Treatment of eosinophilic esophagitis with inhaled budesonide in a 7-year-old boy with concomitant persistent asthma: resolution of esophageal submucosal fibrosis and eosinophilic infiltration

Toward uniformity in the diagnosis of eosinophilic esophagitis (EoE): the effect of guidelines on variability of diagnostic criteria for EoE

OBJECTIVES

Recent consensus guidelines for diagnosis of eosinophilic esophagitis (EoE) have been published. Whether these guidelines have standardized diagnostic criteria for EoE is unknown. We aimed to determine if the EoE guidelines had an impact on the diagnostic criteria reported in the EoE literature, and whether the previously observed variability in diagnostic criteria has become more uniform.

METHODS

Two investigators independently conducted a MEDLINE search from 1 January 2007 through 30 June 2010 for all publications reporting EoE in human subjects, and also searched the proceedings of the 2007-2010 American College of Gastroenterology and American Gastroenterological Association meetings, using a predefined search strategy. Data were extracted from all relevant publications.

RESULTS

Of the 799 publications identified, 149 original reports, 99 reviews, and 165 abstracts were included. In all, 32 original reports (21%) used diagnostic criteria consistent with each of the three components of the consensus guidelines. There was a significant increase when comparing original articles published after the release of the guidelines with those published earlier (31 vs. 6%, P<0.001). The proportion of original articles using 15 eosinophils per high-power field (eos/hpf) as a histological cut-point increased significantly (P=0.001). There was still substantial variability in biopsy protocols and eosinophil count methodology. The majority of original articles did not report microscope high-power field (HPF) area.

CONCLUSIONS

The proportion of original reports with diagnostic criteria consistent with the consensus guidelines has increased significantly. However, the majority of articles still did not conform to all three of the criteria in the guidelines, and biopsy and eosinophil count protocols continue to demonstrate significant variability. Standardization of biopsy and eosinophil count protocols is needed.

Fluticasone and food allergen elimination reverse sub-epithelial fibrosis in children with eosinophilic esophagitis

BACKGROUND

Symptoms of vomiting and dysphagia in children with eosinophilic esophagitis may be related to the development of mucosal fibrosis.

AIM

Our aims were to (1) investigate esophageal fibrosis in children with EoE compared to patients with gastroesophageal reflux disease and normal individuals, and (2) to assess the degree of mucosal fibrosis in patients with EoE before and after medical treatment.

METHODS

A retrospective analysis of esophageal biopsies from patients with EoE, GERD, and normal mucosa was performed. Demographic data, clinical information, eosinophil number, and sub-epithelial fibrosis was compared among the groups. A similar comparison was performed in EoE patients, before and after therapy.

RESULTS

Esophageal biopsies from 53 children were included, of which 17 with EoE, 17 GERD, and 19 were normal. A significantly higher number of eosinophils and greater fibrosis was found in EoE patients vs. GERD and normal (fibrosis grade 2: 13 patients in the EoE group vs. one patient for each control group; p=0.0001). After therapy, a significant decrease in fibrosis and eosinophils number was noted in EoE patients [fibrosis grade 2: 10 (71.5%) patients vs. one (7.1%) patient, and eosinophil count was 35.5/HPF vs. 13.4/HPF, pre- and post-therapy, respectively; p<0.05]. The decrease in esophageal fibrosis paralleled the improvement in the related clinical symptoms.

CONCLUSION

A higher degree of esophageal fibrosis was found in patients with EoE compared to GERD or normal esophagus. Conventional therapy in EoE improved obstructive symptoms, decreased eosinophils count, and reversed the degree of fibrosis. We suggest that appropriate therapy in patients with EoE will improve clinical symptoms and histology.

Esophageal Crohn's disease treated "topically" with swallowed aerosolized budesonide

Proximal Crohn's disease, involving the esophagus, the stomach, the duodenum, and the proximal jejunum, is uncommon. Treatment for proximal Crohn's disease is based on data derived from case series than from controlled trials. We present a case of Crohn's colitis with concomitant proximal esophagogastroduodenal involvement treated with conventional treatment plus swallowed aerosolized budesonide as a novel adjuvant topical treatment for the esophageal disease, and we review the treatment options for proximal Crohn's disease.

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

The clinical and pathologic features of eosinophilic esophagitis (EE) include extensive tissue remodeling. Increasing evidence supports a key role for the eosinophil in multiple aspects of the esophageal remodeling and fibrosis seen in this allergic disease. This article reviews the clinical implications of esophageal remodeling and fibrosis in EE and discusses the possible pathogenic mechanisms inducing and regulating these responses. The focus is specifically on eosinophil and cytokine interactions with the esophageal epithelium, vascular endothelium, resident fibroblasts, and smooth muscle. Current and potential therapeutic interventions are discussed that may impact the development or resolution of chronic esophageal remodeling and fibrosis in EE.

Eosinophilic oesophagitis: clinical manifestations and treatment options. The role of the allergologist

Eosinophilic oesophagitis (EO) is an infrequent disorder that is currently underdiagnosed. It has been described in both adults and in children, and is more prevalent among males. The etiology of EO is not clear, though atopy has been suggested as playing an important role in the development of the disease. The clinical presentation of EO is varied, and a differential diagnosis with other digestive tract disorders is required particularly gastro-oesophageal re-flux. Dysphagia and food bolus impactation within the oesophagus are the most characteristic symptoms. Diagnostic confirmation is obtained from multiple oesophageal biopsy, with the detection in some sample or samples of over 15 eosinophils per high-magnification microscopic field. An allergological study is needed to evaluate the existence of allergens (perennial or seasonal environmental allergens and food allergens) responsible for the eosinophilic infiltration found at oesophageal level. There is no specific treatment for EO, and topical corticosteroids (swallowed) are currently the pharmacological treatment of choice. Dietary therapy in children with food allergy as the causal factor may prove effective, though the existence of polysensitisation complicates the correct implementation of such treatment. Oesophageal dilatation is reserved for cases with severe dysphagia, and is not without complications. Treatment with anti-IL-5, antileukotrienes, azathioprine, 6-mercaptopurine, anti-IgE, etc., could constitute alternatives to topical corticosteroids, although information is still lacking on their long-term safety and efficacy in the paediatric population.