Eosinophilic infiltration of the esophagus: gastroesophageal reflux versus eosinophilic esophagitis in children--discussion on daily practice

Pharmacological treatments for eosinophilic esophagitis: current options and emerging therapies

Introduction: The epidemiology of eosinophilic esophagitis (EoE) has increased rapidly to represent a common cause of chronic and recurrent esophageal symptoms. Current treatment options have limitations so the development of novel therapies is a matter of growing interest.Areas covered: This article provides an up-to-date discussion of current therapies and investigational options for EoE. Established anti-inflammatory treatments for EoE at present include dietary therapy, proton pump inhibitors and swallowed topic steroids, which should be combined with endoscopic dilation in case of strictures. Refractoriness, high recurrence rates, and need for long-term therapies have promoted the investigation of novel, esophageal-targeted formulas of topic corticosteroids, and monoclonal antibodies (including mepolizumab, reslizumab, QAX576, RPC4046, dupilumab, omalizumab, infliximab, and vedolizumab) for EoE, with some having been demonstrated as effective and safe in the short term. Several additional promising therapies are also discussed.Expert opinion: Several therapeutic targets have shown efficacy and will be approved to treat EoE, especially corticosteroid-sparing options and those for patients with multiple Th2-associated diseases. Personalized therapeutic strategies for initial and maintenance treatments of EoE must be rationally designed, to reduce the burden of disease and answer meaningfully the needs of all stakeholders involved in EoE.

Treatment of eosinophilic esophagitis in the pediatric patient: an evidence-based approach

Eosinophilic esophagitis (EoE) is a unique form of non-IgE-mediated food allergy characterized by esophageal eosinophilic infiltration that commonly causes dysphagia and food impaction in children and adolescents. Assessing the efficacy of dietary restrictions or drug therapies to achieve clinical and histologic resolution of EoE through randomized controlled trials and meta-analyses has resulted in new evidence-based guidelines. Avoiding food triggers is the only therapy targeting the cause of the disease. None of the currently available food allergy tests adequately predict food triggers for EoE. Exclusively feeding with an amino acid-based elemental diet and empiric six-food elimination diet (avoiding the six foods most commonly related with food allergy) has consistently provided the best cure rates, but their high level of restriction and need for multiple endoscopies are deterrents for implementation. Simpler and less restrictive empirical methods, like a four-food (milk, gluten-containing cereals, egg, legumes) or a two-food (milk and gluten) elimination diet, show encouraging results. Proton pump inhibitors are currently a first-line treatment, achieving histological remission and improvement of symptoms in 54.1 and 64.9% of pediatric EoE patients, respectively. The efficacy of topical corticosteroids in EoE assessed in several trials and summarized in meta-analyses indicates that budesonide and fluticasone propionate are significantly superior to placebos, both in decreasing eosinophil mucosal infiltration and in relieving symptoms. Owing to differences in drug delivery, viscous budesonide formulas seem to be the best pharmacological therapy for EoE.

CONCLUSION

Applying evidence-based therapies and a practical management algorithm provide an effective control of EoE. What is Known: • Eosinophilic esophagitis (EoE) now constitutes the main cause of dysphagia and food impaction in children, adolescents, and young adults. • Its chronic course and frequent progression to subepithelial fibrosis leading to strictures and narrow-caliber esophagus indicate the need for treatment. What is New: • Therapeutic goals in children with EoE include resolution of esophageal symptoms, to cure esophageal inflammation (mucosal healing) and restore a proper esophageal caliber in case of fibrostenotic endoscopic findings. Avoiding iatrogenic drug effects and nutritional deficiencies, as well as maintaining an adequate quality of life, is also essential. • Novel evidence-based guidelines, endorsed by several European scientific societies, incorporate recent advances in knowledge from several randomized controlled trials and systematic reviews to provide the best standard of care to pediatric patients, by following simple management algorithms.

Frequency of Esophageal Eosinophilia in a Pediatric Population from Central Brazil

Here we report a retrospective cross-sectional study on Esophageal eosinophilia (EsEo) frequency in Brazil, for 2, 425 pediatric patients with symptoms associated with gastroesophageal diseases in 2012. EsEo is defined by ≥15 eosinophils per high power field (400x) and confirmed through histological analyses of esophageal biopsies. Overall, 126 patients had EsEo equating to a frequency of 5.2%. There was a significant difference between the endoscopic features of patients with EsEo, where 10.7% had erosive esophagitis, 3.0% had non-erosive esophagitis and 1% showed normal esophageal mucosa. According to the interaction of the variables in the Classification and Regression Tree Analysis, most patients diagnosed with EsEo were older males with erosive esophagitis. On the other hand, the lowest frequency of EsEo was found among younger females with non-erosive esophagitis/normal mucosa. Environmental conditions, including climate variation and changes, were observed in association with EsEo, supporting a potential role for environmental factors in its pathogenesis. There was an inverse correlation between the number of EsEo, rainfall and humidity. EsEo is a relatively frequent finding in the pediatric population of Brazil with symptoms of gastroesophageal diseases. Both clinical and histological examinations of patients are important for a reliable diagnostic of EsEo cases and to patient care.

Possible Noninvasive Biomarker of Eosinophilic Esophagitis: Clinical and Experimental Evidence

Eosinophilic esophagitis (EoE) diagnosis and follow-up response to therapy is based on repeated endoscopies and histological examination for eosinophils/HPF. The procedure is invasive and risky in particular for the pediatric population. Presently, there is no highly sensitive and specific noninvasive blood test available to monitor the disease pathogenesis. Reports indicate the expression of PDL1 (CD274) on the eosinophils in allergic patients. Herein, we report that CD274-expressing and -nonexpressing eosinophils were detected in both examined pediatric and adult EoE patients. We show that CD274 expression on blood eosinophils and blood mRNA expression levels increase in the blood of EoE patients and decrease following treatment. These observations are consistent with the esophageal eosinophilia of before and after treatment in both examined patients. These two clinical and experimental analysis reports provide the possibility that the CD274 mRNA and CD274-expressing esinophil levels may be novel possible noninvasive biomarkers for EoE.

Efficacy of Proton Pump Inhibitor Drugs for Inducing Clinical and Histologic Remission in Patients With Symptomatic Esophageal Eosinophilia: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Proton pump inhibitor (PPI) therapy might lead to clinical and histologic remission in a significant proportion of patients with symptomatic esophageal eosinophilia (>15 eos/high-power field). We aimed to evaluate systematically the efficacy of PPI therapy for these patients.

METHODS

A search in MEDLINE, EMBASE, and SCOPUS databases, and the American Gastroenterological Association Institute, American College of Gastroenterology, and United European Gastroenterology meetings abstract books, was performed. Primary outcomes were clinical response and histologic remission (<15 eos/high-power field) after PPI therapy. Secondary outcomes were the influence on the response to PPIs of age group, study design/quality, PPI type, doses and interval dosing, and pH monitoring results. Data were pooled using a random-effects model.

RESULTS

Thirty-three studies (11 prospective studies) comprising 619 patients with symptomatic esophageal eosinophilia (188 children and 431 adults) were included. PPI therapy led to a clinical response in 60.8% (95% confidence interval, 48.38%-72.2%; I(2) = 80.2) and histologic remission in 50.5% (95% confidence interval, 42.2%-58.7%; I(2) = 67.5) of patients. No differences were observed regarding the study population (children vs adults), the type of publication, or its quality. PPIs were nonsignificantly more effective in prospective studies (52.6% vs 39.1%) administered twice daily compared with once daily (55.9% vs 49.7%), and with pathologic pH monitoring (65.4% vs 49.3%). A significant publication bias in favor of studies reporting histologic responses to PPIs was observed.

CONCLUSIONS

PPI therapy induces clinicohistologic remission in half of patients with symptomatic esophageal eosinophilia. This finding should be interpreted with caution because of poor-quality evidence, heterogeneity, and publication bias.

Pathogenesis of allergen-induced eosinophilic esophagitis is independent of interleukin (IL)-13

Several studies have shown that IL-13 is induced in the esophageal biopsies of EoE patients and promotes esophageal eosinophilia in mice following an IL-13 challenge. However, the role of IL-13 has not been clearly investigated in allergen-induced EoE. Accordingly, we tested the hypothesis that IL-13 is required in allergen-induced EoE. Mice deficient in IL-13, STAT (signal transducer and activator of transcription)6 and both IL-4/IL-13 genes with their respective controls were challenged with aspergillus extract and IL-5 gene-deficient with their control were challenged with recombinant IL-13, intranasally The lung and esophageal eosinophils, mast cells and collagen accumulation were examined. Herein, we report that intranasal delivery of IL-13 promotes IL-5 dependent esophageal eosinophilia. However, allergen-induced EoE is not impaired in the IL-13 gene-deficient mice. In addition, wild type and IL-13 gene-deficient mice demonstrated a comparable level of mast cells and collagen accumulation in the esophagus following allergen-induced experimental EoE. Similarly, we found that esophageal eosinophilia in IL-4/IL-13 double gene-deficient and STAT6 gene-deficient mice were also not reduced following allergen-induced experimental EoE. In contrast, lung eosinophilia was significantly reduced in mice deficient in IL-13, both IL-4/IL-13 and STAT6 genes following allergen challenge. In conclusion, our data establish that allergen-induced EoE pathogenesis is independent of IL-13; whereas, IL-13 is required for allergen-induced lung eosinophilia.

Clinical manifestations, treatment, and outcomes of children and adolescents with eosinophilic esophagitis

OBJECTIVE

This study aimed to describe the clinical, endoscopic, and histologic characteristics, as well as the response to conventional treatment of pediatric patients with the classical form of eosinophilic esophagitis (EoE).

METHODS

Study of clinical, laboratory, endoscopic, and histologic data and response to conventional treatment of 43 previously followed pediatric patients with the classical form of EoE.

RESULTS

A total of 43 patients diagnosed with EoE were included in the study, of which 37 were males (86%), with a mean age of 8.4 years. The most common symptoms were: nausea, vomiting, and abdominal pain (100%) in children younger than 7 years, and loss of appetite (60%), heartburn (52%), and food impaction (48%) in children older than 7 years and adolescents. Regarding the endoscopic findings, 12 (28%) patients had whitish plaques on the esophageal lining, 8 (18.5%) had longitudinal grooves, 2 (4.5%) had concentric rings, 3 (7%) had longitudinal grooves and whitish plaques, and the remaining 18 (42%) had esophageal mucosa with normal appearance. Despite the initial favorable response, 76.7% of patients required more than one course of corticosteroid therapy (systemic or aerosol) and diet (exclusion or elimination of food or elementary allergens). Persistence of eosinophil infiltration was found in some patients despite favorable clinical response.

CONCLUSIONS

The classic form of EoE typically shows different symptoms according age range. A significant number of patients required more than one treatment cycle to show clinical remission. Endoscopic and histologic improvement was observed; however, eosinophilic infiltration persisted in some patients.

Eosinophils in the oesophageal mucosa: clinical, pathological and epidemiological relevance in children: a cohort study

Objectives Eosinophilic oesophagitis (EO) shows eosinophilic infiltration of the mucosa and can present with symptoms indistinguishable from gastrooesophageal reflux disease (GORD). The authors describe the clinical, endoscopic and histopathological features of all cases of histological EO presenting during 2007-2008 with a 2-year follow-up. The incidence of paediatric EO and the features of a subgroup with features of both GORD and EO ('overlap' syndrome (OS)) are described. Design Biopsies with an average of 15 eosinophils/high-power field (HPF) were reviewed in the cohort. OS was suggested when there was coexistence of clinical and histological features of EO and GORD (abnormal pH study), which improved with proton pump inhibitors. Setting Tertiary care. Participants All cases with ≥15 eosinophils/HPF entered the study. Primary outcome measures Patients with EO had an average of 15 eosinophils/HPF. Secondary outcome measures Other histological features of EO included microabscesses, dilated intercellular spaces, basal cell hyperplasia, papillary elongation, etc. Results 24 cases of EO were identified, 13 men and 11 women. The incidence of paediatric oesophageal eosinophilia in the region was 9/100 000 children. 11 of the 24 patients (46%) presented with some form of allergy, six with poor feeding/food aversion, five with dysphagia and four with vomiting. After follow-up, 56.5% were confirmed to have EO, 30.5% responded to treatment for GORD and were categorised as OS, 9% developed eosinophilic gastroenteritis and 4% did not have further upper gastrointestinal symptoms. Conclusions Accurate diagnosis of EO, especially the differentiation from GORD, requires appropriate clinicopathological correlation. A significant proportion of patients with eosinophilia in the mucosa also have GORD (OS). These patients improve after treating the underlying GORD. The study was registered as a Service Evaluation with the Trust (number SE74).

Indoor insect allergens are potent inducers of experimental eosinophilic esophagitis in mice

EE is an emerging disease reported in children and adults of urbanized countries, where indoor insect allergens are major health risk factors. Review of our hospital patient database uncovered that a number of EE patients have hypersensitivity to indoor cat, dog, cockroach, and dust mite allergens. We tested the hypothesis whether inhaled indoor insect allergens are effective inducers of experimental EE. We delivered cat, dog, cockroach, and dust mite allergen extracts intranasally to wild-type and eotaxin-1/2-, CCR3-, and IL-5-deficient mice. Interestingly, wild-type mice exposed to cockroach or dust mite allergens develop a significant increase in the levels of esophageal eosinophils and mast cells compared with saline-challenged mice. The eosinophil numbers in the esophagus of cockroach- and dust mite-exposed mice were 18.3+/-6.8/mm2 and 33.4+/-11.1/mm2 compared with 2.3+/-1.8/mm2 and 2.1+/-1.2/mm2 in saline-challenged mice. Additionally, we observed an additive effect of these two allergens in inducing esophageal eosinophilia and mastocytosis. Histopathological analysis detected intraepithelial esophageal eosinophilia in mice exposed to both allergens. Furthermore, mice exposed to cockroach and/or dust mite had increased levels of total IgE and antigen-specific IgG1 in the blood and increased esophageal expression of eosinophil-active cytokines (IL-13) and chemokines (eotaxin-1). Notably, mice deficient in eotaxin-1/2, CCR3, and IL-5 showed ablated esophageal eosinophilia following cockroach or dust mite allergen exposure. These data indicate that indoor insect allergens are potent inducers of IL-5 and eotaxin-mediated esophageal eosinophilia. These experimental studies are in accordance with clinical data but may have some limitations inherent to animal models of human disease.

Mechanism of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a newly recognized disease and is an emerging entity throughout developing and developed countries, including the United States. Therefore, understanding the causes, natural history, diagnosis, and management is important for future therapeutic interventions. The pathogenesis of EoE is still not clear, but a growing body of evidence has established that this condition represents a T-cell-mediated immune response involving several proinflammatory mediators and chemoattractants known to regulate eosinophilic accumulation in the esophagus, such as IL-4, IL-5, IL-3 and eotaxin-1, -2, and -3. Determining the mechanism or mechanisms through which human esophageal-derived factors ultimately induce the functional abnormalities observed, and to which antigens patients who have EoE are sensitized that lead to the manifestation of symptoms, is of significant interest.

Biology and treatment of eosinophilic esophagitis

Eosinophilic esophagitis is a recently recognized but expanding disorder characterized by antigen-driven eosinophil accumulation in the esophagus. Symptoms frequently mimic those of gastroesophageal reflux disease, but the diseases are distinct in their histopathology, gene expression signature, response to therapy, hereditary risk, and association with allergies. The pathogenesis of eosinophilic esophagitis involves environmental and genetic factors, particularly food antigens and expression level of the eosinophil chemoattractant eotaxin-3, respectively. Analyses of gene expression signatures and animal models have indicated the importance of adaptive T-cell immunity that involves interleukin-5 and interleukin-13-induced esophageal epithelial cell responses. Symptoms, dysregulation of esophageal gene expression, and pathology are largely reversible following reduced exposure to specific food antigens as well as anti-inflammatory therapy, but chronic treatment is necessary to prevent relapse. Therefore, eosinophilic esophagitis is a disease with unique features that include chronic esophagitis, atopy, immune sensitization to oral antigens, reversibility, and familial association.

Patient and caregiver perspective on pediatric eosinophilic esophagitis and newly developed symptom questionnaires*

OBJECTIVE

Eosinophilic esophagitis (EE), a rare chronic inflammatory condition of the esophagus, is predominantly observed in children and is primarily manifested with feeding difficulties. To our knowledge, no self- or caregiver-reported questionnaires are available to assess pediatric EE symptoms and their impact as reported directly by children or their parents/caregivers. The objectives of this study were to characterize the symptoms and impact of EE among children as reported by patients and parents/caregivers and to assess the content validity of two newly developed pediatric eosinophilic esophagitis symptom questionnaires, one parent/caregiver-reported questionnaire for ages 2-7 years and one child-reported questionnaire for ages 8-17 years. The questionnaires were developed based on a review of the literature and clinical expert consultation.

RESEARCH DESIGN AND METHODS

This cross-sectional study involving one-on-one interviews with patients and caregivers was conducted at an American Partnership for Eosinophilic Disorders conference. Parents of patients aged 2-7 years (n = 12) and patients aged 8-17 years (n = 16) were first asked about symptoms and their impact on everyday life, using open-ended questions. Participants then completed the appropriate symptom questionnaire and were asked to provide feedback on the relevance, comprehensiveness, and clarity of each item and other questionnaire issues (time to complete, length, format, etc.). All reported symptoms were enumerated, and the feedback on the symptom questionnaires was analyzed qualitatively.

RESULTS

The majority of study participants were white (82%) and male (86%). The most frequently reported symptoms of 2-7-year olds were vomiting (92%), "reflux" (50%), dysphagia (25%), abdominal pain (25%), and trouble sleeping (25%). The 8-17-year group reported abdominal pain (56%), vomiting (31%), throat pain (25%), diarrhea (25%), and food getting stuck (25%). Symptoms and treatment were reported to have a major impact on daily life, particularly on school, after-school activities and social events, feeling frustrated regarding symptoms and treatment, and feeling "different". Overall, participants thought that the questionnaires were clear, relevant, and appropriate for symptom assessment.

LIMITATION

This study was based on a small and convenient sample of participants attending an EE conference and hence may not be representative of the general EE patient population.

CONCLUSIONS

EE is associated with a range of symptoms that vary in terms of the type, frequency and severity across and within patients. The results provide adequate support for the content validity of the self- and caregiver-reported versions of the symptom-specific questionnaires. Minor modifications were made based on the feedback obtained. A psychometric evaluation of the revised questionnaires is needed next to assess the construct validity, reliability, and responsiveness of the measures.

Eosinophilic esophagitis: management and pharmacotherapy

Eosinophilic esophagitis represents the most debated disease of the last 10 years, too often speculated or overestimated and certainly well known and examined. The aim of this study was to summarize the recent therapeutic trends in order to show persistent doubts regarding several debated therapies. The study combined the most recent international literature and the authors' daily experience to define the scope of the review, with limits caused by a lack of available randomized studies between dietetic and pharmacological treatment. It was concluded that eosinophilic esophagitis is an immunoallergic disease that is generally caused by identifiable food and environmental allergens although, in a minority of cases, the etiological trigger remains undetermined. Therapy usually fights the responsible agents, but sometimes they are not resolved. A need for more pathogenetically driven treatments is invoked.

Epidemiology and etiology of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is an inflammatory disease of the esophagus characterized by eosinophilic infiltration of the esophageal mucosa. Symptoms of EE are variable, and include gastroesophageal reflux symptoms, abdominal pain, growth failure, and dysphagia. Dysphagia is a more common presentation in adults and older children. Serious complications of EE consisting of esophageal food impactions necessitating urgent endoscopic removal of the food and esophageal strictures requiring endoscopic balloon dilatations are also seen. The potential severity of these symptoms points to the importance of proper recognition and management of the disease, especially given that EE has become more prevalent over the past decade. In this article, available evidence on the epidemiology and etiology of EE is discussed.

Eosinophilic gastroenteritis: a review

Eosinophilic gastroenteritis is a rare benign disease characterized by tissue eosinophilic infiltration that may involve several digestive tract layers. Also known as allergic, or eosinophilic allergic, gastroenteropathy, it usually involves the stomach and small intestine: rarely the colon. It may or may not be accompanied by higher counts of eosinophils in the peripheral blood. The main clinical manifestations depend on the site affected. It has been classified according to clinical and pathological features, and the symptoms depend on the patient's immunological response to several cytokines released by eosinophils. Because of lack of understanding of the etiology and triggering factors, treatment is based mainly on corticosteroids; although other drugs acting on the immune system have been tested, the results are not always satisfactory. This review focuses on the epidemiology, pathophysiology, clinical features, and treatment of this hitherto under-diagnosed disease.

Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gastrointestinal eosinophilia

Gastrointestinal eosinophilia, a broad term for abnormal eosinophil accumulation in the gastrointestinal tract, involves many different disease identities. These diseases include primary eosinophil associated gastrointestinal diseases, gastrointestinal eosinophilia in hypereosinophilic syndrome, and all gastrointestinal eosinophilic states associated with known causes. Each of these diseases has its unique features but there is no absolute boundary between them. All three groups of gastrointestinal eosinophila are described in this article, although the focus is on primary gastrointestinal eosinophilia.

Rapidly increasing prevalence of eosinophilic oesophagitis in Western Australia

AIM

To assess the prevalence of eosinophilic oesophagitis in a tertiary paediatric gastroenterology clinic population.

METHODS

A retrospective audit of Western Australian children investigated for oesophageal disease by paediatric gastroenterologists in the years 1995, 1999 and 2004. Macroscopic appearance of the oesophagus at endoscopy, original histological findings and diagnosis were recorded for each child. Biopsy specimens were blindly re-evaluated, with re-coded histological diagnoses compared with original reports. Age, sex and socioeconomic status were identified for each child.

RESULTS

The prevalence of eosinophilic oesophagitis in Western Australia increased over the decade 1995-2004, rising from 0.05 to 0.89 per 10 000 children, with a concomitant increase in the severity of oesophagitis as determined by inflammatory cell numbers and associated features of inflammation. Children diagnosed with eosinophilic oesophagitis had a median age of 78.9 months (6.58 years), with no associated predisposition by sex or socioeconomic status trend. Almost one third of cases were macroscopically normal at endoscopy. All children with an original diagnosis of eosinophilic oesophagitis had > or =40 eosinophils per high-power field.

CONCLUSION

Over the decade 1995-2004, a true increase was seen in the prevalence of eosinophilic oesophagitis, not accounted for by diagnostic shift. Histological samples should be taken at endoscopy to confirm or exclude the diagnosis of eosinophilic oesophagitis.

Eosinophil infiltration and degranulation in oesophageal mucosa from adult patients with eosinophilic oesophagitis: a retrospective and comparative study on pathological biopsy

AIM

To examine eosinophil infiltration and degranulation in 50 oesophageal biopsy specimens from 30 patients (21 men, 9 women; mean 39 years) with eosinophilic oesophagitis, by haematoxylin and eosin staining and immunohistochemistry.

METHODS

Immunohistochemistry was carried out using a monoclonal antibody for human eosinophilic major basic protein (MBP). Eosinophils were counted in three high power fields (x40) and degranulation, as quantified by extracellular MBP immunostaining, was scored on a scale of 1-4. Morphological changes (basal cell hyperplasia, elongation of papillae and dilatation of intercellular spaces) were scored on a 1-4 scale on sections stained with haematoxylin and eosin.

RESULTS

Numbers of intraepithelial eosinophils were significantly higher with MBP immunostaining than with haematoxylin and eosin staining (mean 109.6 v 80.6; p<0.001), whereas numbers of eosinophils were considerably correlated (r = 0.794). Eosinophil degranulation was higher in the distal oesophagus. Additionally, basic morphological changes were markedly associated with eosinophil infiltration. Extracellular deposition of eosinophil-MBP and eosinophil infiltration in subepithelial connective tissue, present in the biopsy specimens, were detected by immunohistochemistry.

CONCLUSION

Numbers of eosinophils and degranulation are underestimated by haematoxylin and eosin staining. Immunohistochemistry detected up to two times more eosinophils than routine haematoxylin and eosin staining. Moreover, eosinophil-MBP immunoreactivity in extracellular regions indicates the release of toxic eosinophil granule proteins and gives further evidence for a causative role of eosinophils with regard to structural changes in eosinophilic oesophagitis. Immunohistochemistry may serve as a useful diagnostic tool to support the morphological differential diagnosis of eosinophilic oesophagitis and gastro-oesophageal reflux disease.

Eosinophilic esophagitis: a 10-year experience in 381 children

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) is a disorder characterized by a severe, isolated eosinophilic infiltration of the esophagus unresponsive to aggressive acid blockade but responsive to the removal of dietary antigens. We present information relating to our 10-year experience in children diagnosed with EoE.

METHODS

We conducted a retrospective study between January 1, 1994, and January 1, 2004, to evaluate all patients diagnosed with EoE. Clinical symptoms, demographic data, endoscopic findings, and the results of various treatment regimens were collected and evaluated.

RESULTS

A total of 381 patients (66% male, age 9.1 +/- 3.1 years) were diagnosed with EoE: 312 presented with symptoms of gastroesophageal reflux; 69 presented with dysphagia. Endoscopically, 68% of patients had a visually abnormal esophagus; 32% had a normal-appearing esophagus despite a severe histologic esophageal eosinophilia. The average number of esophageal eosinophils (per 400 x high power field) proximally and distally were 23.3 +/- 10.5 and 38.7 +/- 13.3, respectively. Corticosteroids significantly improved clinical symptoms and esophageal histology; however, upon their withdrawal, the symptoms and esophageal eosinophilia recurred. Dietary restriction or complete dietary elimination using an amino acid-based formula significantly improved both the clinical symptoms and esophageal histology in 75 and 172 patients, respectively.

CONCLUSIONS

Medications such as corticosteroids are effective; however, upon withdrawal, EoE recurs. The removal of dietary antigens significantly improved clinical symptoms and esophageal histology in 98% of patients.

Contemporary diagnostic and management techniques for extraesophageal reflux disease

PURPOSE OF REVIEW

To review recent advances in the diagnosis and treatment of extraesophageal reflux.

RECENT FINDINGS

For most patients, the diagnosis of extraesophageal reflux relies on history and laryngoscopic exam. The reliability and reproducibility of reporting these measures may be improved with validated symptom questionnaires and standardized scoring of physical exam findings. Though dual probe pH monitoring has been the gold standard for diagnosis, it does not measure non-acid reflux events. Intraluminal impedance monitoring has the capability of measuring all esophageal reflux events (liquid, solid, gas) and may be useful in the diagnosis of non-acid reflux. Proton pump inhibitors have replaced histamine receptor antagonists as the mainstay of treatment for extraesophageal reflux. Histamine receptor antagonists are used predominantly for nocturnal acid breakthrough, or step-down therapy. Promotility and cytoprotective agents are used less commonly. Baclofen is currently being evaluated for its ability to decrease the incidence of transient lower esophageal sphincter relaxations and reduce post-prandial acid and non-acid reflux events. For individuals refractory to medical therapy, laparoscopic fundoplication techniques have proven efficacy in relieving some symptoms; the long-term benefit is not yet known. There is yet no established data on the effects of endoluminal therapies on extraesophageal reflux symptoms.

SUMMARY

The diagnosis of extraesophageal reflux for most patients relies on history and laryngoscopic exam. The diagnosis can be further verified by dual probe pH and impedance monitoring. Proton pump inhibitors are the mainstay of treatment. Laparoscopic fundoplication is proven to relieve symptoms, but there is yet no data on the effects of endoluminal therapies on extraesophageal reflux symptoms.

Eosinophilic esophagitis

PURPOSE OF REVIEW

Eosinophilic esophagitis (EE) is an isolated, eosinophilic inflammation of the esophagus. In the past, the symptoms of EE were often confused for gastroesophageal reflux (GER). Thus, many physicians unsuccessfully treated patients with EE with medications used for GER. Because the incidence of EE is rising and EE is easily diagnosed by endoscopy with biopsy, it is important for physicians to not only accurately identify patients with EE but also understand the treatment options available.

RECENT FINDINGS

While patients with acid reflux may have a few eosinophils, patients with EE have high levels of eosinophils in their esophagus as part of an allergic response to food antigens. The inflammation may cause abdominal pain, nausea, or vomiting. If EE persists for years, it may cause a narrowing of the esophagus that leads to dysphagia. In young children, many of the symptoms of EE mimic those of gastroesophageal reflux. Medications used to treat reflux are not effective against EE. Over the past few years, many new reports and retrospective studies have been written on the subject of EE. The focus of these papers concentrated on the etiology and treatment of EE.

SUMMARY

The diagnosis of EE requires a biopsy of the esophagus. Typical allergy tests are not effective for diagnosis of EE because the allergic reaction involved in EE is non-IgE mediated. The most commonly involved foods include milk, eggs, nuts, beef, wheat, fish, shellfish, corn, and soy; however, almost all foods have been implicated. Because allergy tests are often unable to determine the causative foods, complete elimination of all foods is often required. In these cases, patients must be placed on a strict elemental formula for 1 to 3 months to heal the esophagus. Repeat endoscopy with biopsy is often necessary. Several medications have been used including corticosteroids, cromolyn sodium, and leukotriene inhibitors. This review discusses the past year's literature, concentrating on the etiology, diagnosis, and treatment of EE in both children and adults.