Cost-effectiveness model of endoscopic biopsy for eosinophilic esophagitis in patients with refractory GERD

Gastroesophageal reflux disease: recent innovations in endoscopic assessment and treatment

Innovations in endoscopy have brought about some impressive improvements in diagnosing and treating gastroesophageal reflux disease (GERD). GERD, as one of the most prevalent gastrointestinal disorders in the world, has always been on the cutting edge of endoscopic interventions. A primary diagnosis of GERD is based on symptoms and an initial trial of proton-pump inhibitor (PPI) therapy, which is devoid of adequately instructive value for therapeutic strategies. Endoscopy and optional biopsies can be used to directly observe and determine the abnormal structural and pathophysiological damage in the esophagus. The emergence of minimally invasive endoscopic therapy fills the gap between patients who are reluctant or insensitive to PPIs and candidates who are not indicated for surgical anti-reflux fundoplication. In this review, we discuss the utility of endoscopy and biopsy in patients with persistent GERD-related manifestations after proper medical anti-reflux treatment. Moreover, we portray a landscape of four current endoscopic GERD therapies and clarify the merits and disadvantages of each technique. Future research needs to concentrate on stratifying GERD patients based on personal conditions and elucidating the primary pathophysiology of GERD.

Utility of Routine Esophageal Biopsies in Patients With Refractory Reflux Symptoms

INTRODUCTION

This study aimed to assess the diagnostic yield of routine esophageal biopsies in patients with refractory reflux symptoms.

METHODS

We prospectively enrolled consecutive patients referred for upper endoscopy and collected histological, clinical, and endoscopic data.

RESULTS

Of the 301 included patients, 14 (4.7%) patients met the clinicopathological diagnostic definition of eosinophilic esophagitis. Presence of dysphagia, food bolus impaction, atopic background, and typical endoscopic features were the factors with the strongest association and diagnostic accuracy for eosinophilic esophagitis. The diagnostic yield in patients lacking symptoms of dysphagia or endoscopic features was negligible (0% and 1.9%, respectively).

DISCUSSION

Routine esophageal biopsy sampling in patients with refractory reflux symptoms has a low diagnostic yield. Esophageal biopsies should only be obtained in patients with refractory reflux symptoms who also present with dysphagia (see Visual abstract, Supplementary Digital Content 2, http://links.lww.com/AJG/B792).

Value of biopsy in a cohort of children with high-titer celiac serologies: observation of dynamic policy differences between Europe and North America

Background

Healthcare systems implement change at different rates because of differences in incentives, organizational processes, key influencers, and management styles. A comparable set of forces may play out at the national and international levels as demonstrated in significant differences in the diagnostic management of pediatric Celiac Disease (CD) between European and North American practitioners.

Methods

We use retrospective clinical cohorts of 27,868 serum tissue transglutaminase (tTG) immunoglobulin A levels and 7907 upper gastrointestinal endoscopy pathology reports to create a dataset of 793 pathology reports with matching tTG results between July 1 of 2014 and July 1 of 2018. We use this dataset to characterize histopathological findings in the duodenum, stomach and esophagus of patients as a function of serum tTG levels. In addition, we use the dataset to estimate the local and national cost of endoscopies performed in patients with serum tTG levels greater than 10 times the upper limit of normal.

Results

Using evidence from a US tertiary care center, we show that in the cohort of pediatric patients with high pre-test probability of CD as determined by serum tTG levels, biopsy provides no additional diagnostic value for CD, and that it counter-intuitively introduces diagnostic uncertainty in a number of patients. We estimate that using the European diagnostic algorithms could avoid between 4891 and 7738 pediatric endoscopies per year in the US for evaluation of CD.

Conclusions

This study considers the North American and European management guidelines for the diagnosis of pediatric CD and highlights the slow adoption in North America of evidence-based algorithms developed and applied in Europe for triage of endoscopy and biopsy. We suggest that system dynamics influences that help maintain the status quo in North America include a variety of social and economic factors in addition to medical evidence. This work contributes to the growing body of evidence that the dynamics that largely favor maintaining status quo management policies in a variety of systems extend to clinical medicine and potentially influence clinical decisions at the level of individual patients and the population.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12913-020-05815-0.

The Lyon Consensus: Does It Differ From the Previous Ones?

Gastroesophageal reflux disease (GERD) is a complex disorder with heterogeneous symptoms and a multifaceted pathogenetic basis, which prevent a simple diagnostic algorithm or any categorical classification. Clinical history, questionnaires and response to proton pump inhibitor (PPI) therapy are insufficient tools to make a conclusive diagnosis of GERD and further investigations are frequently required. The Lyon Consensus goes beyond the previous classifications and defines endoscopic and functional parameters able to establish the presence of GERD. Evidences for reflux include high-grade erosive esophagitis, Barrett’s esophagus, and peptic strictures at endoscopy as well as esophageal acid exposure time > 6% on pH-metry or combined pH-impedance monitoring. Even if a normal endoscopy does not exclude GERD, its combination with distal acid exposure time < 4% on off-PPI pH-impedance monitoring provides sufficient evidence refuting this diagnosis. Reflux-symptom association on pH-monitoring provides supportive evidence for reflux-triggered symptoms and may predict a better treatment outcome, when present. Also recommendations to perform pH-impedance “on” or “off” PPI are well depicted. When endoscopy and pH-metry or combined pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (eg, microscopic esophagitis), high-resolution manometry (ie, ineffective esophagogastric barrier and esophageal body hypomotility), and novel impedance metrics, such as mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index, can contribute to better identify patients with GERD. Definition of individual patient phenotype, based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the esophagogastric junction, and clinical presentation, will lead to manage GERD patients with a tailored approach chosen among different types of therapy.

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)

OBJECTIVE

Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery.

DESIGN

We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.

RESULTS

Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis.

CONCLUSION

With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

Development and Validation of a Mucosal Impedance Contour Analysis System to Distinguish Esophageal Disorders

BACKGROUND & AIMS

Diagnostic testing for chronic esophageal disorders relies on histopathology analysis of biopsies or uncomfortable transnasal catheters or wireless pH monitoring, which capture abnormal intraluminal refluxate. We therefore developed a balloon mucosal impedance (MI) catheter system that instantly detects changes in esophageal mucosal integrity during endoscopy over a long segment of the esophagus. We performed a prospective study to evaluate the ability of a balloon-incorporated MI catheter to detect and evaluate esophageal disorders, including gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE).

METHODS

We performed a prospective study of 69 patients undergoing esophagogastroduodenoscopy with or without wireless pH monitoring. Patients were classified as having GERD (erosive esophagitis or abnormal pH; n = 24), EoE (confirmed with pathology analysis of tissues from both distal and proximal esophagus; n = 21), or non-GERD (normal results from esophagogastroduodenoscopy and pH tests; n = 24). Receiver operating characteristic curves and area under the operating characteristic curve (AUC) were used to compare the accuracy of balloon MI in diagnosis. Probabilities of assignment to each group (GERD, non-GERD, or EoE) were estimated using multinomial logistic regression. Association between MI patterns and diagnoses were validated using data from patients seen at 3 separate institutions.

RESULTS

MI pattern along the esophageal axis differed significantly (P < .01) among patients with GERD, EoE, and non-GERD. Patients with non-GERD had higher MI values along all measured segments. The MI pattern for GERD was easily distinguished from that of EoE: in patients with GERD, MI values were low in the distal esophagus and normalized along the proximal esophagus, whereas in patients with EoE, measurements were low in all segments of the esophagus. Intercept and rate of rise of MI value (slope) as distance increased from the squamocolumnar junction identified patients with GERD with an AUC = 0.67, patients with EoE with an AUC = 0.84, and patients with non-GERD with an AUC = 0.83 in the development cohort. One patient had an adverse event (reported mild chest pain after the procedure) and was discharged from the hospital without further events.

CONCLUSIONS

We developed a balloon MI catheter system that instantly detects changes in esophageal mucosal integrity during endoscopy and found it to be safe and able to identify patients with GERD, EoE, or non-GERD. We validated our findings in a separate cohort for patients. ClinicalTrials.gov ID NCT03103789.

Cost-effective care in eosinophilic esophagitis

OBJECTIVE

To examine costs related to eosinophilic esophagitis (EoE), understand the source of these costs, discuss a possible approach for cost-effective care in EoE, and identify areas for future research in this topic.

DATA SOURCES/STUDY SELECTIONS

Narrative review of the literature from 1977 (first description of EoE) to March 2019, focusing on costs and cost-effectiveness analyses in EoE.

RESULTS

High costs in EoE can be related to diagnostic delays, requirement for upper endoscopy with biopsy for diagnosis and monitoring of disease activity, expensive medications currently used off-label, increased food costs related to dietary elimination treatment, frequent doctor visits with subspecialists, and complications or disease exacerbations. Provision of cost-effective care in EoE is an understudied area, and a patient-centric approach is key. There are multiple areas in which future research can make an impact. These include determining predictors of treatment response, minimally or noninvasive methods to monitor disease activity, and validation of the use of multidisciplinary care.

CONCLUSION

Eosinophilic esophagitis (EoE) is considered to be a rare disease, but the costs of care and burden of disease attributed to EoE are substantial. However, few studies examine either the costs related to EoE or the approach to cost-effective care for the EoE patient. To provide cost-effective care, a patient-centric approach and shared decision-making model are optimal. In addition, a rational strategy for EoE diagnosis and initial treatment, effective maintenance therapy for disease control and ideally to prevent complications, and appropriate long-term monitoring are all required.

A Prospective Study of Eosinophilic Esophagitis and the Expression of Tight Junction Proteins in Patients with Gastroesophageal Reflux Disease Symptoms

Background/Aims

Eosinophilic esophagitis (EoE) is often erroneously diagnosed as gastroesophageal reflux disease (GERD). The aim of this study is to investigate the prevalence of EoE and the expression of tight junction (TJ) proteins in patients with GERD symptoms.

Methods

One hundred patients with GERD symptoms and 10 healthy controls were prospectively studied. Sixty-two patients had symptoms refractory to proton pump inhibitors (PPI). All patients underwent esophageal biopsy. Patients were diagnosed with EoE if the number of eosinophil granulocytes per high-power field was ≥15. Immunohistochemical analysis of TJ proteins (claudin-1, claudin-4, occludin, and zonula occludin-1 [ZO-1]) was performed.

Results

EoE was diagnosed in six of 100 patients (6%) with GERD symptoms and in six patients (9.7%) of 62 patients with PPI-refractory GERD. Only one had typical EoE endoscopic findings. The proportion of ZO-1-positive cells was significantly lower in the lower than in the middle esophagus (56.0%±14.0% vs 66.0%±11.5%, p＜0.05). There were no significant correlations between TJ protein expression and GERD symptoms.

Conclusions

The prevalence of EoE among patients with PPI-refractory GERD is approximately 10%. Regardless of endoscopic findings, esophageal biopsy is crucial in diagnosing EoE. The disruption of ZO-1 expression in the lower esophagus is significantly associated with GERD symptoms.

Gastroesophageal reflux disease: A clinical overview for primary care physicians

OBJECTIVE

GERD is among the most common outpatient disease processes encountered by clinicians on a daily basis. This review provides insights about how to approach GERD in terms of disease management and treatment.

METHODS

Review articles were searched using PUBMED and MEDLINE using criteria that included English language articles published in the last 5 years concerning studies carried out only in humans. The key words used in the searches were GERD, PPI, and erosive esophagitis. Recommendations from the American College of Gastroenterology are also included in this manuscript.

RESULTS

The search resulted in ∼260 articles. The manuscript brings together and presents the results of recent recommendations from professional societies and recently published review articles on GERD.

CONCLUSION

GERD is one of the most common diagnoses made by gastroenterologists and primary care physicians. It is important to recognize the typical and atypical presentations of GERD. This paper helps primary care physicians understand the disease's pathophysiology, and when, how, and with what to treat GERD before referring patients to gastroenterologists or surgeons.

Utility of esophageal mucosal impedance as a diagnostic test for esophageal disease

PURPOSE OF REVIEW

The aim of this review is to summarize the use of direct mucosal impedance (MI) for the evaluation and management of esophageal diseases.

RECENT FINDINGS

Esophageal multichannel intraluminal impedance with pH (MII-pH) monitoring has been considered the most sensitive test for gastroesophageal reflux disease (GERD), but recent studies have failed to establish impedance parameters that reliably predict treatment response to medical and surgical GERD therapies. MII-pH uses a catheter passed through the nose, which is uncomfortable for patients, and the test is compromised by the day-to-day variability of reflux patterns. Recently, an MI device has been developed that can be passed through the working channel of an endoscope to measure esophageal epithelial conductivity as a marker of chronic GERD. The MI values so obtained are available within seconds, correlate with histological findings of epithelial barrier dysfunction, normalize with effective treatment, and show promise for diagnosing eosinophilic esophagitis and for distinguishing it from GERD.

SUMMARY

MI can differentiate esophageal disorders instantly during endoscopy, and can monitor treatment responses in GERD and eosinophilic esophagitis.

Cost Utility Analysis of Topical Steroids Compared With Dietary Elimination for Treatment of Eosinophilic Esophagitis

BACKGROUND & AIMS

Topical corticosteroids or dietary elimination are recommended as first-line therapies for eosinophilic esophagitis, but data to directly compare these therapies are scant. We performed a cost utility comparison of topical corticosteroids and the 6-food elimination diet (SFED) in treatment of eosinophilic esophagitis, from the payer perspective.

METHODS

We used a modified Markov model based on current clinical guidelines, in which transition between states depended on histologic response simulated at the individual cohort-member level. Simulation parameters were defined by systematic review and meta-analysis to determine the base-case estimates and bounds of uncertainty for sensitivity analysis. Meta-regression models included adjustment for differences in study and cohort characteristics.

RESULTS

In the base-case scenario, topical fluticasone was about as effective as SFED but more expensive at a 5-year time horizon ($9261.58 vs $5719.72 per person). SFED was more effective and less expensive than topical fluticasone and topical budesonide in the base-case scenario. Probabilistic sensitivity analysis revealed little uncertainty in relative treatment effectiveness. There was somewhat greater uncertainty in the relative cost of treatments; most simulations found SFED to be less expensive.

CONCLUSIONS

In a cost utility analysis comparing topical corticosteroids and SFED for first-line treatment of eosinophilic esophagitis, the therapies were similar in effectiveness. SFED was on average less expensive, and more cost effective in most simulations, than topical budesonide and topical fluticasone, from a payer perspective and not accounting for patient-level costs or quality of life.

Diagnosis and treatment of gastroesophageal reflux disease: recommendations of the Asociación Mexicana de Gastroenterología

Emerging concepts in the pathophysiology of gastroesophageal reflux disease (GERD) and the constant technologic advances in the diagnosis and treatment of this clinical condition make it necessary to frequently review and update the clinical guidelines, recommendations, and official statements from the leading academic groups worldwide. The Asociación Mexicana de Gastroenterología (AMG), aware of this responsibility, brought together national experts in this field to analyze the most recent scientific evidence and formulate a series of practical recommendations to guide and facilitate the diagnostic process and efficacious treatment of these patients. The document includes algorithms, figures, and tables for convenient consultation, along with opinions on GERD management in sensitive populations, such as pregnant women and older adults.

The Utility of Endoscopic Biopsies in Patients with Normal Upper Endoscopy

Background and Aims. Upper endoscopy is a valuable tool in the workup of gastrointestinal (GI) complaints. The purpose of this study is to determine cost and yield of taking biopsies in a normal upper GI tract. Methods. This is a retrospective study where all upper GI biopsies were identified between May 2012 and April 2013, at a tertiary care center. Clinical, procedural, and pathology reports were reviewed to identify patient demographics, procedure information, and pathology diagnosis. Results. Biopsies of the upper GI tract were taken in 1297 patients with normal upper endoscopies. In patients with normal upper endoscopy, 22% of esophageal, 44% of gastric, and 12% of duodenal biopsies were abnormal. The most frequent abnormality was reflux esophagitis in 16% of esophageal biopsies, chronic gastritis in 23% of gastric biopsies, and increased intraepithelial lymphocytes in 6% of duodenal biopsies. The additional cost for taking biopsies in a normal upper GI tract for a diagnosis of eosinophilic esophagitis was $2963 Canadian (CAD), H. pylori associated gastritis was $1404 CAD, and celiac disease was $3024 CAD. Conclusions. The yield of biopsy in normal upper endoscopy varied with location, but the additional expense can be costly and should be tailored to appropriate clinical situations.

A Clinical Prediction Tool Identifies Cases of Eosinophilic Esophagitis Without Endoscopic Biopsy: A Prospective Study

OBJECTIVES

Eosinophilic esophagitis (EoE) is difficult to distinguish from gastroesophageal reflux (GERD) and other causes of dysphagia. We assessed the utility of a set of clinical and endoscopic features for predicting EoE without obtaining esophageal biopsies.

METHODS

We prospectively enrolled consecutive adults undergoing outpatient upper endoscopy at the University of North Carolina from July 2011 through December 2013. Incident cases of EoE were diagnosed per consensus guidelines. Non-EoE controls had either GERD- or dysphagia-predominant symptoms. A predictive model containing clinical and endoscopic, but no histological, data was assessed. Receiver operator characteristic curves were constructed and the area under the curve (AUC) was calculated.

RESULTS

A total of 81 EoE cases (mean age 38 years; 60% male; 93% white; 141 eosinophils per high-power field (eos/hpf)) and 144 controls (mean age 52, 38% male; 82% white; 3 eos/hpf) were enrolled. A combination of clinical (age, sex, dysphagia, food allergy) and endoscopic (rings, furrows, plaques, hiatal hernia) features was highly predictive of EoE. The AUC was 0.944, with sensitivity, specificity, and accuracy of 84, 97, and 92%. Similar values were seen after limiting controls to those with only reflux or dysphagia or to those with esophageal eosinophilia not due to EoE.

CONCLUSIONS

We validated a set of clinical and endoscopic features to predict EoE with a high degree of accuracy and allow identification of those at very low risk of disease. Use of these predictors at the point-of-care will avoid the effort and expense of low-yield histological examinations for EoE.

The Proton Pump Inhibitor Non-Responder: A Clinical Conundrum

Gastroesophageal reflux disease (GERD) is a highly prevalent chronic condition where in stomach contents reflux into the esophagus causing symptoms, esophageal injury, and subsequent complications. Proton pump inhibitors (PPI) remain the mainstay of therapy for acid suppression. Despite their efficacy, significant proportions of GERD patients are either partial or non-responders to PPI therapy. Patients should be assessed for mechanisms that can lead to PPI failure and may require further evaluation to investigate for alternative causes. This monograph will outline a diagnostic approach to the PPI non-responder, review mechanisms associated with PPI failure, and discuss therapeutic options for those who fail to respond to PPI therapy.

High-resolution microendoscopy for esophageal cancer screening in China: A cost-effectiveness analysis

AIM

To study the cost-effectiveness of high-resolution microendoscopy (HRME) in an esophageal squamous cell carcinoma (ESCC) screening program in China.

METHODS

A decision analytic Markov model of ESCC was developed. Separate model analyses were conducted for cohorts consisting of an average-risk population or a high-risk population in China. Hypothetical 50-year-old individuals were followed until age 80 or death. We compared three different strategies for both cohorts: (1) no screening; (2) standard endoscopic screening with Lugol's iodine staining; and (3) endoscopic screening with Lugol's iodine staining and an HRME. Model parameters were estimated from the literature as well as from GLOBOCAN, the Cancer Incidence and Mortality Worldwide cancer database. Health states in the model included non-neoplasia, mild dysplasia, moderate dysplasia, high-grade dysplasia, intramucosal carcinoma, operable cancer, inoperable cancer, and death. Separate ESCC incidence transition rates were generated for the average-risk and high-risk populations. Costs in Chinese currency were converted to international dollars (I$) and were adjusted to 2012 dollars using the Consumer Price Index.

RESULTS

The main outcome measurements for this study were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). For the average-risk population, the HRME screening strategy produced 0.043 more QALYs than the no screening strategy at an additional cost of I$646, resulting in an ICER of I$11808 per QALY gained. Standard endoscopic screening was weakly dominated. Among the high-risk population, when the HRME screening strategy was compared with the standard screening strategy, the ICER was I$8173 per QALY. For both the high-risk and average-risk screening populations, the HRME screening strategy appeared to be the most cost-effective strategy, producing ICERs below the willingness-to-pay threshold, I$23500 per QALY. One-way sensitivity analysis showed that, for the average-risk population, higher specificity of Lugol's iodine (> 40%) and lower specificity of HRME (< 70%) could make Lugol's iodine screening cost-effective. For the high-risk population, the results of the model were not substantially affected by varying the follow-up rate after Lugol's iodine screening, Lugol's iodine test characteristics (sensitivity and specificity), or HRME specificity.

CONCLUSION

The incorporation of HRME into an ESCC screening program could be cost-effective in China. Larger studies of HRME performance are needed to confirm these findings.

Clinical features of eosinophilic esophagitis: differences between Asian and Western populations

The prevalence and incidence of eosinophilic esophagitis (EoE) have been rapidly increasing in Western countries. It is thought to be more common among Caucasians than other racial or ethnic groups, but epidemiological studies have not been fully evaluated in Asian populations, and its clinical manifestation is rarely documented. In this review, recent reports regarding EoE in Asian countries have been collected, and differences in the clinical features, including symptoms and endoscopic findings, between Asian and Western populations have been evaluated. In Asia, EoE is still much less prevalent than in Western countries. Baseline values for average age, male/female ratio, and personal history of allergic disease were comparable to those in Western populations. Predominant symptoms were dysphagia, and food impaction was extremely rare among Asian patients. Although the frequency of abnormal endoscopic findings varies among studies, over 90% of patients with EoE have shown abnormal findings such as linear furrow, which is the most common findings, in recent prospective studies in Asia. There are few reports regarding the treatment of EoE and no prospective studies evaluating drugs or elimination diet in patient with EoE have been reported in Asia. Overall, EoE had similar clinical characteristics in Asian populations. Because the incidence of EoE could increase in the future with the increase in allergic disorders in Asian countries, large-scale, nationwide prospective studies should be performed to more fully understand the epidemiology and pathophysiology of EoE in Asian populations.

Gender is a determinative factor in the initial clinical presentation of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease resulting in symptoms of esophageal dysmotility. Abnormalities include dysphagia, food impaction and reflux. Although men appear to comprise a majority of the EoE population, few studies have directly assessed gender-associated clinical differences. The aim of this study is to identify the effect of gender on the initial clinical presentation of adult-onset EoE patients. We reviewed our electronic medical record database from January 2008 to December 2011 for adults diagnosed with EoE per the 2011 updated consensus guidelines. Patient demographics, presenting symptoms, endoscopy findings and complications were recorded. Proportions were compared using chi-squared analysis, and means were compared using the Student's t-test. A total of 162 patients met the inclusion criteria and 71 (44%) were women. Women were more likely to report chest pain (P = 0.03) and heartburn (P = 0.06), whereas men more commonly reported dysphagia (P = 0.04) and a history of food impaction (P = 0.05). Endoscopic findings were similar between groups. No patients suffered esophageal perforations. These data suggest that men report more fibrostenotic symptoms and women report more inflammatory symptoms at the time of diagnosis. There was no difference in endoscopic findings between genders. This is one of the only reviews comparing differences in clinical presentation, endoscopic findings and complications between gender for EoE. The current recommended guidelines state that any patient with symptoms of esophageal dysfunction should be biopsied for EoE. Our findings support biopsying patients with typical and atypical symptoms of dysmotility including heartburn and chest pain.

US-Based Drug Cost Parameter Estimation for Economic Evaluations

INTRODUCTION

In the United States, more than 10% of national health expenditures are for prescription drugs. Assessing drug costs in US economic evaluation studies is not consistent, as the true acquisition cost of a drug is not known by decision modelers. Current US practice focuses on identifying one reasonable drug cost and imposing some distributional assumption to assess uncertainty.

METHODS

We propose a set of Rules based on current pharmacy practice that account for the heterogeneity of drug product costs. The set of products derived from our Rules, and their associated costs, form an empirical distribution that can be used for more realistic sensitivity analyses and create transparency in drug cost parameter computation. The Rules specify an algorithmic process to select clinically equivalent drug products that reduce pill burden, use an appropriate package size, and assume uniform weighting of substitutable products. Three diverse examples show derived empirical distributions and are compared with previously reported cost estimates.

RESULTS

The shapes of the empirical distributions among the 3 drugs differ dramatically, including multiple modes and different variation. Previously published estimates differed from the means of the empirical distributions. Published ranges for sensitivity analyses did not cover the ranges of the empirical distributions. In one example using lisinopril, the empirical mean cost of substitutable products was $444 (range = $23-$953) as compared with a published estimate of $305 (range = $51-$523).

CONCLUSIONS

Our Rules create a simple and transparent approach to creating cost estimates of drug products and assessing their variability. The approach is easily modified to include a subset of, or different weighting for, substitutable products. The derived empirical distribution is easily incorporated into 1-way or probabilistic sensitivity analyses.

The natural history of steroid-naïve eosinophilic esophagitis in adults treated with endoscopic dilation and proton pump inhibitor therapy over a mean duration of nearly 14 years

BACKGROUND

Despite the vast focus of research in eosinophilic esophagitis (EoE), the natural history of untreated EoE remains undefined. Current expert consensus panels are calling for natural history studies to define long-term risks, adverse events, and progression of the disease.

OBJECTIVE

To address the natural course and long-term adverse events of EoE.

DESIGN

Retrospective, single-center study.

SETTING

Tertiary-care center. A cohort of patients from the year 1988 initially diagnosed as having congenital esophageal stenosis who were later reclassified as having EoE.

PATIENTS

Ninety-five patients, with 13 meeting entrance criteria for idiopathic EoE with follow-up >5 years.

INTERVENTIONS

Anti-acids and esophageal dilation.

MAIN OUTCOME MEASUREMENTS

Clinical response, adverse events, long-term clinical outcomes, and progression of disease.

RESULTS

Thirteen patients (mean age at diagnosis 30.3 years, 10 male) were evaluated over a 13.6-year mean follow-up (range 5-24 years). All patients experienced daily dysphagia, with 12 presenting with food impactions. Patients were treated with esophageal dilation (64% Maloney, 34% Savary, 2.5% through-the-scope balloon) and daily anti-acids. Patients were initially treated with an average of 3.2 dilations over the first year (range 1-6) to achieve a luminal size of 15.8 mm (range 14-18 mm). They were maintained successfully with dilations every 2 years, on average, based on symptoms. Two patients not adhering to recommended dilation schedules experienced repeat impactions. One adverse event from a mucosal tear required hospitalization (1 of 157, 0.6%). Seven of 13 had Barrett's esophagus, average length 2.4 cm (range 1-4 cm), 3 on initial EGD and 4 identified over a mean duration of 9.4 years. No patient developed dysplasia or malignancy.

LIMITATIONS

Retrospective, small sample.

CONCLUSION

The course of EoE over a 13.6-year mean duration, although persistent, appears benign and not associated with cancer risk. A program of regular esophageal dilations based on symptom recurrence appears to be a safe, long-term treatment.

Cellular and molecular immunological mechanisms in eosinophilic esophagitis: an updated overview of their clinical implications

Eosinophilic esophagitis (EoE) is a pathophysiologically complex disorder driven by distinct, multiple mechanisms involving a large number of cells, molecules, and genes. Associated with food allergy from its initial descriptions, a key role for the Th2-type cytokines IL-5 and IL-13 in recruiting and activating eosinophils has been described. Epithelial cells have been recognized as major effectors in initiating EoE, both through their recruitment of iNKT cells towards the esophageal epithelium, which constitutes a major cytokine source, and through the release of eotaxin-3 and other chemoattractants. Epithelial and mesenchymal-released TSLP is a key regulator for which a connecting role between the adaptive and innate mucosal-associated immune response has been suggested. Finally, activated eosinophil- and mast cell-derived TGF β1 secretion is crucial in EoE-associated tissue remodeling.

Refractory gastroesophageal reflux disease: advances and treatment

'Refractory gastroesophageal reflux disease' is one of the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive proton pump inhibitor therapy. The term should be replaced with 'refractory symptoms.' We must acknowledge that in many patients symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to diagnostic testing. In majority of patients these tests are normal. The role of non-acid reflux in this group is uncertain and patients should not undergo surgical fundoplication based on this parameter. In patients unresponsive to acid suppressive therapy GERD is most commonly not causal and a search for non-GERD causes must ensue.

Eosinophilic esophagitis: dilate or medicate? A cost analysis model of the choice of initial therapy

Eosinophilic esophagitis (EoE) is an increasingly recognized clinical entity. The optimal initial treatment strategy in adults with EoE remains controversial. The aim of this study was to employ a decision analysis model to determine the less costly option between the two most commonly employed treatment strategies in EoE. We constructed a model for an index case of a patient with biopsy-proven EoE who continues to be symptomatic despite proton-pump inhibitor therapy. The following treatment strategies were included: (i) swallowed fluticasone inhaler (followed by esophagogastroduodenoscopy [EGD] with dilation if ineffective); and (ii) EGD with dilation (followed by swallowed fluticasone inhaler if ineffective). The time horizon was 1 year. The model focused on cost analysis of initial treatment strategies. The perspective of the healthcare payer was used. Sensitivity analyses were performed to assess the robustness of the model. For every patient whose symptoms improved or resolved with the strategy of fluticasone first followed by EGD, if necessary, it cost an average of $1078. Similarly, it cost an average of $1171 per patient if EGD with dilation was employed first. Sensitivity analyses indicated that initial treatment with fluticasone was the less costly strategy to improve dysphagia symptoms as long as the effectiveness of fluticasone remains at or above 0.62. Swallowed fluticasone inhaler (followed by EGD with dilation if necessary) is the more economical initial strategy when compared with EGD with dilation first.

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.

Emerging therapeutic strategies for eosinophilic esophagitis

OPINION STATEMENT

Eosinophilic esophagitis (EoE) is recognized as an increasingly common cause of chronic and recurrent esophageal symptoms that significantly impact quality of life and may occasionally result in severe complications in both pediatric and adult patients. The disease is triggered and maintained by exposure to food antigens in most patients, with an additional role proposed for airborne allergens. Different diet-based approaches focused on restricting potentially offending foods have proven to be effective long-term therapies for EoE. Dietary therapy is thus an attractive, yet challenging treatment option that should be considered for all pediatric and adult EoE patients. However, limitations related to food restriction, patient willingness to undergo repeated endoscopies and biopsies, and the variable results of allergy testing imply that dietary management is for the most part currently restricted to highly motivated healthcare providers treating highly motivated patients reluctant to utilize drug-based therapy on a chronic basis. Pharmacological therapies for EoE mainly comprise swallowed topical steroids, especially fluticasone propionate and budesonide, which were originally developed to treat bronchial asthma and are now extensively used "off label" in EoE patients. In fact, topical steroids currently constitute the prevailing therapeutic option and will probably continue to do so in the near future; indeed, several randomized clinical trials are currently underway to test these drugs for approval as the first pharmacological agents for EoE patients. Immunomodulators and several anti-allergic agents must be further assessed as therapeutic alternatives for refractory cases or patients with complications. Endoscopic dilation represents the third pillar in the therapeutic management of EoE patients, since they frequently present reductions in the esophageal caliber as a result of collagen deposition and a progressive fibrous remodeling process promoted by chronic eosinophilic infiltration. Dilation provides at least temporary symptom relief with similar complication rates to esophageal strictures from a different origin. However, although repeated endoscopic dilation has sometimes been used as the sole therapy for EoE, it best constitutes an adjuvant therapy along with dietary or pharmacological-based interventions, especially since dilation has no effect on the underlying esophageal inflammation. Current therapeutic management of EoE varies widely, with physician experience being a major explanatory factor. New evidence from ongoing research on EoE should thus seek to define a common treatment algorithm to optimize EoE patient management.

New Approaches to Management of PPI-Refractory Gastroesophageal Reflux Disease

OPINION STATEMENT

"Refractory GERD" is one the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive, often twice-daily proton pump inhibitor therapy. The term should be replaced with "refractory symptoms." We must acknowledge that in many patients, symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus, and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to esophagogastroduodenoscopy followed by pH or impedance monitoring. In the majority of patients these tests are normal. The role of non-acid reflux measured by impedance pH testing in this group is uncertain at best and the results from this test alone should not be used to refer patients to surgical fundoplication. In patients unresponsive to acid suppressive therapy, reflux is most commonly not causal and a search for non-GERD causes must ensue.

Ambulatory reflux monitoring in GERD--which test should be performed and should therapy be stopped?

Diagnosing gastroesophageal reflux disease (GERD) often entails using a combination of patient symptoms, response to proton pump inhibitors (PPI), upper endoscopy, and ambulatory reflux testing. Each of these has limitations of which the clinician must be aware when managing patients with reflux symptoms. Ambulatory reflux monitoring, in particular, can potentially document the true presence of pathologic GERD. Consequently, reflux testing is often necessary in our evaluation of patients with reflux symptoms, and can be useful in distinguishing etiologies driving a lack of response to PPI therapy. Reflux testing results can be also used to guide appropriate PPI prescribing and clinical decision making for appropriate or unnecessary therapy. This review focuses on the limitations of our current diagnostic paradigm and highlights how reflux testing can be helpful in the diagnosis and management of patients with poor response to PPI therapy.

Management of gastro-oesophageal reflux disease symptoms that do not respond to proton pump inhibitors

PURPOSE OF REVIEW

Treatment-refractory gastro-oesophageal reflux disease (GERD) remains a significant problem in the gastroenterology clinic. In recent years, several studies have investigated the assessment and treatment of refractory GERD.

RECENT FINDINGS

Patients presenting with 'refractory GERD' in fact represent a quite heterogeneous group consisting of those with ongoing reflux-related symptoms and those with reflux-unrelated problems such as functional heartburn, dyspepsia or even eosinophilic oesophagitis. The greatest symptom indicators of persistent true reflux are retrosternal burning and acid taste in the mouth alone. Combined pH-impedance studies allow detection of reflux regardless of pH, and weakly acidic reflux has been suggested as a mechanism of residual symptoms in some patients. The use of reflux-symptom association calculations may help to determine the symptom causation, but refinement and outcome studies are needed. New treatments of refractory GERD have been disappointing. Surgery remains an option in very carefully selected patients, but again better outcome studies are required.

SUMMARY

Careful history and investigation is required in the assessment of the proton pump inhibitor (PPI)-refractory patient. Care to exclude alternative diagnoses is needed, and to phenotype those with reflux-related symptoms. Optimization of PPI therapy may help, as may surgery in selected patients.

Clinical characteristics of Japanese patients with eosinophilic esophagitis and eosinophilic gastroenteritis

BACKGROUND

The clinical characteristics of Japanese patients with eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE) have not been fully clarified. For understanding the pathogenesis as well as providing support for accurate diagnosis, precise information regarding clinical characteristics of these diseases is important.

METHODS

A questionnaire-based survey of EoE and EGE was conducted in 1,078 teaching hospitals. Clinical data of patients with confirmed EoE or EGE diagnosed from 2004 to 2009 were collected.

RESULT

Clinical data from 26 patients with EoE and 144 patients with EGE were collected. The mean ages of patients in both groups were in the 40s. Those with EoE frequently complained of dysphagia and heartburn, and had characteristic endoscopic features such as longitudinal furrows and multiple concentric rings in the esophagus, while only 34% had peripheral eosinophilia. Patients with EGE frequently complained of abdominal pain and diarrhea, and approximately 80% of them have peripheral eosinophilia. They did not have characteristic endoscopic features helpful for diagnosis. Computed tomography (CT) findings and the presence of peripheral eosinophilia were diagnostic for EGE. EGE patients with a small intestinal involvement showed the highest peripheral eosinophil counts. Glucocorticoid administration was the most widely used treatment for these diseases and its effect was favorable for at least induction of remission.

CONCLUSION

EGE is more prevalent than EoE in Japan. Patients with EGE have abdominal pain and diarrhea, high peripheral eosinophil counts, and gastrointestinal wall thickening identifiable by CT findings, while EoE is characterized by dysphagia and characteristic endoscopic features.

The natural history of eosinophilic oesophagitis in the transition from childhood to adulthood

BACKGROUND

Eosinophilic oesophagitis (EoE) is a chronic inflammatory condition affecting both children and adults. Little is known about the natural history of EoE in the transition from childhood into adulthood.

AIM

To determine the prevalence of EoE symptoms and impact of EoE on quality of life among adults diagnosed with EoE during childhood.

METHODS

This is a cross-sectional study of EoE patients from the Children's Hospital of Philadelphia EoE registry. Patients ≥18 years diagnosed with EoE during childhood were administered validated dysphagia [Mayo Dysphagia Questionnaire (MDQ)-30] and Quality of Life (PAGI-QOL) questionnaires. Ongoing EoE treatments were ascertained.

RESULTS

A total of 140 EoE patients ≥18 years were identified; 53 completed all questions. Only 6 (11%) subjects had positive (n = 2) or indeterminate (n = 4) dysphagia scores. However, of 47 patients with negative scores, 18 (37%) reported ongoing difficulty swallowing. The mean PAGI-QOL score was 4.58/5. The dietary dimension score was 3.73/5. Current pharmacological EoE treatments were topical steroids (3/53) and interleukin-5 antagonists (3/53). Additionally, 26/53 (49%) were on PPI therapy and 40/53 (76%) were following allergy directed diets.

CONCLUSIONS

The majority of young adults diagnosed with EoE during childhood continue to require pharmacological treatment and/or dietary modification for EoE. A substantial proportion of this population experiences ongoing swallowing difficulties that a standard dysphagia questionnaire fails to capture. Dietary quality of life, but not total quality of life, appears to be adversely affected. These data suggest that EoE diagnosed during childhood remains a significant medical issue during early adulthood, and that better EoE symptom measurement instruments are needed.

Eosinophilic esophagitis: diagnostic tests and criteria

PURPOSE OF REVIEW

To present the clinical, endoscopic, and histologic features of eosinophilic esophagitis (EoE), review the current diagnostic guidelines for EoE, and present an approach for diagnosis of EoE. It will also highlight selected techniques that are under development that may be useful in the future for diagnosis of EoE.

RECENT FINDINGS

Recently updated guidelines emphasize that EoE is a clinicopathologic condition. Specifically, three criteria must be met to diagnose EoE: clinical symptoms of esophageal dysfunction; an esophageal biopsy with a maximum eosinophil count of at least 15 eosinophils per high-power microscopy field, with few exceptions; and exclusion of other possible causes of esophageal eosinophilia, including proton-pump inhibitor responsive esophageal eosinophilia (PPI-REE). A PPI trial is typically required both to assess for PPI-REE and to evaluate for the presence of concomitant gastroesophageal reflux disease.

SUMMARY

EoE is a chronic, immune-mediated disorder. Because no single symptom, endoscopic finding, or histopathologic feature is pathognomonic, diagnosis can be challenging. In the future, symptom scores, tissue or serum biomarkers, and genetic testing may play a role in diagnosis, but these methods have yet to be validated and are not yet recommended for routine clinical use.

Efficacy of leukotriene receptor antagonist for erosive esophagitis: a preliminary retrospective comparative study

While diagnostic overlap exists between gastroesophageal reflux disease and eosinophilic esophagitis especially on histological findings, therapeutic approaches for the two disease entities are very different. Recently, anti-inflammatory treatment, in addition to acid suppressants, has been investigated for gastroesophageal reflux disease. This study investigated whether the incidence of endoscopic erosive esophagitis was lower in recipients of long-term leukotriene receptor antagonist (LTRA) treatment. This retrospective comparative study included 207 recipients of an LTRA and an equal number of controls who underwent screening upper endoscopic examination. Twenty-two (10.6%) and 51 (24.6%) cases of erosive esophagitis were detected in the LTRA and control groups, respectively (P < 0.001). A significantly higher incidence of minimal change esophagitis was also found in the controls compared with the LTRA group (14.5% vs. 2.4%, P < 0.001). On multivariate analysis, LTRA treatment was significantly and inversely associated with erosive esophagitis (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.13 to 0.46). Within the LTRA treatment group, an increased risk of erosive esophagitis was strongly associated with the presence of hiatal hernia (OR, 5.89; 95% CI, 2.20-15.73, P < 0.001) and short duration of LTRA treatment (OR, 0.64; 95% CI, 0.37-0.89, P= 0.022). In conclusion, this preliminary retrospective analysis demonstrated that patients who underwent long-term treatment with a LTRA had low incidence of endoscopic minimal change esophagitis.