Might the use of acid-suppressive medications predispose to the development of eosinophilic esophagitis?

Review article: Emerging insights into the epidemiology, pathophysiology, diagnostic and therapeutic aspects of eosinophilic oesophagitis and other eosinophilic gastrointestinal diseases

BACKGROUND

Eosinophilic gastrointestinal diseases (EGIDs) are chronic, immune-mediated disorders characterised clinically by gastrointestinal symptoms and histologically by a pathologic increase in eosinophil-predominant inflammation in the gastrointestinal tract, in the absence of secondary causes of eosinophilia.

AIMS

To highlight emerging insights and research efforts into the epidemiology, pathophysiology, diagnostic and therapeutic aspects of eosinophilic oesophagitis (EoE) and non-EoE EGIDs, and discuss key remaining knowledge gaps.

METHODS

We selected and reviewed original research, retrospective studies, case series, randomised controlled trials, and meta-analyses.

RESULTS

Standardised nomenclature classifies EGIDs as EoE, eosinophilic gastritis (EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC). Incidence and prevalence of EoE are rising, emphasising the need to better understand how environmental risk factors and genetic features interact. Advances in understanding EoE pathophysiology have led to clinical trials of targeted therapy and the approval (in the United States) of dupilumab for EoE. Several therapies that are under investigation hope to satisfy both histologic and clinical targets. For non-EoE EGIDs, efforts are focused on better defining clinical and histopathologic disease determinants and natural history, as well as establishing new therapies.

CONCLUSIONS

Unmet needs for research are dramatically different for EoE and non-EoE EGIDs. In EoE, non-invasive diagnostic tests, clinicopathologic models that determine the risk of disease progression and therapeutic failure, and novel biologic therapies are emerging. In contrast, in non-EoE EGIDs, epidemiologic trends, diagnostic histopathologic thresholds, and natural history models are still developing for these more rare disorders.

Global Incidence and Prevalence of Eosinophilic Esophagitis, 1976-2022: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Owing to 2018 expanded diagnostic criteria for eosinophilic esophagitis (EoE) and thus a possible increase in diagnosis, previous studies on the global incidence and prevalence of EoE may need to be updated. We aimed to describe global, regional, and national trends in the incidence and prevalence of EoE from 1976 to 2022 and analyze their associations with geographic, demographic, and social factors through a systematic review.

METHODS

We searched the PubMed/MEDLINE, Embase, CINAHL, Google Scholar, and Cochrane databases from their inception dates to December 20, 2022, for studies that reported the incidence or prevalence of EoE in the general population. We calculated the global incidence and prevalence of EoE using pooled estimates with 95% confidence intervals (CIs) and performed subgroup analysis based on age, sex, race, geographical area, World Bank income group, and diagnostic criteria of EoE.

RESULTS

Forty studies met the eligibility criteria, including over 288 million participants and 147,668 patients with EoE from 15 countries across the five continents. The global pooled incidence and prevalence of EoE were 5.31 cases per 100,000 inhabitant-years (95% CI, 3.98-6.63; number of studies, 27; sample population, 42,191,506) and 40.04 cases per 100,000 inhabitant-years (95% CI, 31.10-48.98; number of studies, 20; sample population, 30,467,177), respectively. The pooled incidence of EoE was higher in high-income countries (vs low- or middle-income countries), males, and North America (vs Europe and Asia). The global prevalence of EoE followed a similar pattern. The pooled prevalence of EoE gradually increased from 1976 to 2022 (1976-2001; 8.18; 95% CI, 3.67-12.69 vs 2017-2022; 74.42; 95% CI, 39.66-109.19 cases per 100,000 inhabitant-years).

CONCLUSIONS

The incidence and prevalence of EoE have increased substantially and vary widely across the world. Further research is needed to evaluate the incidence and prevalence of EoE in Asia, South America, and Africa.

Nature with Nurture: the Role of Intrinsic Genetic and Extrinsic Environmental Factors on Eosinophilic Esophagitis

PURPOSE OF REVIEW

As the rising prevalence and incidence of eosinophilic esophagitis (EoE) has quickly outpaced the rate of esophageal biopsies, particularly in Westernized countries, several studies have suggested a link between intrinsic genetic and extrinsic environmental risk factors and the development, presentation, and diagnosis of EoE. This review aims to critically assess existing studies describing the role of the environment on the development, symptomatic presentation, and diagnosis of this recently recognized chronic immune-mediated disease.

RECENT FINDINGS

We present and critically evaluate the working hypotheses and supportive studies thus far on environmental factors on EoE, describe sources of potential bias in diagnosis due to socioeconomic factors and thus undermining studies of EoE etiology, and highlight opportunities for future research. As genetics alone do not explain the rapid rise of EoE, we must look to environmental, or extrinsic, factors both in the early-life period which shape the development of the gut microbiome, as well as later life contributing to diagnosis of this new disease. Future etiologic studies linking risk factors to EoE development in individual patients are needed.

Epidemiology of Eosinophilic Esophagitis in Patients with Cystic Fibrosis: A Population-Based 5-Year Study

PURPOSE

The prevalence of eosinophilic esophagitis (EoE) has been on the rise since it was first described in the 1990s. Several diseases and exogenous factors have been associated with EoE. Our aim was to investigate the epidemiology of EoE in cystic fibrosis (CF) patients.

METHODS

We identified individuals with CF from September 2014 to September 2019 within a database (IBM Explorys Solutions, Inc.). The prevalence of EoE in patients with CF was compared to the general population.

RESULTS

The database included 36,111,860 patients during the 5-year study period: 12,950 with CF (0.036%) and 28,090 with EoE (0.078%). EoE prevalence was higher in CF patients than the general population (46 in 10,000 vs. 7.8 in 10,000, p<0.001). Patients with CF and EoE were more likely to be male (50% vs. 33.5%, p<0.008), children (33.3% vs. 16.5%, p<0.001), and non-Hispanic (100% vs. 88.7%, p<0.001) than CF patients without EoE. CF with EoE patients were more likely to be children than EoE only (33.3% vs. 10.5%, p<0.001). Allergic conditions were generally more prevalent in CF with EoE than CF only (83.3% vs. 68.3%, p=0.01) and EoE only (83.3% vs. 69.3%, p=0.014).

CONCLUSION

EoE is nearly 6-times more prevalent in CF patients. Those patients had higher incidence of other atopic conditions. EoE must be considered in the differential diagnosis of patients with CF presenting with dysphagia, refractory gastroesophageal reflux, vomiting, and other esophagus-related symptoms.

Eosinophilic esophagitis and esophageal motility changes

Eosinophilic esophagitis is a chronic condition that can affect any age, with an increasing prevalence in the last years. Esophageal symptoms are accompanied by normal endoscopic findings or changes suggestive for the disease, like rings, furrows, exudates, or strictures. The definitive diagnosis is based on esophageal biopsies, with identification of at least 15 eosinophils/high power field. In about 1/3 of patients esophageal motility abnormalities are observed. Ineffective esophageal motility is the most frequent. In some cases, major motility disorders, such as achalasia can be observed. The treatment depends on the patients' preferences and on symptoms severity, and usually a step-up approach is used. A diet change can be helpful in more than half of patients, some respond to proton pump inhibitors. In non-responders, short courses of topical corticosteroids are recommended. Endoscopic procedures might be helpful in patients with obstructive motility changes, non-responding to medical therapy. This review discusses the motility changes observed in patients with eosinophilic esophagitis.

Protective Effect of Ultraviolet C Irradiation on the Gastric Mucosa of Rats with Chronic Gastritis Induced by Physicochemical Stimulations

Background

Chronic gastritis (CG) is a common digestive disease with the highest morbidity among multiple digestive diseases, which seriously lowers the life quality of patients. The pathological alternations of gastric mucosa, and its possible mechanisms have been the focus of CG-related researches. Accumulative basic and clinical evidence has confirmed that ultraviolet C (UVC) is effective in relieving superficial acute infective inflammation, skin and mucous membrane injuries, and ulcers, and promoting wound healing.

Objective

This study was aimed at investigating the protective effects of UVC on gastric mucosal injury in rats stimulated with physicochemical irritants like ethanol and exploring the mechanisms underlying the protection by UVC against gastric mucosal injury and CG.

Methods

Fifty Wistar rats were randomly divided into five groups, including Group A (normal), Group B (model), Group C (omeprazole treatment), Group D (intragastric UVC irradiation for 24 s × 2 yields), and Group E (intragastric UVC irradiation for 48 s × 2 yields). Rats in Groups B-E were made CG model by physicochemical stimulations. All rats were sacrificed one week after the 22-week experiment, and gastric tissues were harvested. Histopathological examinations were performed. The activities of superoxide dismutase and catalase as well as the contents of reduced glutathione and malondialdehyde in gastric mucosal tissues were detected. Serum interleukin-6, interleukin-1beta, tumor necrosis factor-alpha, pepsin, and gastrin were measured.

Results

Results showed that physiochemical irritants like ethanol could be used for easily establishing a rat CG model that shared similar pathological features with human CG. Intragastric UVC irradiation could promote the repair of gastric mucosa and improve the atrophy of gastric mucosa by inhibiting the inflammatory factors, increasing the levels of pepsin and gastrin, decreasing the expression of lipid peroxide, and enhancing the activity of superoxide dismutase and catalase and the levels of reduced glutathione. UVC irradiation for 48 s × 2 yields showed the strongest protective effect.

Conclusion

UVC irradiation could inhibit the inflammatory factors, activate the antioxidative system, and enhance the secretion of pepsin and gastrin, which promoted the repair of injured gastric mucosa and improved gastric mucosa atrophy.

Infant acid suppression use is associated with the development of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is an esophageal allergic inflammatory disorder often presenting with infant/toddler gastroesophageal reflux symptoms refractory to treatment, including acid suppression trials with histamine H2 antagonists and proton pump inhibitors. We propose to evaluate the impact of infant acid suppressant exposure in EoE. Geisinger's pediatric EoE cases were matched to controls (1:5 EoE case control ratio) using age, race, sex, and ages at other diagnoses of asthma, eczema, and environmental allergies, totaling 526 EoE cases and 2,630 controls. Comparisons between EoE cases and matched controls were tested with regard to rates of acid suppression use with H2 antagonists and PPIs during infancy. Our analyses found the use of acid suppression in infancy was positively associated with EoE: PPI (5.7% EoE cases vs. 1.6% controls; P < 0.0001), H2 antagonists (8.8% EoE cases vs. 4.5% controls; P < 0.0001). Additionally, analysis of EoE cases using acid suppression during infancy indicated a likelihood for the diagnosis with EoE at an earlier age. Early acid suppression use in infants is significantly associated with the diagnosis of EoE in childhood in this well-matched retrospective cohort study. The potential link warrants additional investigation. Our study further reinforces the evidence-based stewardship of acid suppressant use, especially in our most vulnerable populations.

Characterization of Upper Gastrointestinal Motility in Infants With Persistent Distress and Non-IgE-mediated Cow's Milk Protein Allergy

BACKGROUND

Persistent crying in infancy is common and may be associated with gastroesophageal reflux disease (GERD) and/or non-IgE-mediated cow's milk protein allergy (CMPA). We aimed to document upper gastrointestinal motility events in infants with CMPA and compare these to findings in infants with functional GERD.

METHODS

Infants aged 2 to 26 weeks with persistent crying, GERD symptoms and possible CMPA were included. Symptoms were recorded by 48-hour cry-fuss chart and validated reflux questionnaire (infant GERD questionnaire [IGERDQ]). Infants underwent a blinded milk elimination-challenge sequence to diagnose CMPA. GERD parameters and mucosal integrity were assessed by 24-hour pH-impedance monitoring before and after cow's milk protein (CMP) elimination. C-octanoate breath testing for gastric emptying dynamics, dual-sugar intestinal permeability, fecal calprotectin, and serum vitamin D were also measured.

RESULTS

Fifty infants (mean age 13 ± 7 weeks; 27 boys) were enrolled. On the basis of CMP elimination-challenge outcomes, 14 (28%) were categorized as non-IgE-mediated CMPA, and 17 (34%) were not allergic to milk; 12 infants with equivocal findings, and 7 with incomplete data were excluded. There were no baseline differences in GERD parameters between infants with and without CMPA. In the CMPA group, CMP elimination resulted in a significant reduction in reflux symptoms, esophageal acid exposure (reflux index), acid clearance time, and an increase in esophageal mucosal impedance.

CONCLUSIONS

In infants with persistent crying, upper gastrointestinal motility parameters did not reliably differentiate between non-IgE-mediated CMPA and functional GERD. In the group with non-IgE-mediated CMPA, elimination of CMP significantly improved GERD symptoms, esophageal peristaltic function, and mucosal integrity.

Early Life Risk Factors in Pediatric EoE: Could We Prevent This Modern Disease?

Eosinophilic esophagitis (EoE) is a chronic antigen-mediated inflammatory disease that affects the esophagus. In the last 20 years, a large number of epidemiological studies showed a significant increase in the incidence and prevalence of EoE, especially in developed countries. This phenomenon might correlate to the overall increase in pediatric allergic diseases or might be a result of improved medical awareness and knowledge through modern diagnostic instruments. Since 1993, when EoE was first recognized as a distinct clinical entity, several signs of progress in the pathophysiology of EoE were achieved. However, a few studies reported data on early risk factors for pediatric EoE and how these factors may interfere with genes. Currently, the most defined risk factors for EoE are male sex, Caucasian race, and atopic comorbidities. Other putative risk factors may include alterations in epithelial barrier function and fibrous remodeling, esophageal dysbiosis, variation in the nature and timing of oral antigen exposure, and early prescription of proton pump inhibitors and antibiotics. Notably, the timing and nature of food antigen exposure may be fundamental in inducing or reversing immune tolerance, but no studies are reported. This review summarized the current evidence on the risk factors that might contribute to the increasing development of EoE, focusing on the possible preventive role of early interventions.

Peptic Ulcer Disease: A Brief Review of Conventional Therapy and Herbal Treatment Options

Peptic ulcer is a chronic disease affecting up to 10% of the world's population. The formation of peptic ulcers depends on the presence of gastric juice pH and the decrease in mucosal defenses. Non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori (H. pylori) infection are the two major factors disrupting the mucosal resistance to injury. Conventional treatments of peptic ulcers, such as proton pump inhibitors (PPIs) and histamine-2 (H2) receptor antagonists, have demonstrated adverse effects, relapses, and various drug interactions. On the other hand, medicinal plants and their chemical compounds are useful in the prevention and treatment of numerous diseases. Hence, this review presents common medicinal plants that may be used for the treatment or prevention of peptic ulcers.

Proton Pump Inhibitors: What the Internist Needs to Know

This report reviews the physiology of gastric acid suppression by proton pump inhibitors (PPIs) and anti-inflammatory effects of PPIs that are independent of their acid-suppressive effects. Valid indications for PPI use are discussed, as are putative adverse effects of PPIs that have been identified through weak associations in observational studies that cannot establish cause-and-effect relationships. Although evidence supporting the validity of these adverse effects is weak, there is also insufficient evidence to dismiss the risks. The report emphasizes how PPIs frequently are prescribed inappropriately and encourages physicians to carefully consider the indication for PPI therapy in their patients.

Eosinophilic esophagitis: novel concepts regarding pathogenesis and clinical manifestations

This report explores two hypotheses regarding eosinophilic esophagitis (EoE): (1) that the use of proton pump inhibitors (PPIs) might contribute to the pathogenesis of EoE by preventing peptic digestion of food allergens, by increasing gastric mucosal permeability to enable gastric absorption of those undegraded food allergens, and by causing microbial dysbiosis, and (2) that EoE, like eosinophilic gastroenteritis, might have mucosal-predominant and muscle-predominant forms, and that the muscle-predominant form of EoE might cause a variety of esophageal motility disorders including achalasia.

Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference

BACKGROUND & AIMS

Over the last decade, clinical experiences and research studies raised concerns regarding use of proton pump inhibitors (PPIs) as part of the diagnostic strategy for eosinophilic esophagitis (EoE). We aimed to clarify the use of PPIs in the evaluation and treatment of children and adults with suspected EoE to develop updated international consensus criteria for EoE diagnosis.

METHODS

A consensus conference was convened to address the issue of PPI use for esophageal eosinophilia using a process consistent with standards described in the Appraisal of Guidelines for Research and Evaluation II. Pediatric and adult physicians and researchers from gastroenterology, allergy, and pathology subspecialties representing 14 countries used online communications, teleconferences, and a face-to-face meeting to review the literature and clinical experiences.

RESULTS

Substantial evidence documented that PPIs reduce esophageal eosinophilia in children, adolescents, and adults, with several mechanisms potentially explaining the treatment effect. Based on these findings, an updated diagnostic algorithm for EoE was developed, with removal of the PPI trial requirement.

CONCLUSIONS

EoE should be diagnosed when there are symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (or approximately 60 eosinophils per mm²) on esophageal biopsy and after a comprehensive assessment of non-EoE disorders that could cause or potentially contribute to esophageal eosinophilia. The evidence suggests that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criterion, and we have developed updated consensus criteria for EoE that reflect this change.

Speculation as to why the Frequency of Eosinophilic Esophagitis Is Increasing

PURPOSE OF REVIEW

The frequency of eosinophilic esophagitis (EoE), an immune/antigen-mediated disorder first described in 1993, has been increasing rapidly. The purpose of this review is to consider hypotheses proposed to explain this increase and to speculate on their validity.

RECENT FINDINGS

The hygiene hypothesis attributes the rise of EoE to modern hygienic conditions resulting in fewer childhood infections with microbes that might have protected against allergy development. Microbial dysbiosis, a change in the microbiome's composition and diversity caused by a modern affluent lifestyle, also might contribute to allergic conditions. Environmental factors including modern chemicals contaminating crops, livestock treated with hormones and antibiotics, food additives and processing changes, and pollutants in the air and water conceivably might predispose to EoE. One intriguing hypothesis attributes increasing EoE to increasing use of acid-suppressive medications like proton pump inhibitors, which might prevent peptic digestion of food allergens, increase gastric permeability, and alter the microbiome to favor food allergy development. In a recent pediatric case-control study, use of acid suppressants in infancy was by far the single strongest risk factor identified for later development of EoE. It remains unclear which, if any, of the above factors underlies the rising frequency of EoE. These factors need not be mutually exclusive, and the cause of EoE may well be multifactorial.

Speculation as to why the Frequency of Eosinophilic Esophagitis Is Increasing

PURPOSE OF REVIEW

The frequency of eosinophilic esophagitis (EoE), an immune/antigen-mediated disorder first described in 1993, has been increasing rapidly. The purpose of this review is to consider hypotheses proposed to explain this increase and to speculate on their validity.

RECENT FINDINGS

The hygiene hypothesis attributes the rise of EoE to modern hygienic conditions resulting in fewer childhood infections with microbes that might have protected against allergy development. Microbial dysbiosis, a change in the microbiome's composition and diversity caused by a modern affluent lifestyle, also might contribute to allergic conditions. Environmental factors including modern chemicals contaminating crops, livestock treated with hormones and antibiotics, food additives and processing changes, and pollutants in the air and water conceivably might predispose to EoE. One intriguing hypothesis attributes increasing EoE to increasing use of acid-suppressive medications like proton pump inhibitors, which might prevent peptic digestion of food allergens, increase gastric permeability, and alter the microbiome to favor food allergy development. In a recent pediatric case-control study, use of acid suppressants in infancy was by far the single strongest risk factor identified for later development of EoE. It remains unclear which, if any, of the above factors underlies the rising frequency of EoE. These factors need not be mutually exclusive, and the cause of EoE may well be multifactorial.

Prenatal, intrapartum, and postnatal factors are associated with pediatric eosinophilic esophagitis

BACKGROUND

Multiple lines of evidence point to the potential importance of early-life environmental factors in the rapid increase in the incidence of eosinophilic esophagitis (EoE), but potential exposures have not been extensively studied.

OBJECTIVE

We sought to assess the association between prenatal, intrapartum, and postnatal factors and the development of pediatric EoE using a case-control study.

METHODS

Patients with EoE were recruited from an existing registry at Cincinnati Children's Hospital Medical Center (CCHMC). Population-based community control subjects were identified from a separate CCHMC registry. Mothers of study subjects were contacted and completed a Web-based questionnaire. Crude and adjusted models were used to estimate associations.

RESULTS

Mothers of 127 cases and 121 control subjects were included. We observed a positive association between several early-life factors and EoE, including prenatal (maternal fever: adjusted odds ratio [aOR], 3.18; 95% CI, 1.27-7.98; preterm labor: aOR, 2.18; 95% CI, 1.06-4.48), intrapartum (cesarean delivery: aOR, 1.77; 95% CI, 1.01, 3.09), and infancy (antibiotic use: aOR, 2.30; 95% CI, 1.21-4.38; use of an acid suppressant: aOR, 6.05; 95% CI, 2.55-14.40) factors. We observed an inverse association between having a furry pet in infancy and EoE (aOR, 0.58; 95% CI, 0.34-0.97). No associations were observed for breast-feeding or maternal multivitamin or folic acid supplement use.

CONCLUSION

Early-life factors, including maternal fever, preterm labor, cesarean delivery, and antibiotic or acid suppressant use in infancy, were associated with risk of pediatric EoE; having a pet in the home was protective. These results add to growing evidence that implicate early-life exposures in EoE pathogenesis.

Epidemiology and Natural History of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) has emerged over the past 2 decades as a major cause of upper gastrointestinal morbidity. Over this time, the epidemiology of EoE has also rapidly evolved. EoE has transformed from a rare case-reportable condition to disease that is commonly encountered in the gastroenterology clinic, hospital emergency room, and endoscopy suite. The incidence and prevalence are increasing at rates that outpace increased disease recognition. Current incidence estimates range from 5 to 10 cases per 100,000, and current prevalence estimates range from 0.5 to 1 case per 1000. We review the data and potential reasons behind this increase, examine risk factors, and identify important areas for research into disease etiology. The article also discusses the progression of EoE from an inflammatory to fibrostenotic phenotype. An accurate view of the natural history of EoE is central to discussions with patients regarding disease prognosis and decisions about long-term use of medical, endoscopic, and diet therapies. Progressive remodelling appears to be gradual, but not universal, and the duration of untreated disease is the best predictor of stricture risk. Ultimately, prospective, long-term outcome studies focusing on multiple aspects of disease activity are needed to fully understand the natural history of EoE.

Practice-based interpretation of ultrasound studies leads the way to more effective clinical support and less pharmaceutical and surgical intervention for breastfeeding infants

BACKGROUND

breastfeeding optimises health outcomes for both mothers and infants. Although most women want to breastfeed, they report commencing infant formula because of nipple pain, unsettled infant behaviour, and infant growth concerns. To date, existing approaches to fit and hold ('latch and positioning') have been demonstrated not to help breastfeeding outcomes, and women report widespread dissatisfaction with the quality of support and conflicting advice they receive. Breast and nipple pain, difficulty with latching and sucking, fussing at the breast, back-arching, marathon feeds, excessively frequent feeds, poor weight gain, breast refusal, and crying due to poor satiety often signal suboptimal positional instability and impaired milk transfer, but may be misdiagnosed as medical conditions. Over the past two decades, there has been an exponential increase in numbers of infants being treated with medications, laser or scissors frenotomy, and manual therapy for unsettled behaviour and breastfeeding difficulty. New approaches to clinical breastfeeding support are urgently required.

METHOD AND RESULTS

we analyse the findings of a literature search of PubMed and MEDLINE databases for ultrasound studies measuring sucking in term and preterm infants. The findings demonstrate that the Stripping Action Model of infant suck during breastfeeding, and the resultant Structural Model of infant suck dysfunction, are inaccurate. Instead, ultrasound data demonstrates the critical role of intra-oral vacuum for milk transfer. We integrate these two-dimensional ultrasound results with clinical experience of the third dimension, volume, to propose a Gestalt Model of the biomechanics of healthy infant suck during breastfeeding. The Gestalt Model hypothesises that optimal intra-oral vacuums and breast tissue volumes are achieved when mother-infant positional stability eliminates conflicting intra-oral vectors, resulting in pain-free, effective milk transfer.

CONCLUSION

the Gestalt Model of the biomechanics of healthy infant suck during breastfeeding opens up the possibility of a new clinical method which may prevent unnecessary medical treatments for breastfeeding problems and related unsettled infant behaviour in early life.

An Overview of the Diagnosis and Management of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by symptoms of esophageal dysfunction and eosinophilic infiltration of the esophageal mucosa. The diagnosis requires esophageal biopsies demonstrating at least 15 eosinophils per high-powered field following a course of high-dose proton pump inhibitors. Management of EoE consists of the three Ds: drugs, dietary therapy, and esophageal dilation. In this review, we discuss the epidemiology, pathogenesis, diagnosis, and treatment of EoE to include the role of emerging therapies.

Environmental and infectious factors in eosinophilic esophagitis

Identifying possible environmental or infectious etiologic factors for eosinophilic esophagitis (EoE) may offer insight into opportunities for disease prevention and treatment. We reviewed the current literature to assess environmental and infectious factors evaluated in EoE. Few studies have been conducted, however a consistent inverse association between EoE and H. pylori has been described. Several studies suggest a weak association between season and EoE diagnosis, but the evidence is inconclusive. EoE has also been associated with early life factors, including Cesarean delivery and antibiotic use. Larger studies are needed to evaluate these associations more thoroughly. Several papers have speculated the potential for anti-secretory agents to contribute to EoE. This has not been formerly evaluated. In summary, there is significant opportunity in the future to advance our understanding of possible environmental etiologic factors for EoE.

Distinguishing GERD from eosinophilic oesophagitis: concepts and controversies

Over the past three decades, the detection of oesophageal mucosal eosinophils has transitioned from a biomarker of GERD to a diagnostic criterion for eosinophilic oesophagitis (EoE). In GERD, oesophageal eosinophils are considered part of the chronic inflammatory response to acid reflux, whereas the marked eosinophilia in EoE is viewed as a central feature of the immune response to ingested food and/or environmental antigen stimulation. Descriptions of a considerable subset of patients with symptomatic, endoscopic and histological findings of EoE that resolve with PPI therapy has led to confusion and controversy regarding the distinction of EoE from GERD. Study findings indicate that PPI-responsive oesophageal eosinophilia (PPI-REE) more closely resembles EoE than GERD, both from a clinical and immunological aspect. Although responsiveness to PPI therapy should not be utilized to exclude EoE, PPI therapy is effective at reducing oesophageal eosinophilia in ∼40% of patients, and PPI therapy is both a safe and practical initial step in the management of patients with oesophageal eosinophilia. Ongoing studies elucidating the mechanism behind PPI-REE will improve our understanding and management of EoE. In this Review, the mechanisms and evidence that underlie the controversy in the distinction between GERD and EoE are evaluated.

Risk factors for eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic antigen driven disease, whereby food and/or aeroallergens result in inflammation and luminal narrowing, and the clinical symptoms of dysphagia and food bolus obstruction events (FBOE). Established risk factors are male gender, Caucasian race and atopy. Increased risk amongst family members, and a single nucleotide polymorphism (SNP) in a gene coding thymic stromal lymphopoietin (TSLP) on the pseudoautosomal region of the X and Y chromosomes supports a genetic predisposition. Environmental factors including the timing and nature of food and aeroallergen exposure to the developing immune system may be important, whilst esophageal barrier function integrity and the influence of microbiota are worthy of future research.

Small intestinal permeability in patients with eosinophilic oesophagitis during active phase and remission

BACKGROUND

Eosinophilic oesophagitis (EoE) is presumed to be an isolated oesophageal disease; yet other allergic diseases associated with eosinophilic infiltration of target tissues, such as asthma and eczema, show perturbed functions of other sites that may be involved in the diathesis of allergy modulation.

AIM

To analyse small intestinal permeability in patients with active EoE and in a separate group of patients in remission.

METHODS

Small bowel permeability was determined using a dual sugar method by calculating lactulose:mannitol (L:M) ratio in 17 patients who met consensus criteria for active EoE (>15 eos/HPF) and 8 patients in remission (<5 eos/HPF). Data from 28 healthy controls was used for comparison.

RESULTS

Patients with active EoE had significantly higher L:M ratios when compared to controls (0.045 vs. 0.033, p<0.001) and to EoE in remission (0.041 vs. 0.027, p<.001). There was no significant difference in L:M between the group with EoEin remission and healthy controls. The current data show that L:M ratio of 0.033 also provides a reasonable cut-off that defined the active EoE group compared to patients in remission. The main component explaining the change in L:M ratio was increased absorption (and excretion) of lactulose ((1601 ± 106 ug) when compared to the EoE remission (969 ± 91 ug) and control (1043 ± 92 ug, p<.001) groups.

CONCLUSIONS

Small bowel permeability is overall increased in patients with active EoE, and is normal in patients with EoE in remission when compared to healthy controls. The role of the small bowel in active EoE deserves further investigation.

Advances in clinical management of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated clinicopathologic condition that has become an increasingly important cause of upper gastrointestinal morbidity in adults and children over the past 2 decades. It is diagnosed based on symptoms of esophageal dysfunction, the presence of at least 15 eosinophils/high-power field in esophageal biopsy specimens, and exclusion of competing causes of esophageal eosinophilia, including proton pump inhibitor-responsive esophageal eosinophilia. We review what we have recently learned about the clinical aspects of EoE, discussing the clinical, endoscopic, and histological features of EoE in adults and children. We explain the current diagnostic criteria and challenges to diagnosis, including the role of gastroesophageal reflux disease and proton pump inhibitor-responsive esophageal eosinophilia. It is also important to consider the epidemiology of EoE (with a current incidence of 1 new case per 10,000 per year and prevalence of 0.5 to 1 case per 1000 per year) and disease progression. We review the main treatment approaches and new treatment options; EoE can be treated with topical corticosteroids, such as fluticasone and budesonide, or dietary strategies, such as amino acid-based formulas, allergy test-directed elimination diets, and nondirected empiric elimination diets. Endoscopic dilation has also become an important tool for treatment of fibrostenotic complications of EoE. There are a number of unresolved issues in EoE, including phenotypes, optimal treatment end points, the role of maintenance therapy, and treatment of refractory EoE. The care of patients with EoE and the study of the disease span many disciplines; EoE is ideally managed by a multidisciplinary team of gastroenterologists, allergists, pathologists, and dieticians.

Eosinophilic esophagitis: interactions with gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE) are not mutually exclusive. The notion that GERD and EoE can be distinguished by the response to proton pump inhibitor (PPI) treatment is based on the mistaken assumption that gastric acid suppression is the only important therapeutic effect of PPIs, and therefore only GERD can respond to PPIs. We believe that a clinical or histologic response to PPIs does not rule in GERD or rule out EoE. We recommend a trial of PPI therapy for patients with symptomatic esophageal eosinophilia, even if the diagnosis of EoE seems clear-cut.

Epidemiology of eosinophilic esophagitis

In this article, the epidemiology of eosinophilic esophagitis (EoE) is reviewed. Demographic features and natural history are described, the prevalence and incidence of EoE are highlighted, and risk factors for EoE are discussed. EoE can occur at any age, there is a male predominance, it is more common in whites, and there is a strong association with atopic diseases. EoE is chronic, relapses are frequent, and persistent inflammation increases the risk of fibrostenotic complications. The prevalence is currently estimated at 0.5-1 in 1000, and EoE is now the most common cause of food impaction. The incidence of EoE is approximately 1/10,000 new cases per year, and the increase in incidence is outpacing increases in recognition and endoscopy volume, but the reasons for this evolving epidemiology are not yet fully delineated.

National survey of Australian paediatricians' approach to infant crying

AIM

Persistent crying in infancy (i.e. crying that lasts for more than 3 h a day for more than 3 days per week for at least 3 weeks) is widespread. Although there is no gold standard approach to its management, guidelines exist with common management principles. This study aims to document how Australian general paediatricians (i) assess and manage persistent crying compared with published guidelines; (ii) screen for and manage associated post-natal depression; and (iii) rate their training in this area.

METHODS

Online survey were administered to all 394 members of the Australian Paediatric Research Network in November 2011 to February 2012. Members are predominantly general paediatricians.

RESULTS

A total of 168 paediatricians (45%) responded. The majority (n = 96 (69%)) take one session to assess infant crying and at least two sessions to manage it (n = 106 (79%)). Specific approaches are not always evidence based (e.g. use of antacids/simethicone by 8%) and do not follow available guidelines. Most paediatricians routinely asked about maternal (n = 120 (88%)) but not paternal (n = 51 (33%)) mental health. Paediatricians typically received training around this issue before rather than after gaining formal paediatric qualifications (61% vs. 37%, respectively) and rate their training as satisfactory (67%). Despite this, only 39% feel very confident in managing infant crying.

CONCLUSION

The lack of a gold standard approach to managing persistent infant crying has likely contributed to a lack of uniform care among Australian general paediatricians. Given that most paediatricians do not feel very confident in dealing with this problem, there is a scope for further training supported by evidence-based guidelines.

The complex relationship between eosinophilic esophagitis and gastroesophageal reflux disease

That gastroesophageal reflux and eosinophilic esophagitis (EoE) may both lead to esophageal eosinophilia is well known. What is not known is how, if at all, these entities interact to contribute to this pathologic entity in specific patients and how often they occur in patients as synergistic contributors to the disease as opposed to distinct processes. There are several hypotheses by which gastroesophageal reflux disease (GERD) and EoE might interact to cause esophageal eosinophilia. These include (1) reflux of food from the stomach with increased antigenic exposure to esophageal epithelium; (2) reflux-induced dilation of intercellular spaces in the epithelium facilitating dendritic cell and antigen movement through the mucosa, and (3) a common inflammatory pathway activated by both GERD and EoE. Although these hypotheses appear plausible, supporting clinical data is not readily available. For example, it is unclear if the beneficial effect of proton pump inhibitors on esophageal eosinophilia is mediated through control of acid exposure to esophageal mucosa or independent anti-inflammatory effects. There is also a lack of definitive evidence to support an increased incidence of GERD in the pediatric population in the absence of evident risk factors such as obesity. One would think if GERD were an important cofactor in this disease, the incidence of GERD would rise similarly to EoE. It is speculated that GERD and EoE coexist and in some patients interact to facilitate esophageal eosinophilia and its sequelae. However, the presence and degree of this interaction likely varies remarkably. Their presence could be influenced by other factors such as age of the patient and genetic predisposition to EoE.

Historical aspects of eosinophilic esophagitis: from case reports to clinical trials

Eosinophilic esophagitis (EoE) is a clinicopathological condition characterized clinically by symptoms of esophageal dysfunction in the absence of acid reflux, with typical endoscopic findings and eosinophilia on biopsy. This article looks into the historical clinical recognition and description of EoE, in particular clinical manifestations, natural history, and epidemiology. Additionally, the evolution of endoscopic recognition and development of clinical trials are described: EoE is an isolated disease of the esophagus, although it is associated with other antigen-driven diseases such as asthma, rhinitis, and atopic dermatitis. After initial case reports which were mostly not typical of the disease state now described, the first case series were described in 1993 and 1994 in adults, and 1995 in children. Although rarely seen before 2000, the disease is now commonly recognized. Randomized clinical trials have now been performed on topical steroids, and on biological agents targeted against IL-5, IL-13, and other mediators. Therapy with dilatation may be best guided by measures of compliance and distensibility. Work is needed on biomarkers of the disease's severity and progression, and predictive indexes of complications. EoE is a relatively new disease of increasing importance. It represents an important diagnosis in patients with upper gastrointestinal symptoms and must be considered in all patients with dysphagia where the diagnosis is not certain and in all patients who have an assumed diagnosis of reflux but are not responding to standard reflux therapy.

Does Barrett's esophagus regress after surgery (or proton pump inhibitors)?

Barrett's esophagus, the condition in which metaplastic columnar epithelium that predisposes to cancer development replaces the squamous epithelium that normally lines the distal esophagus, is a complication of gastroesophageal reflux disease (GERD). Metaplasia is a potentially reversible condition, and partial regression of Barrett's metaplasia has been documented with effective medical or surgical therapy for GERD. The important issue for patient management is not whether antireflux treatment causes Barrett's esophagus to regress, but rather whether antireflux therapy prevents cancer in Barrett's esophagus. Proton pump inhibitors (PPIs) would be expected to prevent this cancer because they heal reflux esophagitis, reduce exposure to a potential carcinogen (acid), and might prevent acid-induced proliferation and cancer-promoting cytokine secretion by esophageal epithelial cells. Furthermore, observational studies have shown that PPI use is associated with a decreased incidence of neoplasia in Barrett's esophagus. In theory, successful antireflux surgery, which eliminates the reflux of both acid and bile, should be better for cancer prevention than medical therapy, which only decreases the reflux of acid. However, high-quality studies show no significant difference in cancer incidence between medically and surgically treated patients with GERD and Barrett's esophagus. Furthermore, for individual patients with nondysplastic Barrett's metaplasia, the cancer risk is so small and the number needed to treat for cancer prevention with surgery so large, that it does not matter whether or not surgery provides a tiny margin of extra protection against cancer beyond that provided by medical therapy. The cost and risks of the operation overwhelm any small, additional cancer protective benefit. Antireflux surgery is very effective at controlling the endoscopic signs and symptoms of GERD, but the operation should not be recommended to patients solely with the rationale that it protects against cancer better than medical therapy.

Clinical and endoscopic characteristics do not reliably differentiate PPI-responsive esophageal eosinophilia and eosinophilic esophagitis in patients undergoing upper endoscopy: a prospective cohort study

OBJECTIVES

Proton-pump inhibitor-responsive esophageal eosinophilia (PPI-REE) is a newly recognized entity that must be differentiated from eosinophilic esophagitis (EoE). Little is known about this condition. We aimed to determine the prevalence of PPI-REE and EoE in patients undergoing upper endoscopy and determine features that distinguish the two groups.

METHODS

This prospective study conducted at the University of North Carolina from 2009 to 2011 enrolled consecutive adult patients undergoing outpatient upper endoscopy. Subjects had esophageal biopsies to quantify the maximum eosinophil count per high-power field (eos/hpf; hpf=0.24 mm(2)). If biopsies revealed ≥15 eos/hpf, subjects were treated with twice daily PPI for 8 weeks and endoscopy was repeated. If ≥15 eos/hpf persisted despite PPI therapy, EoE was diagnosed. If there were <15 eos/hpf, PPI-REE was diagnosed. The proportion of patients in each group was calculated, and patients with EoE and PPI-REE were compared.

RESULTS

Of the 223 subjects enrolled, 173 had dysphagia and 50 did not. Of those with dysphagia, 66 (38%) had ≥15 eos/hpf. After the PPI trial, 40 (23%) were confirmed to have EoE, and 24 (14%) had PPI-REE. Of those without dysphagia, 2 (4%) had ≥15 eos/hpf, and after the PPI trial, 1 (2%) had EoE. Compared with EoE, PPI-REE patients were more likely to be older and male and less likely to have typical endoscopic findings of EoE. However, none of the individual factors was independently predictive of PPI-REE status on multivariable analysis. Similarly, although some endoscopic findings were differentially distributed between PPI-REE and EoE, none were significantly associated with disease status on multivariable analysis.

CONCLUSIONS

Esophageal eosinophilia is common among patients undergoing esophagogastroduodenoscopy for dysphagia. Although EoE was seen in nearly a quarter of patients with dysphagia, PPI-REE was almost as common, and accounted for over one-third of those with ≥15 eos/hpf. No clinical or endoscopic features independently distinguished PPI-REE from EoE before the PPI trial.

Esophagitis in children: an update on current pharmacotherapy

INTRODUCTION

A common diagnostic entity in children is Esophagitis with multiple etiologies and complex immuno-pathogenic mechanisms. Our understanding of these mechanisms and of the pharmacotherapy of esophagitis is still evolving.

AREAS COVERED

Areas of focus for this review were chosen based on recent clinical practice and research interest in esophagitis in infants and children. A literature search was conducted with the relevant keywords ('gastroesophageal reflux disease' in pediatric age group, 'eosinophilia', 'esophageal eosinophilia', 'esophagitis', 'eosinophilic esophagitis', 'proton pump inhibitors'). Use, safety and efficacy of proton pump inhibitors in young infants and older children, the concepts of esophageal eosinophilia and overlap of reflux and eosinophilic esophagitis are discussed here.

EXPERT OPINION

Proton pump inhibitors are effective in healing reflux esophagitis in children of all ages but do not improve gastroesophageal reflux related symptoms in infants. An overlap in clinical and histological features of reflux and eosinophilic esophagitis exists, and proton pump inhibitors may exert their action in pathways other than just acid suppression. The role of weakly acidic/alkaline reflux in gastroesophageal reflux symptoms, development of newer reflux modifying medications and tools to assess efficacy of therapeutic intervention in eosinophilic esophagitis are promising areas for further research and developing knowledge.

A neurobiological model for cry-fuss problems in the first three to four months of life

Although problem crying in the first three to four months of life is usually self-limiting, it is not a trivial condition. Early intervention is important, yet families receive conflicting advice from health professionals. The past decade has seen significant advances in neuroscience, lactation science, and developmental psychology, including new insights into the significance of developmentally sensitive windows. We propose a neurobiological model to explain the mechanisms of cry-fuss problems in the first months of life, and the mechanisms which underlie effective intervention, with a view to facilitating research collaboration and consistency of advice across health disciplines. We hypothesise that crying in the first three to four neurodevelopmentally sensitive months signals activation of the hypothalamic-pituitary-adrenal axis and adrenergic neuronal circuitry in response to perceptions of discomfort or threat. Susceptible infants may be conditioned by early stress, for example, by unidentified feeding difficulties, into a sensitised stress response, which usually settles at three to four months of age with neurodevelopmental maturity. Bouts of prolonged and unsoothable crying result from positive feedback loops in the hypothalamic-pituitary-adrenal and adrenergic systems. Importantly, epigenetic modulation of the infant's limbic neuronal circuitry may explain correlations between regulatory problems in the first months of life, and behavioural problems including feeding problems in later childhood.

Development of food allergies in patients with gastroesophageal reflux disease treated with gastric acid suppressive medications

BACKGROUND

The prevalence of food allergy has steadily increased, especially in children. Reflux disease, a very common problem in children, is often treated with gastric acid suppressive (GAS) medications which may alter the processing of food allergens, thereby affecting oral mucosal tolerance.

OBJECTIVE

The purpose of this study was to determine if use of GAS medications is associated with the occurrence of food allergies in children.

METHODS

Using a large national commercial insurance database, we identified 4724 children aged 0-18 yrs who were diagnosed with Gastroesophageal Reflux Disease (GERD) and treated with GAS medications between January 1, 2008 and September 30, 2009. We then matched 4724 children with GERD not treated with GAS medications and 4724 children without GERD and not treated with GAS medications, at a 1:1 ratio, on age, gender and number of atopic risk factors. Patients were followed for 12 months.

RESULTS

In comparison to the referent (children without GERD who received no GAS medications), children with GERD who were treated with GAS were more likely to be diagnosed with a food allergy (Hazard ratio (HR): 3.67, 95% CI 2.15-6.27), as were children with GERD diagnosis but who were not treated with GAS medications (HR: 2.15, 95% CI: 1.21-3.81). A direct comparison of the two GERD cohorts showed that children with GERD who were treated with GAS had a greater risk of food allergy than those with GERD who were untreated (HR, 1.68, 95%CI, 1.15-2.46).

CONCLUSION

Treatment with GAS medications is associated with the occurrence of food allergy, an effect not apparently related to a diagnosis of GERD alone.

Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry a lot in the first few months overlooks feeding problems

This paper explores two areas in which the translation of research into practice may be improved in the management of cry-fuss behaviours in the first few months of life. Firstly, babies who cry excessively are often prescribed proton pump inhibitors, despite evidence that gastro-oesophageal reflux disease is very rarely a cause. The inaccuracy of commonly used explanatory mechanisms, the side-effects of acid-suppressive medications, and the failure to identify treatable problems, including feeding difficulty when the diagnosis of 'reflux' is applied, are discussed. Secondly, crying breastfed babies are still prescribed lactase or lactose-free formula, despite evidence that the problem of functional lactose overload is one of breastfeeding management. The mechanisms and management of functional lactose overload are discussed. These two problems of research translation need to be addressed because failure to identify and manage other causes of cry-fuss problems, including feeding difficulty, may have adverse outcomes for a small but significant minority of families.

Novel allergens from ancient foods: Man e 5 from manioc (Manihot esculenta Crantz) cross reacts with Hev b 5 from latex

SCOPE

Manioc (Manihot esculenta) is a tuber mainly consumed in the Southern Hemisphere and used worldwide by food and chemistry industry. We aimed to recombinantly produce and characterize the first manioc allergen and evaluate its IgE reactivity in sera of Brazilian and Italian patients.

METHODS AND RESULTS

The molecule, termed Man e5, was expressed in E. coli, characterized by amino acid analysis, mass spectrometry, circular dichroism, HPLC, and dynamic light scattering. A tertiary structural model of the protein was produced using bioinformatics and susceptibility to pepsin digestion was analyzed in vitro. Based on its high content of charged residues, heat stability, flexibility and lack of secondary structure elements, the allergen was determined a member of the intrinsically disordered protein family. Brazilian patients were selected based on manioc allergy and Italians based on latex allergy and sensitization to Hev b 5.71% of Brazilians and 40% of Italians were in vitro IgE positive to Man e5. Cross-inhibition assays suggest a possible involvement of this allergen in the latex-fruit syndrome.

CONCLUSION

Man e5, the first purified allergen from manioc demonstrates IgE cross-reactivity with Hev b 5. Data suggest Hev b 5 might act as primary sensitizer and could therefore lead to allergic manifestations upon manioc consumption without prior exposition.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of pediatric eosinophilic esophagitis: an update

Eosinophilic esophagitis is an important chronic esophageal disorder with gastroesophageal reflux disease (GERD)-like symptoms, prominent esophageal mucosal eosinophilia, strongly associated with allergic disorders and unresponsive to anti-GERD therapy. Treatment of eosinophilic esophagitis has been successful with the use of dietary restrictions and topical corticosteroids. A subset of patients benefits from concurrent anti-GERD therapy; those with demonstrable esophageal strictures report variable duration symptom relief after esophageal dilation. At the current time, anti-interleukin-5 monoclonal antibody agents are being investigated in multicenter trials, and it is hoped that future therapy may be targeted against mediators of esophageal remodeling and fibrosis in eosinophilic esophagitis.

Endoscopic ablative therapy for Barrett's esophagus: a potential cause of eosinophilic esophagitis

Markedly increased esophageal eosinophils are associated with allergy- or reflux-based eosinophilic esophagitis. Other known disorders that cause this entity are unusual. To characterize the clinical, endoscopic, and histological findings of patients who develop marked esophageal eosinophilic infiltration after ablative therapy for Barrett's dysplasia. All patients who underwent endoscopic ablation of Barrett's esophagus between 1991 and 2009 with photodynamic therapy or radio frequency were screened for a pathologic descriptor of 'eosinophils' on biopsy. Patients whose biopsies demonstrated >15 eosinophils per high power (HPF) field in squamous epithelium after ablation were reviewed and included in the study group. Thirteen of 385 (3.4%) patients underwent ablation for Barrett's esophagus and subsequently had large numbers of intraepithelial eosinophils. All patients had long segment Barrett's (mean 8.0 cm) with low- or high-grade dysplasia or adenocarcinoma. All had undergone photodynamic therapy as their form of ablation. No patients had typical symptoms or endoscopic findings of eosinophilic esophagitis. Eleven patients were on proton pump inhibitors. The time between ablation and onset of esophageal eosinophilia ranged from 83 to 692 days. Intraepithelial eosinophil counts ranged from 30 to 150/HPF (mean 90). The majority of cases showed eosinophilic degranulation, spongiosis, increased papillary height, and basal zone thickening. The natural history of esophageal eosinophilia was variable after ablation, persisting consistently or sporadically on biopsy for up to 6 years. Ablation for Barrett's dysplasia can be followed rarely by eosinophil infiltrates with a histological resemblance to allergy-based eosinophilic esophagitis, but lacking dysphagia. The pathophysiology is unknown.

What you need to know when you prescribe a proton pump inhibitor

Ever since they were launched, proton pump inhibitors (PPIs) have been regarded as profligate prescription interventions and have become a favourite target for pharmacy advisers. Now that they are cheap, with generic omeprazole 20 mg daily costing £1.88 per month (£24.51 per annum) in the UK, it is time to ask whether this status should be reviewed, whether there are areas where the message should be reversed and whether there are any circumstances in which the extra cost of branded PPIs or combined preparations is justified. Equally, with the recognition of an extended toxicity profile, is prescribing profligacy not an economic but a safety issue?

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.

Eosinophilic esophagitis: updated consensus recommendations for children and adults

Eosinophilic esophagitis (EoE) is a clinicopathologic condition of increasing recognition and prevalence. In 2007, a consensus recommendation provided clinical and histopathologic guidance for the diagnosis and treatment of EoE; however, only a minority of physicians use the 2007 guidelines, which require fulfillment of both histologic and clinical features. Since 2007, the number of EoE publications has doubled, providing new disease insight. Accordingly, a panel of 33 physicians with expertise in pediatric and adult allergy/immunology, gastroenterology, and pathology conducted a systematic review of the EoE literature (since September 2006) using electronic databases. Based on the literature review and expertise of the panel, information and recommendations were provided in each of the following areas of EoE: diagnostics, genetics, allergy testing, therapeutics, and disease complications. Because accumulating animal and human data have provided evidence that EoE appears to be an antigen-driven immunologic process that involves multiple pathogenic pathways, a new conceptual definition is proposed highlighting that EoE represents a chronic, immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. The diagnostic guidelines continue to define EoE as an isolated chronic disorder of the esophagus diagnosed by the need of both clinical and pathologic features. Patients commonly have high rates of concurrent allergic diatheses, especially food sensitization, compared with the general population. Proved therapeutic options include chronic dietary elimination, topical corticosteroids, and esophageal dilation. Important additions since 2007 include genetic underpinnings that implicate EoE susceptibility caused by polymorphisms in the thymic stromal lymphopoietin protein gene and the description of a new potential disease phenotype, proton pump inhibitor-responsive esophageal eosinophila. Further advances and controversies regarding diagnostic methods, surrogate disease markers, allergy testing, and treatment approaches are discussed.

Anti-acid medication as a risk factor for food allergy

An important feature for oral allergens is their digestion-resistance during gastrointestinal transit. For some oral allergens, digestion stability is an innate feature, whereas digestion-labile antigens may only persist in times of impairment of the digestive system. In this review, we collect evidence from mouse and human studies that besides the inherent molecular characteristics of a food protein, the stomach function is decisive for the allergenic potential. Gastric acid levels determine the activation of gastric pepsin and also the release of pancreatic enzymes. When anti-ulcer drugs inhibit or neutralize gastric acid, they allow persistence of intact food allergens and protein-bound oral drugs with enhanced capacity to sensitize and elicit allergic reactions via the oral route. Mouse studies further suggest that maternal food allergy arising from co-application of a food protein with anti-acid drugs results in a Th2-biased immune response in the offspring. Especially, anti-ulcer drugs containing aluminum compounds act as Th2 adjuvants. Proton pump inhibitors act on proton secretion but also on expression of the morphogen Sonic hedgehog, which has been related to the development of atrophic gastritis. On the other hand, atrophic gastritis and resulting hypoacidity have previously been correlated with enhanced sensitization risk to food allergens in elderly patients. In summary, impairment of gastric function is a documented risk factor for sensitization against oral proteins and drugs.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Japanese case series of 12 patients with esophageal eosinophilia

BACKGROUND

Eosinophilic esophagitis (EoE) has been a rarely recognized condition in Asian populations, and its clinical manifestation is rarely documented. Our aim was to describe clinically, endoscopically, and pathologically the features of patients with esophageal eosinophilia, including EoE.

METHODS

Twelve patients histologically proven to have esophageal eosinophilia were investigated. The histological diagnostic cutoff value was defined as a peak of ≥15 eosinophils/high-power field (HPF) in esophageal biopsies. Symptoms, endoscopic and pathological findings, and treatment outcome were evaluated.

RESULTS

Nine of the 12 patients were male and the 12 patients had a mean age of 47.7 years. Allergic conditions were concurrent in a total of 3 patients. Mild peripheral eosinophilia was observed in only 2 patients. The predominant symptom was solid-food dysphagia, but some patients complained of heartburn, or chest, epigastric, or back pain. Three asymptomatic subjects were also incidentally diagnosed during endoscopic screening. Linear furrows, concentric rings, and white exudates in the esophagus were frequently observed. In 4 of 5 patients who were administered a proton pump inhibitor (PPI), esophageal eosinophilia was histologically decreased or disappeared with symptom relief and endoscopic improvement. In 2 patients unresponsive to PPI, topical steroid therapy, administered by the swallowing of fluticasone propionate, led to symptomatic and histological remission.

CONCLUSIONS

The endoscopic recognition of linear furrows, concentric rings, and white exudates is important in the diagnosis of eosinophilic esophageal inflammation. In a subset of patients this condition improves clinicopathologically with PPI treatment, and typical EoE, as strictly defined by unresponsiveness to PPI, appears to be a rather rare condition.

The unsettled baby: crying out for an integrated, multidisciplinary primary care approach

Unsettled behaviour in the first few months of life is a common clinical problem, with the associated risks of postnatal depression, premature cessation of breastfeeding, long-term psychological disturbance, and child abuse. Parents of new babies complain of difficulty accessing appropriate care and receiving conflicting advice. Although organic disturbance is implicated in only 5% of cases, gastro-oesophageal reflux disease, food allergies and lactose intolerance are often mistakenly diagnosed in unsettled babies. There is no evidence that acid-suppressive medications help in treating unsettled behaviour and, until the hypothesis that proton-pump inhibitors may predispose to food allergies has been properly investigated, treatment with acid-suppressive medications should be avoided in this population. Although unsettled behaviour in infants is commonly a transient neurodevelopmental phenomenon that peaks at 6 weeks of age, failure to diagnose other correctable problems, including breastfeeding difficulty and cows milk allergy, risks entrenching anxiety and disrupted mother-infant interactions in the long term. In the current climate of health system reform, the design and evaluation of an integrated, evidence-based, multidisciplinary primary care approach to management of unsettled babies and their mothers is a priority.

Practice patterns for the evaluation and treatment of eosinophilic oesophagitis

BACKGROUND

Although consensus guidelines for eosinophilic oesophagitis have been published, it remains unclear whether gastroenterologists follow these recommendations.

AIM

To assess academic and community practice patterns for the evaluation and treatment of eosinophilic oesophagitis and to compare these practices with current guidelines.

METHODS

This was a prospective study of academic and community gastroenterologists using a self-administered online survey.

RESULTS

A total of 60% (34 of 57) of academic and 29% (38 of 133) of community gastroenterologists completed the survey. Only 24% of academic and 3% of community gastroenterologists follow consensus guidelines to diagnose eosinophilic oesophagitis (P = 0.007). A proton pump inhibitor trial or negative pH study prior to diagnosis was required by just 25% of all gastroenterologists. A majority (60%) do not use the recommended threshold of 15 eosinophils per high powered field to diagnosis eosinophilic oesophagitis. Half (51%) mistakenly require a positive endoscopic finding. For first-line treatment, about half of the gastroenterologists surveyed treat with a swallowed topical steroid (53% academic, 56% community; P = N.S.), consistent with the guidelines.

CONCLUSIONS

There is variability in practice patterns for both diagnosis and treatment of eosinophilic oesophagitis. Ongoing education and research concerning diagnosis and treatment are needed.

Adverse effects of proton pump inhibitor drugs: clues and conclusions

PURPOSE OF REVIEW

To review evidence relating to the strength of associations that have appeared in largely observational studies, between high-dose or long-term use of proton pump inhibitor drugs and certain possibly attributable side-effects, which emerge from studies confounded by other variables. In retrospective studies not designed to assess safety, evidence of causality is generally lacking.

RECENT FINDINGS

The associations of fractures of hip, wrist, forearm and other sites appear weak and only slightly higher than the risks in control populations matched for age. They may increase with drug exposure, but probably do so only in individuals in whom other risk factors are also operational (smoking, alcohol, poor nutrition, steroids, etc.). The risks of Clostridium difficile colitis, other enteric infections, small bowel bacterial overgrowth and possibly spontaneous bacterial peritonitis also appear increased. Impaired gastric secretion may adversely affect the absorption of various nutrients, but their clinical impact is ill defined. Potentially more important are the consequences of hypergastrinemia, including rebound hypersecretion of acid, and possible development of various cancers, including carcinoid tumors. Effects of other drugs, including clopidogrel, on metabolism are reviewed, but clouded by uncertainties.

SUMMARY

The safety of long-term PPI administration needs serious prospective study.

Eosinophilic diseases of the gastrointestinal tract

Eosinophilic gastrointestinal disorders (EGIDs) are a diverse group of disorders whose diagnosis is on the rise and are characterized by symptoms caused by infiltration by eosinophils of the different sections of the digestive tract. Although little is known of their etiology, it seems to be multifactorial. Alteration of the immunological capacity of the digestive mucosa is determined by the exposure of genetically predisposed individuals to potential airborne or food allergens. EGIDs are classified based on the location of the inflammatory response even though their symptoms, prognosis, and treatment vary considerably. Eosinophilic esophagitis is the most widely recognized entity in this family and is characterized by exclusive eosinophilic infiltration of the esophagus. Breakthroughs in understanding its etiopathogeny have been extrapolated to eosinophilic gastroenteritis, a rare disease identified many years ago commonly involving the stomach and small bowel which should be distinguished from hypereosinophilic syndrome. Eosinophilic colitis, which usually affects children, could be considered a specific non-IgE-mediated allergy to food protein. The physiopathological bases of these entities need to be established in order to define specific treatment aimed at preventing and altering their clinical evolution.