana Stoilova, PhD, of PharmaGenesis London, London, UK, and funded by Takeda Pharmaceuticals USA, Inc.
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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 at Chapel Hill, Chapel Hill, NC, USA
| | - Ellyn Kodroff
- Campaign Urging Research for Eosinophilic Disease, Lincolnshire, IL, USA
| | - Anne Brooks
- Evidera, 7101 Wisconsin Ave #1400, Bethesda, MD, 20814, USA
| | - Adam Bailey
- Evidera, 7101 Wisconsin Ave #1400, Bethesda, MD, 20814, USA
| | - James Williams
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Nirav K Desai
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
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9
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Hiremath G, Sun L, Collins MH, Bonis PA, Arva NC, Capocelli KE, Chehade M, Davis CM, Falk GW, Gonsalves N, Gupta SK, Hirano I, Leung J, Khoury P, Mukkada VA, Martin LJ, Spergel JM, Wechsler JB, Yang GY, Aceves SS, Furuta GT, Rothenberg ME, Koyama T, Dellon ES. Esophageal Epithelium and Lamina Propria Are Unevenly Involved in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2023; 21:2807-2816.e3. [PMID: 36967100 PMCID: PMC10518022 DOI: 10.1016/j.cgh.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/28/2023] [Accepted: 03/13/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND & AIMS The nature of the involvement of esophageal tissue in eosinophilic esophagitis (EoE) is unclear. We estimated the intrabiopsy site agreements of the EoE Histologic Scoring System (EoEHSS) scores for the grade (degree) and stage (extent) of involvement of the esophageal epithelial and lamina propria and examined if the EoE activity status influenced the intrabiopsy site agreement. METHODS Demographic, clinical, and EoEHSS scores collected as part of the prospective Outcome Measures for Eosinophilic Gastrointestinal Diseases Across Ages study were analyzed. A weighted Cohen's kappa agreement coefficient (k) was used to calculate the pairwise agreements for proximal:distal, proximal:middle, and middle:distal esophageal biopsy sites, separately for grade and stage scores, for each of the 8 components of EoEHSS. A k > 0.75 was considered uniform involvement. Inactive EoE was defined as fewer than 15 eosinophils per high-powered field. RESULTS EoEHSS scores from 1263 esophageal biopsy specimens were analyzed. The k for the stage of involvement of the dilated intercellular spaces across all 3 sites in inactive EoE was consistently greater than 0.75 (range, 0.87-0.99). The k for lamina propria fibrosis was greater than 0.75 across some of the biopsy sites but not across all 3. Otherwise, the k for all other features, for both grade and stage, irrespective of the disease activity status, was 0.75 or less (range, 0.00-0.74). CONCLUSIONS Except for the extent of involvement of dilated intercellular spaces in inactive EoE, the remaining epithelial features and lamina propria are involved unevenly across biopsy sites in EoE, irrespective of the disease activity status. This study enhances our understanding of the effects of EoE on esophageal tissue pathology.
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Affiliation(s)
- Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Lili Sun
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital at Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carla M Davis
- Immunology, Allergy, and Retrovirology Division, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Gary W Falk
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - John Leung
- Boston Specialists/Boston Food Allergy Center, Boston, Massachusetts
| | - Paneez Khoury
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Vincent A Mukkada
- Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine Department of Pediatrics, Cincinnati, Ohio
| | - Lisa J Martin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan M Spergel
- Division of Allergy-Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Pennsylvania
| | - Joshua B Wechsler
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Guang-Yu Yang
- Division of Anatomical Pathology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Seema S Aceves
- Division of Rheumatology, Allergy & Immunology, Rady Children's Hospital, San Diego, San Diego, California
| | - Glenn T Furuta
- Section of Pediatric Gastroenterology and Hepatology, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Colorado
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, University of Cincinnati College of Medicine, Ohio
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
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10
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Jensen ET, Langefeld CD, Howard TD, Dellon ES. Validation of Epigenetic Markers for the Prediction of Response to Topical Corticosteroid Treatment in Eosinophilic Esophagitis. Clin Transl Gastroenterol 2023; 14:e00622. [PMID: 37439560 PMCID: PMC10522102 DOI: 10.14309/ctg.0000000000000622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/07/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION We previously identified 18 CpG methylation biomarkers associated with treatment response to topical corticosteroids (tCS) in eosinophilic esophagitis (EoE). In this study, in an independent cohort, we assessed the validity of these CpG sites as treatment response biomarkers. METHODS DNA was extracted from prospectively biobanked esophageal biopsies from patients with newly diagnosed EoE enrolled in a randomized trial of 2 tCS formulations. Histologic response was defined as <15 eosinophils per high-power field. Pretreatment DNA methylation was assayed on the Illumina Human MethylationEPIC BeadChip. Logistic regression and area under the receiver operating characteristic curve analyses, adjusting for chip, position on the chip, age, sex, and baseline eosinophil count, were computed to test for an association between DNA methylation and treatment response at the 18 previously identified CpG sites. RESULTS We analyzed 88 patients (58 histologic responders, 30 nonresponders), with a mean age of 38 ± 16 years, 64% male, 97% White race. Of the 18 CpG sites, 13 met quality control criteria, and 3 were associated with responder status ( P < 0.012), including sites within UNC5B (cg26152017), ITGA6 (cg01044293), and LRRC8A (cg13962589). All 3 showed evidence of reduced methylation in treatment responders, consistent with the original discovery associations. The predictive probability for nonresponse with all 3 CpG sites was strong (area under the receiver operating characteristic curve = 0.79). DISCUSSION We validated epigenetic biomarkers (CpG methylation sites) for the prediction of tCS response in patients with EoE in an independent population. While not all previously identified markers replicated, 3 demonstrated a relatively high predictive probability for response to treatment and hold promise for guiding tCS treatment in EoE.
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Affiliation(s)
- Elizabeth T. Jensen
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Carl D. Langefeld
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Wake Forest University School of Medicine, Center for Precision Medicine, Winston-Salem, North Carolina USA
| | - Timothy D. Howard
- Wake Forest University School of Medicine, Center for Precision Medicine, Winston-Salem, North Carolina USA
- Department of Biochemistry, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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11
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Role of mast cells in eosinophilic esophagitis. Curr Opin Gastroenterol 2022; 38:541-548. [PMID: 36165008 DOI: 10.1097/mog.0000000000000888] [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: 12/10/2022]
Abstract
PURPOSE OF REVIEW This review will present what is known from recent research on the involvement of mast cells in eosinophilic esophagitis and identify questions requiring further investigation. RECENT FINDINGS In the adults and children with eosinophilic esophagitis, there is increasing evidence that mastocytosis can persist, despite resolution of eosinophilia and is associated with persistent mucosal abnormalities and symptoms. Despite, treatment mast cells have an activated transcriptome. Mast cells likely contribute to epithelial barrier dysfunction, smooth muscle hypertrophy and contraction, and subepithelial fibrosis. It remains unclear whether targeting MCs alone has therapeutic efficacy to improve tissue damage. SUMMARY Mast cells appear to play a key role in eosinophilic esophagitis and serve as a biomarker of mucosal healing in conjunction with eosinophils. Excessive mast cell activation likely contributes to tissue damage in eosinophilic esophagitis and need to be considered as a target of therapy along with eosinophils.
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12
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Muir AB, Ackerman SJ, Pan Z, Benitez A, Burger C, Spergel JM, Furuta GT, Rothman J, Wilkins BJ, Arnold MA, Dolinsky L, Grozdanovic M, Menard-Katcher C. Esophageal remodeling in eosinophilic esophagitis: Relationships to luminal captured biomarkers of inflammation and periostin. J Allergy Clin Immunol 2022; 150:649-656.e5. [PMID: 35405206 PMCID: PMC10367933 DOI: 10.1016/j.jaci.2022.03.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Esophageal remodeling is a factor in disease progression and symptom severity for patients with eosinophilic esophagitis (EoE). Remodeling can begin early in children, resulting in stricture and food impaction. Detection of esophageal remodeling often depends on endoscopy and is appreciated only in its later stages. OBJECTIVE We sought to determine whether luminal eosinophil-associated and remodeling proteins captured by the esophageal string test (EST) correlate with measures of esophageal remodeling and biomarkers of the epithelial-mesenchymal transition (EMT). METHODS Patients with EoE (7-18 years old) were enrolled from 2 pediatric hospitals. Participants performed the EST and underwent endoscopy. Histology, distensibility measured by endoluminal functional lumen imaging probe, and symptoms were assessed. Protein quantitation by ELISA was performed on mucosal biopsy and EST samples. Tissue sections were evaluated for EMT. Outcome measures were summarized, and Spearman ρ was used to assess bivariate correlations. RESULTS Forty patients (68% male) were enrolled (mean age, 12.5 years). Twenty-four (60%) had active disease (≥15 eosinophils per high-power field). EST-captured eotaxin-3, major basic protein 1, EDN, eosinophil peroxidase, and Charcot-Leyden crystal protein/galectin-10 showed significant correlations with peak eosinophils per high-power field (ρ 0.53-0.68, P < .001). Luminal proteins positively correlated with endoscopic features and markers of EMT, and negatively with esophageal distensibility. Periostin was captured by the EST and correlated with eosinophil density, basal zone hyperplasia, endoscopic appearance, and markers of EMT. CONCLUSION Luminal markers of esophageal remodeling in addition to biomarkers of eosinophilic inflammation correlate with epithelial and functional remodeling in EoE.
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Affiliation(s)
- Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| | - Steven J Ackerman
- Departments of Biochemistry and Molecular Genetics, and Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Zhaoxing Pan
- Research Institute, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Alain Benitez
- Division of Gastroenterology, Hepatology, and Nutrition, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Cassandra Burger
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology & Nutrition, Gastrointestinal Eosinophilic Diseases Program, and the Digestive Health Institute; Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Jonathan M Spergel
- Division of Allergy and Immunology and Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Glenn T Furuta
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology & Nutrition, Gastrointestinal Eosinophilic Diseases Program, and the Digestive Health Institute; Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | - Joshua Rothman
- Division of Gastroenterology, Hepatology, and Nutrition, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Benjamin J Wilkins
- Department of Pathology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Michael A Arnold
- Department of Pathology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Lauren Dolinsky
- Division of Gastroenterology, Hepatology, and Nutrition, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perlman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Milica Grozdanovic
- Departments of Biochemistry and Molecular Genetics, and Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Calies Menard-Katcher
- Research Institute, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
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13
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Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R, Morris D, Epstein J, Novelli MR, Hunter H, Cordell A, Hall S, Hayat JO, Kapur K, Moore AR, Read C, Sami SS, Turner PJ, Trudgill NJ. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022; 71:1459-1487. [PMID: 35606089 PMCID: PMC9279848 DOI: 10.1136/gutjnl-2022-327326] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE. METHODS The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance. RESULTS Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research. CONCLUSIONS These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.
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Affiliation(s)
- Anjan Dhar
- Gastroenterology, Darlington Memorial Hospital, Darlington, UK .,Teesside University, Middlesbrough, UK
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea University, Swansea, UK,Department of Gastroenterology, University Hospital Llandough, Llandough, UK
| | | | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
| | - Jason M Dunn
- Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
| | - Rami Sweis
- Research Department of Tissue and Energy, Division of Surgery & Interventional Science, University College London, London, UK
| | - Danielle Morris
- Department of Gastroenterology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Hannah Hunter
- Department of Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Amanda Cordell
- Trustee & Chair, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sharon Hall
- Department of Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Jamal O Hayat
- Gastroenterology, St George's Healthcare NHS Trust, London, UK
| | - Kapil Kapur
- Gastroenterology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Andrew Robert Moore
- Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Carol Read
- Medical advisor/Patient advocate, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sarmed S Sami
- Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul J Turner
- National Heart and Lung Institute Section of Allergy and Clinical Immunology, London, UK,Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
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14
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. Gastroenterology 2022; 163:59-76. [PMID: 35606197 PMCID: PMC9233087 DOI: 10.1053/j.gastro.2022.03.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Bob Geng
- University of California San Diego, San Diego, California; Rady Children's Hospital, San Diego, California
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock, Arkansas; Arkansas Children's Hospital, Little Rock, Arkansas
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven, Connecticut; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden, Connecticut
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children, Indianapolis, Indiana; Community Health Network, Indianapolis, Indiana
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville, Virginia
| | - Fouad J Moawad
- Division of Gastroenterology, Scripps Clinic, La Jolla, California
| | - Kathryn A Peterson
- Division of Gastroenterology, University of Utah Health, Salt Lake City, Utah
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Rady Children's Hospital, San Diego, California; Division of Allergy, Immunology, University of California-San Diego, San Diego, California
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. J Allergy Clin Immunol 2022; 150:33-47. [PMID: 35606166 PMCID: PMC9549868 DOI: 10.1016/j.jaci.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/13/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora; Children's Hospital Colorado, Aurora
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati; Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora; Digestive Health Institute, Children's Hospital Colorado, Aurora
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam
| | - Bob Geng
- University of California San Diego, San Diego; Rady Children's Hospital, San Diego
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock; Arkansas Children's Hospital, Little Rock
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis; Riley Hospital for Children, Indianapolis; Community Health Network, Indianapolis
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid; Instituto de Investigación Sanitaria La Princesa, Madrid
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville
| | | | | | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora
| | - Seema S Aceves
- Rady Children's Hospital, San Diego; Division of Allergy, Immunology, University of California-San Diego, San Diego
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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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Eosinophilic Esophagitis Symptom Scores Are High in Children Without Eosinophilic Disease. J Pediatr Gastroenterol Nutr 2022; 74:396-401. [PMID: 34636795 DOI: 10.1097/mpg.0000000000003324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The Pediatric Eosinophilic Esophagitis (EoE) Symptom Score version 2 (PEESSv2.0) is an EoE-specific validated metric for disease monitoring, but its use has not been explored outside of EoE. Our aim was to determine if PEESSv2.0 scores differentiate between children with EoE and non-EoE esophageal dysfunction undergoing initial esophagogastroduodenoscopy (EGD). METHODS A prospective cohort study of pediatric subjects was conducted. Children ages 1-18 undergoing initial EGD for esophageal dysfunction were enrolled. Demographics, clinical history, and child self-report and parent-proxy report PEESSv2.0 symptom scores were collected at the time of EGD. Esophageal biopsies were reviewed, and EoE was defined as >15 eosinophils/high powered field (hpf) seen in any level of the esophagus. Non-EoE was defined as <15 eosinophils/hpf. RESULTS Seventy-one children were included in the study from 2015 to 2018 [59% (42/71) males; mean age 9.2 years; range 1-17 years]. Fifty-eight percent (41/71) met criteria for EoE, and 42% (30/71) were labeled non-EoE. Non-EoE children and their parents had higher/worse median PEESSv2.0 total scores than those with EoE [47.0 vs 28.0 (P = 0.001) and 40.5 vs 26.5 (P = 0.012), respectively]. Non-EoE children reported higher median GERD [9.0 vs 4.0 (P = 0.003)], nausea/vomiting [9.0 vs 4.0 (P = 0.003)], and pain [11.0 vs 6.0 (P = 0.001)] subdomain scores compared to those with EoE. PEESSv2.0 dysphagia subdomain scores (child and parent-proxy) did not differ between EoE and non-EoE groups [22.0 vs 15.0 (P = 0.184) and 18.5 vs 17.4 (P = 0.330), respectively]. DISCUSSION Total PEESSv2.0 scores were worse in non-EoE group compared to EoE group. Although PEESSv2.0 is validated for use in monitoring EoE therapy, it does not distinguish children with EoE from non-EoE esophageal dysfunction at the time of diagnostic EGD.
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Prospective Endoscopic Activity Assessment for Eosinophilic Gastritis in a Multisite Cohort. Am J Gastroenterol 2022; 117:413-423. [PMID: 35080202 PMCID: PMC8897269 DOI: 10.14309/ajg.0000000000001625] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 12/27/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Eosinophilic gastritis (EG) is a chronic inflammatory disease of the stomach characterized by eosinophil-predominant gastric mucosal inflammation and gastrointestinal symptoms. The aim of this study was to prospectively evaluate endoscopic features in a large series of children and adults with EG to better understand the endoscopic manifestations and develop a standardized instrument for investigations. METHODS Data were prospectively collected as part of the Consortium for Eosinophilic Gastrointestinal Disease Researchers, a national collaborative network. Endoscopic features were prospectively recorded using a system specifically developed for EG, the EG Endoscopic Reference System (EG-REFS). Correlations were made between EG-REFS and clinical and histologic features. RESULTS Of 98 patients with EG, 65 underwent assessments using EG-REFS. The most common findings were erythema (72%), raised lesions (49%), erosions (46%), and granularity (35%); only 8% of patients with active histology (≥30 eosinophils/high-power field) exhibited no endoscopic findings. A strong correlation between EG-REFS scores and physician global assessment of endoscopy severity was demonstrated (Spearman r = 0.84, P < 0.0001). The overall score and specific components of EG-REFS were more common in the antrum than in the fundus or body. EG-REFS severity was significantly correlated with active histology, defined by a threshold of ≥30 eosinophils/high-power field (P = 0.0002). DISCUSSION Prospective application of EG-REFS identified gastric features with a strong correlation with physician global assessment of endoscopic activity in EG. Endoscopic features demonstrated greater severity in patients with active histology and a predilection for the gastric antrum. Further development of EG-REFS should improve its utility in clinical studies.
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Development and Validation of Web-Based Tool to Predict Lamina Propria Fibrosis in Eosinophilic Esophagitis. Am J Gastroenterol 2022; 117:272-279. [PMID: 34932022 PMCID: PMC8858426 DOI: 10.14309/ajg.0000000000001587] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/19/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Approximately half of esophageal biopsies from patients with eosinophilic esophagitis (EoE) contain inadequate lamina propria, making it impossible to determine the lamina propria fibrosis (LPF). This study aimed to develop and validate a web-based tool to predict LPF in esophageal biopsies with inadequate lamina propria. METHODS Prospectively collected demographic and clinical data and scores for 7 relevant EoE histology scoring system epithelial features from patients with EoE participating in the Consortium of Eosinophilic Gastrointestinal Disease Researchers observational study were used to build the models. Using the least absolute shrinkage and selection operator method, variables strongly associated with LPF were identified. Logistic regression was used to develop models to predict grade and stage of LPF. The grade model was validated using an independent data set. RESULTS Of 284 patients in the discovery data set, median age (quartiles) was 16 (8-31) years, 68.7% were male patients, and 93.4% were White. Age of the patient, basal zone hyperplasia, dyskeratotic epithelial cells, and surface epithelial alteration were associated with presence of LPF. The area under the receiver operating characteristic curve for the grade model was 0.84 (95% confidence interval: 0.80-0.89) and for stage model was 0.79 (95% confidence interval: 0.74-0.84). Our grade model had 82% accuracy in predicting the presence of LPF in an external validation data set. DISCUSSION We developed parsimonious models (grade and stage) to predict presence of LPF in esophageal biopsies with inadequate lamina propria and validated our grade model. Our predictive models can be easily used in the clinical setting to include LPF in clinical decisions and determine its effect on treatment outcomes.
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20
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Responsiveness of a Histologic Scoring System Compared With Peak Eosinophil Count in Eosinophilic Esophagitis. Am J Gastroenterol 2022; 117:264-271. [PMID: 34797816 DOI: 10.14309/ajg.0000000000001571] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The optimal instrument for assessing histologic disease activity in patients with eosinophilic esophagitis (EoE) is unclear. We assessed the responsiveness of the EoE Histologic Scoring System (EoE-HSS) when compared with that of the peak eosinophil count (PEC). METHODS Histopathology slides were obtained from patients with EoE at baseline and after 8 weeks of treatment with swallowed topical budesonide or elimination diet. Two blinded gastrointestinal pathologists scored biopsies on the EoE-HSS, PEC, and 100-mm visual analog scale (VAS) of overall histologic severity. Change was defined as an improvement by ≥0.5 SD in baseline VAS. Responsiveness was quantified using the standardized effect size (SES) and the probability that the index distinguishes a patient with improvement from a patient without improvement, which is the area under the receiver operating characteristic curve (AUC). Longitudinal validity was assessed using Pearson correlations between changes in EoE-HSS and both PEC and VAS. RESULTS The EoE-HSS grade (SES 2.18 [95% confidence interval, CI: 1.46-2.88]; AUC 0.73 [95% CI: 0.57-0.84]) and stage (SES 2.07 [95% CI: 1.37-2.77]; AUC 0.73 [95% CI: 0.58-0.84]) were highly responsive, similar to PEC (SES 1.44 [95% CI: 0.80-2.07]; AUC 0.73 [95% CI: 0.58-0.84]). The EoE-HSS grade and stage were more highly correlated with changes in VAS (grade 0.92 [95% CI: 0.86-0.95]; stage 0.89 [95% CI: 0.81-0.94]) than with changes in PEC (grade 0.74 [95% CI: 0.58-0.85]; stage 0.66 [95% CI: 0.47-0.80]). DISCUSSION The EoE-HSS is highly responsive, performs similarly to PEC, and is better correlated with changes in overall histologic activity in patients with EoE.
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21
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Ma C, Schoepfer AM, Dellon ES, Bredenoord AJ, Chehade M, Collins MH, Feagan BG, Furuta GT, Gupta SK, Hirano I, Jairath V, Katzka DA, Pai RK, Rothenberg ME, Straumann A, Aceves SS, Alexander JA, Arva NC, Atkins D, Biedermann L, Blanchard C, Cianferoni A, Ciriza de Los Rios C, Clayton F, Davis CM, de Bortoli N, Dias JA, Falk GW, Genta RM, Ghaffari G, Gonsalves N, Greuter T, Hopp R, Hsu Blatman KS, Jensen ET, Johnston D, Kagalwalla AF, Larsson HM, Leung J, Louis H, Masterson JC, Menard-Katcher C, Menard-Katcher PA, Moawad FJ, Muir AB, Mukkada VA, Penagini R, Pesek RD, Peterson K, Putnam PE, Ravelli A, Savarino EV, Schlag C, Schreiner P, Simon D, Smyrk TC, Spergel JM, Taft TH, Terreehorst I, Vanuytsel T, Venter C, Vieira MC, Vieth M, Vlieg-Boerstra B, von Arnim U, Walker MM, Wechsler JB, Woodland P, Woosley JT, Yang GY, Zevit N, Safroneeva E. Development of a core outcome set for therapeutic studies in eosinophilic esophagitis (COREOS). J Allergy Clin Immunol 2022; 149:659-670. [PMID: 34242635 PMCID: PMC8733049 DOI: 10.1016/j.jaci.2021.07.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/07/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND End points used to determine treatment efficacy in eosinophilic esophagitis (EoE) have evolved over time. With multiple novel therapies in development for EoE, harmonization of outcomes measures will facilitate evidence synthesis and appraisal when comparing different treatments. OBJECTIVE We sought to develop a core outcome set (COS) for controlled and observational studies of pharmacologic and diet interventions in adult and pediatric patients with EoE. METHODS Candidate outcomes were generated from systematic literature reviews and patient engagement interviews and surveys. Consensus was established using an iterative Delphi process, with items voted on using a 9-point Likert scale and with feedback from other participants to allow score refinement. Consensus meetings were held to ratify the outcome domains of importance and the core outcome measures. Stakeholders were recruited internationally and included adult and pediatric gastroenterologists, allergists, dieticians, pathologists, psychologists, researchers, and methodologists. RESULTS The COS consists of 4 outcome domains for controlled and observational studies: histopathology, endoscopy, patient-reported symptoms, and EoE-specific quality of life. A total of 69 stakeholders (response rate 95.8%) prioritized 42 outcomes in a 2-round Delphi process, and the final ratification meeting generated consensus on 33 outcome measures. These included measurement of the peak eosinophil count, Eosinophilic Esophagitis Histology Scoring System, Eosinophilic Esophagitis Endoscopic Reference Score, and patient-reported measures of dysphagia and quality of life. CONCLUSIONS This interdisciplinary collaboration involving global stakeholders has produced a COS that can be applied to adult and pediatric studies of pharmacologic and diet therapies for EoE and will facilitate meaningful treatment comparisons and improve the quality of data synthesis.
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Affiliation(s)
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc, London, Ontario, Canada
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brian G Feagan
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Colorado School of Medicine, Aurora, Colo
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children/Indiana University School of Medicine, Indianapolis, Ind
| | - Ikuo Hirano
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minn
| | - Rish K Pai
- Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Ariz
| | - 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
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Seema S Aceves
- Division of Allergy Immunology, University of California, San Diego, Rady Children's Hospital, San Diego, Calif
| | | | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, Children's Hospital of Colorado, Section of Allergy and Immunology, University of Colorado School of Medicine, Aurora, Colo
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Carine Blanchard
- Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé, Vevey, Switzerland
| | - Antonella Cianferoni
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Constanza Ciriza de Los Rios
- Department of Gastroenterology, Hospital Clínico San Carlos, Universidad Complutense, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Frederic Clayton
- Department of Pathology, The University of Utah, Huntsman Cancer Hospital, Salt Lake City, Utah
| | - Carla M Davis
- Immunology, Allergy, and Retrovirology Section of the Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - Nicola de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Jorge A Dias
- Pediatric Gastroenterology, Centro Hospitalar S. João, Porto, Portugal
| | - Gary W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Robert M Genta
- Inform Diagnostics, Irving, Tex; Department of Pathology, Baylor College of Medicine, Houston, Tex
| | - Gisoo Ghaffari
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Pennsylvania State College of Medicine, Hershey, Pa
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Russell Hopp
- University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, Neb
| | - Karen S Hsu Blatman
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Elizabeth T Jensen
- Wake Forest University School of Medicine, Department of Epidemiology and Prevention, Winston-Salem, NC
| | | | - Amir F Kagalwalla
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Division of Gastroenterology, Department of Pediatrics, John H. Stroger Jr Hospital of Cook County, Chicago, Ill
| | - Helen M Larsson
- Department of ENT, Head, and Neck Surgery, NÄL Medical Centre, Trollhättan, Sweden
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, Mass
| | - Hubert Louis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Calies Menard-Katcher
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Colorado School of Medicine, Aurora, Colo
| | - Paul A Menard-Katcher
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Fouad J Moawad
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, Calif
| | - Amanda B Muir
- Center for Pediatric Eosinophilic Diseases, Division of Gastroenterology and Hepatology & Nutrition, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Robert D Pesek
- Division of Allergy and Immunology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Kathryn Peterson
- Division of Gastroenterology, The University of Utah, Salt Lake City, Utah
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alberto Ravelli
- University Department of Pediatrics, Children's Hospital-Spedali Civili, Brescia, Italy
| | - Edoardo V Savarino
- Department of Surgery, Oncology, and Gastroenterology, DiSCOG, University of Padua, Padua, Italy
| | - Christoph Schlag
- II. Medizinische Klinik, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Philipp Schreiner
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Jonathan M Spergel
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Tiffany H Taft
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Ingrid Terreehorst
- Department of ENT, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Tim Vanuytsel
- Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Translational Research in Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Carina Venter
- Gastrointestinal Eosinophilic Diseases Program, Children's Hospital of Colorado, Section of Allergy and Immunology, University of Colorado School of Medicine, Aurora, Colo
| | - Mario C Vieira
- Department of Pediatrics, Pontifical Catholic University of Paraná and Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Michael Vieth
- Institute for Pathology, Klinikum Bayreuth, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | | | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology, and Infectious Diseases, University Hospital, Magdeburg, Germany
| | - Marjorie M Walker
- Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Barts, and the London School of Medicine and Dentistry, Queen Mary University of London, London, England, United Kingdom
| | - John T Woosley
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Guang-Yu Yang
- Division of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
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22
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Chang N, Raja S, Betancourt R, Randall C, Keene S, Lilly A, Fowler M, Woosley JT, Shaheen NJ, Dellon ES. Generic Measures of Quality of Life Are Not Correlated with Disease Activity in Eosinophilic Esophagitis. Dig Dis Sci 2021; 66:3312-3321. [PMID: 33492534 PMCID: PMC8310530 DOI: 10.1007/s10620-020-06719-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/15/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND The relationship between histologic disease activity in eosinophilic esophagitis (EoE) and generic measures of quality of life (QoL) is unclear. AIMS To determine differences in QoL in adults with EoE based on histologic activity and assess changes in QoL over time. METHODS We performed an analysis of prospectively collected data from patients in the University of North Carolina EoE Registry. Patients were categorized with histologically active (≥ 15 eosinophils per high-power field [eos/hpf]) or inactive (< 15 eos/hpf) disease. Dysphagia severity was measured with a Likert scale. QoL was measured with 36-Item Short Form (SF-36), compared between active and inactive groups, and assessed longitudinally. RESULTS Of 147 EoE cases, those with inactive disease (n = 56) reported less dysphagia severity (3.2 vs. 1.9; p = 0.003) and had lower endoscopic severity (3.8 vs. 1.0; p < 0.001) than those with active disease (n = 91). While SF-36 scores did not differ between active and inactive status, lower mental component scores (MCS) were seen in patients treated with empiric dietary elimination (44.9 vs. 50.8; p = 0.005). Dysphagia severity was negatively correlated with both physical component score (PCS) (r = -0.33; p < 0.001) and MCS (r = -0.18; p = 0.03). Despite more cases achieving histologic response over time, SF-36 scores did not improve on either raw or adjusted analyses. CONCLUSION QoL measured by SF-36 in EoE was similar regardless of histologic disease activity and was in the range of population averages. General QoL metrics like the SF-36 do not appear to have substantial utility in EoE.
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Affiliation(s)
- Nicole Chang
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Soha Raja
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Renee Betancourt
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Cara Randall
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Staci Keene
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Amy Lilly
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Mark Fowler
- 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, Division of Gastroenterology and Hepatology; University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology; University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology; University of North Carolina School of Medicine, Chapel Hill, NC
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23
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What influences complementary medicine use for children with eosinophilic esophagitis? Findings from a cross-sectional survey. Complement Ther Clin Pract 2021; 45:101448. [PMID: 34583253 DOI: 10.1016/j.ctcp.2021.101448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/16/2021] [Accepted: 07/19/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE Utilization of complementary medicines (CMs) amongst children with eosinophilic esophagitis (EoE) in Australia is high. Carers' beliefs, perceptions and use of CM can influence the decision to use CM in children in their care. This study explores the factors influencing the use of CM for a child's EoE when the carer also uses CM. MATERIALS AND METHODS Carers of children aged 0-18 years with EoE participated in a national cross-sectional online survey, conducted in Australia between September 2018 and February 2019. Data analysis included bivariate analysis, Cramer's V, backwards stepwise logistic regression and binomial logistic regression. RESULTS Of the 181 total survey responses, 165 (91.2 %) respondents indicated they had utilized some form of CM for themselves. Children whose carer had used some form of CM for themselves were more likely to have used CM than children whose carer had not used CM (OR 4.6; p = 0.001). Of the CM self-using carers, 125 (75.8 %) had also chosen to utilize CM for their child's EoE. Use of CM in children was more likely amongst children who had used a pharmaceutical for their EoE (OR 7.51; p = 0.010), and those whose carer had consulted with "other health practitioners or health workers" for their child's EoE (OR 5.34; p < 0.001) or had consulted with a chiropractor for themselves (OR 2.70; p = 0.029). CONCLUSION High CM self-use amongst carers is associated with their decision to also use CM for their child's EoE, a concern given the absence of evidence for CM's safety and efficacy in this population. CM use in this population warrants further attention. Effective conventional medicines for EoE are limited and utilization of CM amongst children with EoE in Australia is high. The recommendation of CM for children with EoE warrants further attention given the substantial concomitant pharmaceutical care, and the absence of evidence for CM's safety and efficacy in this population. Further research into the role of CM practitioners, products, and therapies in an integrative model between CM and conventional healthcare must be undertaken.
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24
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Clinicopathologic Correlations in Eosinophilic Gastrointestinal Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3258-3266. [DOI: 10.1016/j.jaip.2021.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 12/17/2022]
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25
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Hiremath G, Choksi YA, Acra S, Correa H, Dellon ES. Factors Associated With Adequate Lamina Propria Sampling and Presence of Lamina Propria Fibrosis in Children with Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2021; 19:1814-1823.e1. [PMID: 32707338 PMCID: PMC8033509 DOI: 10.1016/j.cgh.2020.07.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal biopsies in children with eosinophilic esophagitis (EoE) are often inadequate for assessment of lamina propria and lamina propria fibrosis (LPF). For children with EoE, little is known about the factors associated with adequate lamina propria (aLP) sampling or the relationship among epithelial features in esophageal biopsies with and without LPF. We aimed to evaluate aLP in esophageal biopsies from children with and without EoE, identify factors associated with aLP and LPF, and examine the relationship among epithelial features in biopsies with and without LPF in children with EoE. METHODS In a retrospective study, we analyzed clinical, endoscopic, and histologic data from 217 children (124 with EoE and 94 without EoE [controls]) using descriptive statistics, logistic regression, Spearman's correlation, and receiver operating characteristic curve analysis. Active and inactive EoE were defined per the 2011 consensus guidelines. RESULTS aLP was observed in biopsies from higher proportion of children with EoE (69%) than controls (31%) (P = .0001). Active EoE was independently associated with aLP (adjusted odds ratio [aOR], 4.23; 95% CI, 1.00-18.13; P = .05). Patient sex (aOR for boys, 8.37; 95% CI, 1.23-56.74; P = .03) and peak eosinophil count (aOR, 1.02; 95% CI, 1.01-1.04; P = .01) were independently associated with LPF. Epithelial features were strongly interrelated in biopsies with LPF, and the presence of specific epithelial features was associated with LPF. CONCLUSIONS aLP was observed in a higher proportion of esophageal biopsies from children with EoE than controls. EoE status, patient sex, and peak eosinophil count were associated with aLP sampling and LPF. Given the intricate relationship between epithelial features and LPF, computational models can be developed to identify children with esophageal biopsies without aLP who are at risk for LPF.
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Affiliation(s)
- Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Yash A. Choksi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA,Veterans Affairs Tennessee Valley Health Care System, Nashville, Tennessee, USA
| | - Sari Acra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hernan Correa
- Division of Pediatric Pathology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill North Carolina, USA
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26
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Mehta P, Pan Z, Skirka S, Kwan BM, Menard-Katcher C. Medication Adherence Aligns with Age and a Behavioral Checklist but Not Symptoms or Quality of Life for Patients with Eosinophilic Esophagitis. J Pediatr 2021; 235:246-252.e1. [PMID: 33811869 PMCID: PMC8316273 DOI: 10.1016/j.jpeds.2021.03.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To measure adherence rates to swallowed topical steroids in children with eosinophilic esophagitis (EoE), describe factors related to adherence, and determine the association between adherence, symptoms, perceived disease severity, and quality of life in children with EoE. STUDY DESIGN Subjects in this cross-sectional study of 117 children between 5 and 18 years old with EoE completed the Pediatric Eosinophilic Esophagitis Symptoms Score V2.0 (PEESS), Pediatric Quality of Life Inventory Eosinophilic Esophagitis Module (PedsQL EoE), a Medication-Taking Checklist (MTC), and a demographics questionnaire. Adherence rate was calculated based on reported number of missed doses/prescribed doses in the last week. Parent-reported measures were used for children aged 5-12 years and self-report was used for children aged 13-18 years. RESULTS Adolescents had lower adherence rates than younger children (76.2 ± 24.5% vs 88.6 ± 16.7%, P = .002). Adherence rates were not associated with disease history, PEESS, or PedsQL EoE scores but instead correlated with MTC scores (Pearson r of 0.65, P < .001 for child-report and Pearson r of 0.74, P < .001 for parent-report). Symptomatology was associated with worse quality of life (PEESS Frequency: r = -0.7, P < .001; PEESS Severity: r = -0.71, P < .001 for children 5-12 years old; PEESS Frequency: r = -0.61, P < .001; PEESS Severity: r = -.5, P < .001 for adolescents). CONCLUSIONS Unrelated to their clinical history, demographic factors, symptoms, and quality of life, adolescents with EoE have lower medication adherence rates. The MTC may serve as a clinical tool to discuss adherence and provide targeted educational counseling regarding adherence interventions.
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Affiliation(s)
- Pooja Mehta
- Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Zhaoxing Pan
- Department of Biostatistics, University of Colorado School of Medicine
| | | | - Bethany M. Kwan
- Department of Family Medicine, University of Colorado School of Medicine
| | - Calies Menard-Katcher
- Children’s Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine
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27
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Hannan N, McMillan SS, Tiralongo E, Steel A. Treatment Burden for Pediatric Eosinophilic Esophagitis: A Cross-Sectional Survey of Carers. J Pediatr Psychol 2021; 46:100-111. [PMID: 33216917 DOI: 10.1093/jpepsy/jsaa095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To investigate treatment burden and impact on health-related quality of life (HRQoL) for children with eosinophilic esophagitis (EoE) and their carers. METHODS An Australian cross-sectional online survey of carers of children aged 18 years and under with EoE between September 2018 to February 2019. RESULTS Of 181 complete responses, more than half of carers experienced reduced HRQoL since their child's diagnosis. Reported mean out-of-pocket expenditure for healthcare utilization (practitioner visits and treatment) was AUD$3064.3 annually. Backwards stepwise linear regression models showed that reduced ability to manage on income and missing more than one workday in the previous 30 days were significant predictors of lower carer HRQoL. Ability to manage on the current income described as "difficult some of the time," "difficult all of the time," and "impossible" were associated with lower child HRQoL. When compared with EoE diagnosis between 13 and 23 months of age, diagnosis between 2 and 4 years was a significant predictor of lowered child HRQoL. CONCLUSIONS Pediatric EoE in Australia leads to high treatment burden for carers. Changes in carer employment and income manageability can negatively impact carer psychosocial wellbeing. Carers of children with EoE need to be informed about available financial and social support to reduce treatment-related burden and improve the quality of life of both the carer and child.
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Affiliation(s)
- Nicole Hannan
- School of Pharmacy and Pharmacology, Griffith University and
| | - Sara S McMillan
- School of Pharmacy and Pharmacology, Griffith University and
| | | | - Amie Steel
- Australian Research Centre in Complementary and Integrative Medicine, Faculty of Health, University of Technology Sydney
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28
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Very early onset eosinophilic esophagitis is common, responds to standard therapy, and demonstrates enrichment for CAPN14 genetic variants. J Allergy Clin Immunol 2020; 147:244-254.e6. [PMID: 33446329 DOI: 10.1016/j.jaci.2020.10.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/03/2020] [Accepted: 10/02/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic, food antigen-mediated disease characterized by esophageal dysfunction and intraepithelial eosinophil accumulation. OBJECTIVE We hypothesized that very early onset EoE (V-EoE) would be enriched for early-life and genetic factors and have worse presentation and prognosis than later-onset pediatric EoE (L-EoE). METHODS We conducted a single-site, retrospective review comparing patients diagnosed at age 12 months or less (V-EoE, n = 57) and age 14 to 18 years (L-EoE, n = 70). These patients underwent medical record, EoE Histology Scoring System, Endoscopic Reference Score, and EoE Diagnostic Panel assessment when sample availability permitted. Genetic association used 2 EoE genotype repositories. Data were analyzed using chi-square tests, t tests, Wilcoxon rank-sum tests, Spearman correlations, cluster analysis, and logistic regression. RESULTS Among pediatric patients with EoE, diagnosis most commonly occurred within early life (0-24 months, 17%). V-EoE was more likely to attain histologic remission via dietary restriction (P < .0001). Basal zone hyperplasia and eosinophil inflammation were greater in V-EoE (P < .05). Esophageal strictures more commonly occurred in L-EoE (P = .03). V-EoE had lower endoscopic scores (P < .05). Molecular expression was very similar between groups. Cesarean delivery was more common in patients with V-EoE (P = .03). Patients with V-EoE demonstrated enrichment of CAPN14 common genetic variants. CONCLUSIONS Early-life diagnosis of EoE is a common occurrence. V-EoE responds to standard therapy without early evidence for complications, suggesting a less severe prognosis than hypothesized. Molecular pathogenesis is preserved between V-EoE and L-EoE. Cesarean delivery and CAPN14 genetic variation likely promote earlier disease development.
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29
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Slack IF, Schwartz JT, Mukkada VA, Hottinger S, Abonia JP. Eosinophilic Esophagitis: Existing and Upcoming Therapies in an Age of Emerging Molecular and Personalized Medicine. Curr Allergy Asthma Rep 2020; 20:30. [PMID: 32506181 DOI: 10.1007/s11882-020-00928-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Recent research efforts have spurred great progress in the diagnosis and management of eosinophilic esophagitis (EoE). Nonetheless, challenges remain in addressing disease burden and impairment in the growing EoE population. We highlight work from the Cincinnati Center for Eosinophilic Disorders, the Consortium of Eosinophilic Gastrointestinal Disease Researchers, and others that address these ongoing challenges. RECENT FINDINGS New tools for characterizing EoE disease activity include the EoE Histology Scoring System (EoEHSS), endoscopic alternatives, validated patient-reported outcome (PRO) questionnaires, and investigational biomarkers. These diagnostic and monitoring strategies have been complemented by advances in EoE therapy. Treatment modalities have refined the traditional approaches of dietary elimination, swallowed steroids, and proton pump inhibitors (PPI), and biologics offer promise for future treatment. This review summarizes EoE advances in disease management and newly defined EoE endotypes that may serve as the foundation for EoE-personalized medicine.
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Affiliation(s)
- Ian F Slack
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7028, Cincinnati, OH, 45229, USA
| | - Justin T Schwartz
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7028, Cincinnati, OH, 45229, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shawna Hottinger
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7028, Cincinnati, OH, 45229, USA
| | - J Pablo Abonia
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7028, Cincinnati, OH, 45229, USA.
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30
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Whelan KA, Godwin BC, Wilkins B, Elci OU, Benitez A, DeMarshall M, Sharma M, Gross J, Klein-Szanto AJ, Liacouras CA, Dellon ES, Spergel JM, Falk GW, Muir AB, Nakagawa H. Persistent Basal Cell Hyperplasia Is Associated With Clinical and Endoscopic Findings in Patients With Histologically Inactive Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2020; 18:1475-1482.e1. [PMID: 31499251 PMCID: PMC7058491 DOI: 10.1016/j.cgh.2019.08.055] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/24/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although eosinophil count is the standard used to monitor disease activity in patients with eosinophilic esophagitis (EoE), there are often disparities between patient-reported symptoms and eosinophil counts. We examined the prevalence of epithelial alterations, namely basal cell hyperplasia (BCH) and spongiosis, among patients with inactive EoE (eosinophil counts below 15 following therapy) and aimed to determine whether maintenance of these changes in epithelial morphology are associated with persistent clinical findings. METHODS Esophageal biopsies of 243 patients (mean age, 16.9 years) undergoing routine endoscopy at the University of Pennsylvania were evaluated for epithelial BCH and spongiosis. Univariable analysis was used to calculate the association between epithelial changes and symptoms as well as endoscopic findings and peak eosinophil count. We validated our findings using data from a cohort of patients at the University of North Carolina. RESULTS The discovery and validation cohorts each included patients with inactive EoE, based on histologic factors, but ongoing BCH and spongiosis. Ongoing BCH, but not spongiosis, in patients with inactive EoE was associated with symptoms (odds ratio, 2.14; 95% CI, 1.03-4.42; P = .041) and endoscopic findings (odds ratio, 7.10; 95% CI, 3.12-16.18; P < .001). CONCLUSIONS In patients with EoE, the presence of BCH might indicate ongoing disease activity, independent of eosinophil count. This might account for the persistent symptoms in patients who are considered to be in remission based on histologic factors.
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Affiliation(s)
- Kelly A. Whelan
- Department of Pathology & Laboratory Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140,Fels Institute for Cancer Research & Molecular Biology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140
| | - Bridget C. Godwin
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA,Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Benjamin Wilkins
- Division of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Okan U. Elci
- Westat-Biostatistics and Data Management Core, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Alain Benitez
- Division of Allergy and Immunology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Maureen DeMarshall
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Medha Sharma
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Jonathan Gross
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA,Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Andres J. Klein-Szanto
- Histopathology Facility and Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Chris A. Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA,Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC 27514, USA
| | - Jonathan M. Spergel
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA,Division of Allergy and Immunology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Gary W. Falk
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Amanda B. Muir
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA,Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Hiroshi Nakagawa
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania.
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Eosinophilic Esophagitis Histology Remission Score: Significant Relations to Measures of Disease Activity and Symptoms. J Pediatr Gastroenterol Nutr 2020; 70:598-603. [PMID: 31977951 PMCID: PMC7183895 DOI: 10.1097/mpg.0000000000002637] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Eosinophilic esophagitis (EoE) is characterized by remissions and relapses. Guidelines defining remission do not exist and therefore remission is inconsistently identified. We sought to define histology remission in EoE. METHODS Esophageal biopsies, obtained at the time the validated pediatric EoE symptoms scores v2.0 (PEESS v2.0) questionnaire was completed (N = 42), were scored using the validated EoE Histology Scoring System. An EoE Histology Remission Score (EoEHRS) was constructed and specified that in all esophageal sites sampled the peak eosinophil count was <15 per high power field (HPF); in addition, neither the total grade (severity of pathology) nor stage (extent of pathology) scores could exceed 3 (possible total maximum score for each was 24). Spearman correlation coefficients were generated for histology/symptom correlations; coefficient range 0.31 to 0.50 was considered moderate. RESULTS EoE Histology Scoring System composite and individual feature scores from proximal and distal esophageal biopsies correlated moderately with PEESS v2.0 mean scores (0.48-0.36, P < 0.01), and with scores in the dysphagia (0.39-0.30, P ≤ 0.01), pain (0.48-0.34, P ≤ 0.01), and gastroesophageal reflux disease (0.51-0.32, P ≤ 0.01) domains. Biopsies that met full EoEHRS criteria had reduced biomarkers, specifically expression of the mast cell markers CPA3 and tryptase mRNA, and reduced eosinophil peroxidase deposition (P < 0.03), compared to those with nonremission scores. Subjects whose biopsies met EoEHRS remission criteria reported reduced symptoms for all domains except nausea and vomiting (P ≤ 0.01). CONCLUSIONS The EoEHRS correlated with reduced biomarkers of disease activity and reduced symptoms, and therefore may be useful to inform clinical care and interstudy comparisons.
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Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical review on the management of eosinophilic esophagitis: a report from the AGA institute and the joint task force on allergy-immunology practice parameters. Ann Allergy Asthma Immunol 2020; 124:424-440.e17. [PMID: 32336463 PMCID: PMC8171057 DOI: 10.1016/j.anai.2020.03.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
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Affiliation(s)
- Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona
| | - Rajiv N Sharaf
- Division of Gastroenterology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Division of Allergy Immunology Center for Immunity, Infection, and Inflammation, University of California, San Diego Rady Children's Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M Spergel
- Division of Allergy-Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland Veterans Affairs Medical Center and University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters. Gastroenterology 2020; 158:1789-1810.e15. [PMID: 32359563 PMCID: PMC9473155 DOI: 10.1053/j.gastro.2020.02.039] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
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Affiliation(s)
- Matthew A. Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo
Clinic, Scottsdale, Arizona
| | - Ravi N. Sharaf
- Division of Gastroenterology, Donald and Barbara
Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T. Furuta
- Digestive Health Institute, Children’s
Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of
Colorado School of Medicine, Aurora, Colorado
| | - Seema S. Aceves
- Division of Allergy Immunology Center for Immunity,
Infection, and Inflammation, University of California, San Diego Rady
Children’s Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children’s
Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M. Spergel
- Division of Allergy-Immunology, Children’s
Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania,
Philadelphia, Pennsylvania
| | - Yngve T. Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland
Veterans Affairs Medical Center and University Hospitals, Case Western Reserve
University School of Medicine, Cleveland, Ohio
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of
Gastroenterology and Hepatology, University of North Carolina School of Medicine,
Chapel Hill, North Carolina
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Collins MH, Dellon ES, Katzka DA, Hirano I, Williams J, Lan L. Budesonide Oral Suspension Significantly Improves Eosinophilic Esophagitis Histology Scoring System Results: Analyses From a 12-Week, Phase 2, Randomized, Placebo-controlled Trial. Am J Surg Pathol 2020; 43:1501-1509. [PMID: 31498177 DOI: 10.1097/pas.0000000000001361] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Budesonide oral suspension (BOS) is a novel topical corticosteroid, which has been shown to improve symptoms and endoscopic appearance, and reduce peak eosinophil counts in patients with eosinophilic esophagitis (EoE). This trial evaluated the effect of BOS or placebo on the severity (grade) and extent (stage) of 8 histopathologic features observed in EoE, using the validated eosinophilic esophagitis histologic scoring system (EoE HSS). Patients with EoE aged 11 to 40 years with dysphagia were randomized to receive either BOS (2.0 mg twice daily) or placebo for 12 weeks. Mean (SD) EoE HSS grade and stage total scores at baseline for placebo and BOS groups were: grade, 0.42 (0.16) and 0.49 (0.14), respectively; stage: 0.38 (0.14) and 0.46 (0.11), respectively. These scores significantly decreased (improved) from baseline for patients receiving BOS versus placebo (grade: least squares mean change [SE]: placebo vs. BOS, -0.04 [0.03] vs. -0.24 [0.02]; P<0.0001; stage: -0.01 [0.02] vs. -0.19 [0.02]; P<0.0001). EoE HSS total scores improved for 6 of the 8 and 5 of the 8 histopathologic features for grade and stage, respectively, versus placebo. Change in EoE HSS total scores correlated moderately but significantly with change in endoscopic severity (endoscopic reference score; grade: R=0.5349; stage: R=0.5416; both P<0.0001). Change in EoE HSS stage total score correlated weakly with change in Dysphagia Symptom Questionnaire scores (grade: R=0.1925; P=0.0740; stage: R=0.2135; P=0.0471). These data demonstrate that the EoE HSS is a valuable endpoint of treatment response in randomized clinical trials and should be considered for future trials for EoE.
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Affiliation(s)
- Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Lan Lan
- Shire, a Takeda Company, Lexington, MA
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Esophageal type 2 cytokine expression heterogeneity in eosinophilic esophagitis in a multisite cohort. J Allergy Clin Immunol 2020; 145:1629-1640.e4. [PMID: 32197970 DOI: 10.1016/j.jaci.2020.01.051] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/07/2020] [Accepted: 01/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is strong evidence for a role of type 2 cytokines in the pathogenesis of eosinophilic esophagitis (EoE); however, heterogeneity in type 2 gene expression has not been examined. OBJECTIVE We examined type 2 immunity-associated gene expression in esophageal biopsy specimens, aiming to determine the degree of cytokine heterogeneity and its potential clinical significance. METHODS Patients (n = 312) were recruited from 10 sites associated with the Consortium of Eosinophilic Gastrointestinal Disease Researchers. In addition to histologic and endoscopic assessment, esophageal biopsy specimens were examined for expression of 96 genes within the EoE diagnostic panel. RESULTS Five subgroups of patients with active EoE were identified by unsupervised clustering based on expression of IL4, IL5, IL13, C-C motif chemokine ligand 26 (CCL26), thymic stromal lymphopoietin (TSLP), Charcot-Leyden crystal (CLC), C-C motif chemokine receptor 3 (CCR3), and CPA3. These groups differed in age (P < .02) and EoE diagnostic panel score (P < 1.08E-30) but not in eosinophil levels. The group V patients had the highest expression of IL5, TSLP, and CCL26 and genes associated with tissue remodeling, such as COL8A1, actin γ-2 (ACTG2), and tetraspanin 12 (TSPAN12). IL5 and IL13 were highly expressed in group IV; however, groups IV and V differed in age (34 vs 14 years [P < .05]). Groups II and III, which exhibited intermediate expression of IL5 and CPA3, were differentiated by high TSLP and IL13 in group III. CONCLUSION We observed heterogeneous type 2 gene expression among patients with active EoE. Type 2 gene overexpression was not directly proportional to disease features; this was especially true for tissue remodeling events. These findings highlight a clinical opportunity for leveraging molecular endotypes to implement personalized medicine in EoE.
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Hannan N, Steel A, McMillan SS, Tiralongo E. Health Service Use and Treatment Choices for Pediatric Eosinophilic Esophagitis: Findings From a Cross-Sectional Survey of Australian Carers. Front Pediatr 2020; 8:147. [PMID: 32363170 PMCID: PMC7180181 DOI: 10.3389/fped.2020.00147] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/16/2020] [Indexed: 01/09/2023] Open
Abstract
Objectives: The incidence and the prevalence of eosinophilic esophagitis (EoE) are increasing, and healthcare utilization among children with EoE is high. This study provides novel insights into the health services and the treatments, including complementary medicines (CMs), used by carers to manage their children's EoE as well as the carers' beliefs and attitudes toward these treatments. Methods: A national cross-sectional online survey was conducted in Australia between September 2018 and February 2019. The survey included questions about health service and treatment utilization, health insurance and government support, health-related quality of life of children with EoE and their carers, views and attitudes toward CM use, and perceived efficacy of treatment. Results: The survey was completed by 181 carers (96.6% of whom were mothers) of EoE children. Most children (91.2%, n = 165) had seen a medical doctor for their EoE, and almost half had consulted with a CM practitioner (40.3%, n = 73). Pharmaceuticals (n = 156, 86.2%) were the most commonly used treatment option, followed by dietary changes (n = 142, 78.5%), CM products (n = 109, 60.2%), and CM therapies (n = 42, 23.2%). Most children received care from numerous practitioners on multiple occasions, indicating a substantial financial and treatment-related burden. Conclusions: A variety of practitioners are involved in the care of children with EoE, and a high rate of CM use warrants further attention to ensure that appropriate treatment is provided. Carer involvement and guidance, combined with individual practitioner expertise, referrals, and collaboration between providers, is essential to successfully navigate this complex disease and provide adequate care for these patients.
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Affiliation(s)
- Nicole Hannan
- School of Pharmacy and Pharmacology, Griffith University, Southport, QLD, Australia
| | - Amie Steel
- Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Ultimo, NSW, Australia
| | - Sara S McMillan
- School of Pharmacy and Pharmacology, Griffith University, Southport, QLD, Australia
| | - Evelin Tiralongo
- School of Pharmacy and Pharmacology, Griffith University, Southport, QLD, Australia
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Gonsalves NP, Aceves SS. Diagnosis and treatment of eosinophilic esophagitis. J Allergy Clin Immunol 2020; 145:1-7. [PMID: 31910983 PMCID: PMC6986782 DOI: 10.1016/j.jaci.2019.11.011] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is an eosinophil-rich, TH2 antigen-mediated disease of increasing pediatric and adult worldwide prevalence. Diagnosis requires greater than or equal to 15 eosinophils per high-power field on light microscopy. Symptoms reflect esophageal dysfunction, and typical endoscopic features include linear furrows, white plaques, and concentric rings. Progressive disease leads to pathologic tissue remodeling, with ensuing esophageal rigidity and loss of luminal diameter caused by strictures. Therapies include proton pump inhibitors, elimination diets, and topical corticosteroids. Effective treatment can reverse tissue fibrosis in some patients, as well as decrease the rate of food impactions. Esophageal dilation might be required to increase luminal patency. The chronic nature of EoE necessitates long-term therapy to avoid disease recurrence and complications. This review serves the function of providing the current state-of-the-art diagnostic criteria and disease management for adult and pediatric EoE.
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Affiliation(s)
- Nirmala P Gonsalves
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Ill.
| | - Seema S Aceves
- Division of Allergy Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, and Rady Children's Hospital, San Diego, Calif.
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Aceves S, Collins MH, Rothenberg ME, Furuta GT, Gonsalves N. Advancing patient care through the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR). J Allergy Clin Immunol 2019; 145:28-37. [PMID: 31758958 PMCID: PMC6981250 DOI: 10.1016/j.jaci.2019.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/19/2022]
Abstract
Recent advances in rare disease research are accelerated by the work of consortia that have been supported by the National Institutes of Health. Development of such consortia rely on multidisciplinary relationships and engagement with patient advocacy groups, as well as the National Institutes of Health and industry and academic partners. In this rostrum we present the development of such a process that focuses on eosinophilic gastrointestinal diseases. Principal investigators, patient advocacy groups, research assistants, and trainees work together to perform natural history studies that promote clinical trial readiness tools, conduct clinical trials, train a new generation of investigators, and perform innovative pilot studies.
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Affiliation(s)
- Seema Aceves
- Division of Allergy Immunology, University of California, San Diego, and Rady Children's Hospital, San Diego, La Jolla, Calif
| | - Margaret H Collins
- Division of Pathology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, 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, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colo.
| | - Nirmala Gonsalves
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Klion AD, Rothenberg ME. Advances in eosinophilic diseases in 2018. J Allergy Clin Immunol 2019; 144:1490-1494. [PMID: 31655098 DOI: 10.1016/j.jaci.2019.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 12/22/2022]
Abstract
Interest in eosinophil biology and eosinophilic diseases is increasing, as reflected in a doubling of the number of annual articles focused on this topic published in the Journal of Allergy and Clinical Immunology over the past decade. Although the majority of these publications relate to eosinophilic asthma, a growing proportion of them focus on breakthroughs in the diagnosis, treatment, and pathogenesis of other eosinophilic disorders, most notably eosinophilic esophagitis. This review highlights advances in our understanding of eosinophilia and eosinophilic disorders (excluding asthma) published in the Journal in 2018.
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Affiliation(s)
- Amy D Klion
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Dellon ES, Gupta SK. A Conceptual Approach to Understanding Treatment Response in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2019; 17:2149-2160. [PMID: 30710696 PMCID: PMC6667323 DOI: 10.1016/j.cgh.2019.01.030] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/15/2019] [Accepted: 01/20/2019] [Indexed: 02/07/2023]
Abstract
While the diagnosis and initial treatment of eosinophilic esophagitis are becoming more standardized, there are still major gaps in knowledge related to measuring treatment response. One such question centers on how to measure treatment response and what treatment endpoints should be. This impacts not only patient care and engagement in decision-making, but also the field of drug development. In addition, studies so far have use a myriad of treatment endpoints including over a dozen histologic endpoint criteria. This review will discuss the various stakeholders involved in assessment of treatment endpoints of a complex condition, including patients, practitioners and regulatory agencies, and the care settings in which treatment response is assessed, including routine clinical care, clinical trials, and observational studies. Potential parameters or treatment endpoints such as histology, symptoms, patient-reported outcomes, endoscopy, and biomarkers are discussed along with associated challenges and opportunities. A framework on how to define treatment outcomes is discussed and a conceptual approach treatment response is proposed. This takes into account histology, symptoms, and endoscopic findings and harnesses existing, validated tools. It includes definitions of nonresponse, complete normalization, and a graded response category between these 2 extremes, and also permits flexibility and latitude for modifications as newer knowledge emerges. In addition, ways to position the pediatric population in these endeavors are discussed as are future research directions.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, University of Illinois College of Medicine, Peoria, IL
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Collins CA, Palmquist J, Proudfoot JA, Qian A, Wangberg H, Khosh-Hemmat E, Dohil R, Aceves SS. Evaluation of long-term course in children with eosinophilic esophagitis reveals distinct histologic patterns and clinical characteristics. J Allergy Clin Immunol 2019; 144:1050-1057.e5. [PMID: 31255641 PMCID: PMC6820855 DOI: 10.1016/j.jaci.2019.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 06/12/2019] [Accepted: 06/14/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic and increasingly prevalent antigen-driven disease. There is a paucity of information on long-term course in children. OBJECTIVE We sought to understand the longitudinal trajectory of pediatric EoE during routine clinical care. METHODS We prospectively enrolled children into an EoE database and reviewed their medical and pathologic records over 13 years. RESULTS From 2011 to 2015, 146 children with EoE seen for their first visit at our center had 2 or more years of follow-up and 3 or more endoscopies over an average follow-up period of 5.13 years (range, 2-13 years). Longitudinal eosinophilic inflammation during treatment demonstrated 3 patterns over time. Children with less than 15 eosinophils/high-power field (hpf) for greater than 75% of their follow-up period were termed continuous responders (CRs). Children with waxing and waning inflammation of less than 15 eosinophils/hpf for less than 75% but 25% or more of the follow-up period were termed intermittent responders (IRs). Nonresponders (NRs) were defined as having less than 15 eosinophils/hpf for less than 25% of their follow-up. Fifty-nine (40%) of 146 patients were CRs, 65 (45%) of 146 were IRs, and 22 (15%) of 146 were NRs. CRs differed from IRs and NRs on the parameter of male/female ratio (1:1 in CRs, 4:1 in IRs, and 6:1 in NRs; P < .001) and in their initial response to any therapy, including proton pump inhibitors (P < .001). Endoscopic severity correlated with esophageal eosinophilia (r = 0.73, P < .001). On multivariate analysis, female sex and initial therapeutic response to medications or elimination diet were associated with long-term control of esophageal eosinophilia. CONCLUSIONS Long-term pediatric EoE followed 3 different longitudinal trajectories of inflammation. The long-term histologic groups differed significantly in biological sex and initial therapeutic response.
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Affiliation(s)
- Cathleen A Collins
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Jacob Palmquist
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - James A Proudfoot
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Altman Clinical Translational Research Institute, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Alex Qian
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif
| | - Hannah Wangberg
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Department of Medicine, University of California, San Diego, La Jolla, Calif
| | - Emad Khosh-Hemmat
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Ranjan Dohil
- Division of Gastroenterology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif
| | - Seema S Aceves
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Calif; Department of Medicine, University of California, San Diego, La Jolla, Calif; Rady Children's Hospital, San Diego, Calif.
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GUPTA SANDEEPK, FALK GARYW, ACEVES SEEMAS, CHEHADE MIRNA, COLLINS MARGARETH, DELLON EVANS, GONSALVES NIRMALA, HIRANO IKUO, MUKKUDA VINCENTA, PETERSON KATHRYNA, SPERGEL JONATHAN, YANG GUANGYU, FURUTA GLENNT, ROTHENBERG MARCE. Consortium of Eosinophilic Gastrointestinal Disease Researchers: Advancing the Field of Eosinophilic GI Disorders Through Collaboration. Gastroenterology 2019; 156:838-842. [PMID: 30452923 PMCID: PMC8033416 DOI: 10.1053/j.gastro.2018.10.057] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/18/2018] [Accepted: 10/24/2018] [Indexed: 12/30/2022]
Affiliation(s)
- SANDEEP K. GUPTA
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine, and Children’s Hospital of Illinois, Peoria, Illinois
| | - GARY W. FALK
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - SEEMA S. ACEVES
- Division of Allergy Immunology, University of California-San Diego, San Diego, California
| | - MIRNA CHEHADE
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - MARGARET H. COLLINS
- Division of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - EVAN S. DELLON
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - NIRMALA GONSALVES
- Division of Gastroenterology & Hepatology, Northwestern University, Chicago, Illinois
| | - IKUO HIRANO
- Division of Gastroenterology & Hepatology, Northwestern University Chicago, Illinois
| | - VINCENT A. MUKKUDA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical, Cincinnati, Ohio
| | - KATHRYN A. PETERSON
- Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, Utah
| | - JONATHAN SPERGEL
- Division of Allergy and Immunology, University of Pennsylvania Perelman School of Medicine/Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - GUANG-YU YANG
- Department of Pathology and Laboratory Medicine, Northwestern University, Chicago, Illinois
| | - GLENN T. FURUTA
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children’s Hospital Colorado and Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - MARC E. ROTHENBERG
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine/Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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Nhu QM, Moawad FJ. New Developments in the Diagnosis and Treatment of Eosinophilic Esophagitis. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:48-62. [PMID: 30707411 PMCID: PMC6519728 DOI: 10.1007/s11938-019-00216-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Eosinophilic esophagitis (EoE) is a chronic, allergen-driven, immune-mediated disease of the esophagus that progresses to esophageal fibrostenosis if left untreated. The aim of this review is to provide a concise update on recent clinically relevant advances in the development of diagnostic and therapeutic approaches for EoE. RECENT FINDINGS Current diagnostic and disease monitoring protocols for EoE rely on repetitive endoscopic evaluations and esophageal tissue acquisition for histopathologic analysis. Recent advancements in EoE diagnosis include endoscopic functional lumen imaging probe (FLIP), transnasal endoscopy (TNE), and the emergence of non-invasive diagnostic tools including cytosponge, esophageal string test, and mucosal impedance probe. Biomarkers for EoE have not yet proven their clinical utility. No Food and Drug Administration (FDA)-approved drugs currently exist for the treatment of EoE. Topical corticosteroid, proton-pump inhibitors (PPI), elimination diet, and dilation are the current treatment modalities for confirmed EoE. Promising results from clinical trials are emerging for biologic agents that target the interleukin (IL)-13 and the IL-4/IL-13 receptor, specifically, RPC4046 and dupilumab, respectively. New diagnostic algorithms, non-invasive diagnostic strategies, and treatment modalities for EoE are emerging. Patients with EoE continue to require a multimodal and multi-disciplinary management approach.
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Affiliation(s)
- Quan M Nhu
- Division of Gastroenterology & Hepatology, Scripps Clinic, 10666 N. Torrey Pines Road, Suite 203N, La Jolla, CA, 92037, USA.
- Scripps Research Translational Institute, The Scripps Research Institute, La Jolla, CA, USA.
| | - Fouad J Moawad
- Division of Gastroenterology & Hepatology, Scripps Clinic, 10666 N. Torrey Pines Road, Suite 203N, La Jolla, CA, 92037, USA.
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Nhu QM, Aceves SS. Medical and dietary management of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2018; 121:156-161. [PMID: 29753831 DOI: 10.1016/j.anai.2018.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Eosinophilic esophagitis (EoE) is a disease of chronic, allergen-driven, T-helper 2 (Th2) immune-mediated inflammation that progresses to fibrostenosis of the esophagus if left untreated. There are currently no Food and Drug Administration (FDA)-approved drugs for the treatment of EoE. This review focuses on the medical and dietary management of EoE. DATA SOURCES Manuscripts on EoE treatments were identified on PubMed. STUDY SELECTIONS Original research, randomized control trials, retrospective studies, meta-analyses, case series, and on occasions, case reports of high relevance, were selected and reviewed. RESULTS Current treatment strategies available to EoE patients center on monotherapy or combination therapy with dietary modification to exclude antigenic stimulation and topical corticosteroids to control Th2-mediated tissue inflammation and pathologic remodeling. Dilation as a rescue therapy for the narrowed, fibrostenotic, symptomatic esophagus can potentially be avoided with optimal medical and elimination diet therapies. The molecular mechanisms underlying EoE pathogenesis are being unraveled, from which targeted therapies can be developed and evaluated in preclinical and clinical studies. Current clinical research efforts focus on optimization of topical corticosteroid delivery, dosing, frequency, and duration of treatment, either alone or in combination with tailored elimination diet. Preliminary clinical trials with biologics targeting interleukin (IL)-5 and IL-13/IL-4 have been completed. CONCLUSION Topical corticosteroid, elimination diet, and dilation are the current treatment modalities for confirmed EoE. The use of proton-pump inhibitors (PPI) is being suggested as a potential regimen to treat EoE, based on evolving understanding of PPI-responsive esophageal eosinophilia (PPI-REE). The complexity of EoE treatment regimens and frequent follow-ups require a multimodal, multi-disciplinary management approach to optimize patient care.
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Affiliation(s)
- Quan M Nhu
- Scripps Translational Science Institute, The Scripps Research Institute, La Jolla, California; Division of Gastroenterology & Hepatology, Department of Medicine, Scripps Clinic-Scripps Green Hospital, La Jolla, California; Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Seema S Aceves
- Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California; Rady Children's Hospital, San Diego, San Diego, California.
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