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Leiferman KM, Gleich GJ. The true extent of eosinophil involvement in disease is unrecognized: the secret life of dead eosinophils. J Leukoc Biol 2024; 116:271-287. [PMID: 38922831 DOI: 10.1093/jleuko/qiae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/21/2024] [Accepted: 01/29/2024] [Indexed: 06/28/2024] Open
Abstract
Eosinophil-mediated pathophysiology is tissue destructive and tissue altering with proinflammatory, prothrombotic, and profibrotic effects. The distinctive morphology of an eosinophil reveals a cytoplasm chockfull of unique granules, and the granule proteins have numerous toxic effects on cells, tissues, and organs. Eosinophils are not found in most human tissues, and eosinophil involvement in diseased tissues generally is identified by cell infiltration on histopathologic examination. However, eosinophils characteristically lose their structural integrity and deposit granules and granule proteins at sites of inflammation. Hence, their participation in tissue damage may be underrecognized or entirely overlooked. The eosinophil major basic protein 1 is a toxic granule protein and, when deposited, persists in tissues. Major basic protein 1 deposition can be regarded as a footprint of eosinophil activity. Analyses of numerous eosinophil-related diseases have demonstrated clear-cut evidence of major basic protein 1 deposition in affected tissues where eosinophils were not recognized by hematoxylin and eosin tissue staining and light microscopy. Eosinophil granule protein deposition, as exemplified by localization of major basic protein 1, especially when disproportionately greater than cellular infiltration, emerges as a biomarker of hidden eosinophil-related pathophysiology. Consequently, current assessments of recognized eosinophils may vastly underestimate their role in disease.
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Affiliation(s)
- Kristin M Leiferman
- Department of Dermatology, University of Utah Health, Helix Building, 1st Floor South, 30 North Mario Capecchi Drive, Salt Lake City, UT, 84112United States
| | - Gerald J Gleich
- Department of Dermatology, University of Utah Health, Helix Building, 1st Floor South, 30 North Mario Capecchi Drive, Salt Lake City, UT, 84112United States
- Department of Internal Medicine, University of Utah Health, Helix Building, 3rd Floor North, 30 North Mario Capechhi Drive, Salt Lake City, UT, 84112United States
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de Bortoli N, Visaggi P, Penagini R, Annibale B, Baiano Svizzero F, Barbara G, Bartolo O, Battaglia E, Di Sabatino A, De Angelis P, Docimo L, Frazzoni M, Furnari M, Iori A, Iovino P, Lenti MV, Marabotto E, Marasco G, Mauro A, Oliva S, Pellegatta G, Pesce M, Privitera AC, Puxeddu I, Racca F, Ribolsi M, Ridolo E, Russo S, Sarnelli G, Tolone S, Zentilin P, Zingone F, Barberio B, Ghisa M, Savarino EV. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis - Definition, Clinical Presentation and Diagnosis. Dig Liver Dis 2024; 56:951-963. [PMID: 38423918 DOI: 10.1016/j.dld.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/26/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic type 2-mediated inflammatory disease of the esophagus that represents the most common eosinophilic gastrointestinal disease. Experts in the field of EoE across Italy (i.e., EoETALY Consensus Group) including gastroenterologists, endoscopists, allergologists/immunologists, and paediatricians conducted a Delphi process to develop updated consensus statements for the management of patients with EoE and update the previous position paper of the Italian Society of Gastroenterology (SIGE) in light of recent evidence. Grading of the strength and quality of the evidence of the recommendations was performed using accepted GRADE criteria. The guideline is divided in two documents: Part 1 includes three chapters, namely 1) definition, epidemiology, and pathogenesis; 2) clinical presentation and natural history, and 3) diagnosis, while Part 2 includes two chapters: 4) treatment and 5) monitoring and follow-up. This document has received the endorsement of three Italian national societies including the SIGE, the Italian Society of Neurogastroenterology and Motility (SINGEM), and the Italian Society of Allergology, Asthma, and Clinical Immunology (SIAAIC). With regards to patients' involvement, these guidelines involved the contribution of members of ESEO Italia, the Italian Association of Families Against EoE.
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Affiliation(s)
- Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy
| | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Edda Battaglia
- Gastroenterology Unit ASLTO4, Chivasso - Ciriè - Ivrea, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia 27100, Italy; First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia 27100, Italy
| | - Paola De Angelis
- Digestive Endoscopy Unit - Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Iori
- Gastroenterology and Digestive Endoscopy Unit,' Santa Chiara' Hospital, Trento, Italy
| | - Paola Iovino
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi 84084, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia 27100, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia 27100, Italy
| | - Salvatore Oliva
- Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Italy
| | - Gaia Pellegatta
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Marcella Pesce
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | | | - Ilaria Puxeddu
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano - Milan, Italy
| | - Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Erminia Ridolo
- Allergy Unit, Department of Internal Medicine, University Hospital of Parma, Parma, Italy
| | - Salvatore Russo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliera Universitaria of Modena, Modena, Italy
| | - Giovanni Sarnelli
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Campania "Luigi Vanvitelli", Naples 80131, Italy
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, Padua 35128, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, Padua 35128, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, Padua 35128, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, Padua 35128, Italy.
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Visaggi P, Del Corso G, Baiano Svizzero F, Ghisa M, Bardelli S, Venturini A, Stefani Donati D, Barberio B, Marciano E, Bellini M, Dunn J, Wong T, de Bortoli N, Savarino EV, Zeki S. Artificial Intelligence Tools for the Diagnosis of Eosinophilic Esophagitis in Adults Reporting Dysphagia: Development, External Validation, and Software Creation for Point-of-Care Use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1008-1016.e1. [PMID: 38154556 DOI: 10.1016/j.jaip.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/23/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Despite increased awareness of eosinophilic esophagitis (EoE), the diagnostic delay has remained stable over the past 3 decades. There is a need to improve the diagnostic performance and optimize resources allocation in the setting of EoE. OBJECTIVE We developed and validated 2 point-of-care machine learning (ML) tools to predict a diagnosis of EoE before histology results during office visits. METHODS We conducted a multicenter study in 3 European tertiary referral centers for EoE. We built predictive ML models using retrospectively extracted clinical and esophagogastroduodenoscopy (EGDS) data collected from 273 EoE and 55 non-EoE dysphagia patients. We validated the models on an independent cohort of 93 consecutive patients with dysphagia undergoing EGDS with biopsies at 2 different centers. Models' performance was assessed by area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV). The models were integrated into a point-of-care software package. RESULTS The model trained on clinical data alone showed an AUC of 0.90 and a sensitivity, specificity, PPV, and NPV of 0.90, 0.75, 0.80, and 0.87, respectively, for the diagnosis of EoE in the external validation cohort. The model trained on a combination of clinical and endoscopic data showed an AUC of 0.94, and a sensitivity, specificity, PPV, and NPV of 0.94, 0.68, 0.77, and 0.91, respectively, in the external validation cohort. CONCLUSION Our software-integrated models (https://webapplicationing.shinyapps.io/PointOfCare-EoE/) can be used at point-of-care to improve the diagnostic workup of EoE and optimize resources allocation.
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Affiliation(s)
- Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy; Centre for Oesophageal Diseases, Guy's and St. Thomas Hospital, London, United Kingdom
| | - Giulio Del Corso
- Institute of Information Science and Technologies "A. Faedo", National Research Council of Italy (CNR), Pisa, Italy
| | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Serena Bardelli
- Neonatal Learning and Simulation Centre "NINA", Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Arianna Venturini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Delio Stefani Donati
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Emanuele Marciano
- Endoscopy Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Massimo Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Jason Dunn
- Centre for Oesophageal Diseases, Guy's and St. Thomas Hospital, London, United Kingdom
| | - Terry Wong
- Centre for Oesophageal Diseases, Guy's and St. Thomas Hospital, London, United Kingdom
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
| | - Edoardo V Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Sebastian Zeki
- Centre for Oesophageal Diseases, Guy's and St. Thomas Hospital, London, United Kingdom
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Barni S, Pessina B, Scarallo L, Renzo S, Pieri ES, Labriola F, Alvisi P, Villanacci V, Giovannini M, Sarti L, Tomei L, Barp J, Naldini S, Paci M, Mori F, Lionetti P. Eosinophilic esophagitis in children: Multicenter retrospective study in an Italian cohort. Clin Exp Allergy 2024; 54:225-227. [PMID: 38262705 DOI: 10.1111/cea.14455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/24/2023] [Accepted: 01/08/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Simona Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Benedetta Pessina
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Luca Scarallo
- Gastroenterology and Nutrition Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Neurofarba, University of Florence, Florence, Italy
| | - Sara Renzo
- Gastroenterology and Nutrition Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Elena Sofia Pieri
- Pediatric Clinic, Department of Medical and Surgical Science, University of Perugia, Perugia, Italy
| | - Flavio Labriola
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | | | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Jacopo Barp
- Gastroenterology and Nutrition Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Sara Naldini
- Gastroenterology and Nutrition Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Monica Paci
- Gastroenterology and Nutrition Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Paolo Lionetti
- Gastroenterology and Nutrition Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Neurofarba, University of Florence, Florence, Italy
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5
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Koop AH, Middleton J, Travers PM, Ghoz H, Francis D, DeVault KR, Pang M. Number of bottles of esophageal biopsies in the evaluation of eosinophilic esophagitis and clinical outcomes. Clin Res Hepatol Gastroenterol 2023; 47:102142. [PMID: 37263347 DOI: 10.1016/j.clinre.2023.102142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND The number of bottles of esophageal biopsies needed for the evaluation of eosinophilic esophagitis (EoE) is unclear, despite cost differences. AIMS Assess the clinical outcomes between patients with one and two bottles of esophageal biopsies for the assessment of EoE. METHODS Retrospective study of adults who underwent esophagogastroduodenoscopy (EGD) for esophageal symptoms between January 2015 and June 2021 and findings of ≥15 eosinophils per high power field (eos/hpf). Patients with one bottle (1 bottle-EoE) had biopsies from the entire or proximal esophagus. Patients with two bottles had biopsies separated from the distal and proximal esophagus and were separated into those with ≥ 15 eos/hpf in both bottles (2 bottle Dif-EoE), or the distal bottle alone (2 bottle Lim-EoE). The primary outcomes were endoscopic findings at follow-up EGD as assessed by the Eosinophilic Esophagitis Endoscopic Reference Score (EREFS) and the presence of ≥15 eos/hpf. RESULTS Of 85 patients with esophageal eosinophilia who met inclusion criteria, 49 had 2 bottle Dif-EoE, 18 had 2 bottle Lim-EoE, and 18 had 1 bottle-EoE. At median follow-up of 3.3-5.6 months, more patients with 1 bottle EoE had dysphagia (p = 0.029), however there were no differences in the EREFS (p = 0.14) or presence of ≥15 eos/hpf (p = 0.39). More patients with 2 bottle Dif-EoE were treated with topical steroids (16.3% vs. 0% vs. 0%, p = 0.039) and diet (20.4% vs. 0% vs. 5.6%, p = 0.05). CONCLUSION Endoscopic and histologic outcomes were similar in patients who had one and two bottles for esophageal biopsies in the evaluation of EoE.
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Affiliation(s)
- Andree H Koop
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA.
| | - John Middleton
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA.
| | - Paul M Travers
- Division of Community Internal Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 USA.
| | - Hassan Ghoz
- Department of Gastroenterology, University of Missouri, 2301 Holmes St 3rd Floor, Kansas City, MO 64108 USA
| | - Dawn Francis
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA.
| | - Kenneth R DeVault
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA.
| | - Maoyin Pang
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224, USA.
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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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Muroi K, Kakushima N, Furukawa K, Furune S, Ito N, Hirose T, Hida E, Suzuki T, Suzuki T, Hirai K, Shibata H, Ishikawa E, Sawada T, Maeda K, Yamamura T, Ohno E, Nakamura M, Fujishiro M, Kawashima H. Novel endoscopic approaches using the endocytoscopy for the target biopsy in esophageal eosinophilia. Esophagus 2023; 20:325-332. [PMID: 36253658 DOI: 10.1007/s10388-022-00963-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/03/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Multiple biopsies are recommended for the diagnosis of eosinophilic esophagitis (EoE) because inflammatory changes are frequently patchy. Reports on EoE using endocytoscopy (ECS) are limited. This present study aimed to assess if diagnostic yield improves by adding ECS on conventional white light imaging (WLI) in patients with esophageal eosinophilia (EE). METHODS A total of 284 biopsy specimens from 71 patients with a known diagnosis of EE were enrolled and divided into the WLI group (156 specimens) or the ECS group (128 specimens). Four biopsies from 5 and 10 cm proximal to the esophagogastric junction were taken from each patient. In the ECS group, the biopsy was performed where bilobed nuclei were observed. The biopsy sensitivity for EE, eosinophil count of a single specimen and the biopsy sensitivity of each endoscopic finding were evaluated between both groups. RESULTS The sensitivity of a single biopsy specimen was higher in the ECS group than that of the WLI group (62.5 vs. 41.7%, P < 0.001). In addition, the median eosinophil count in the ECS group was significantly higher [19 vs. 6.5/high-power field (HPF), P < 0.001]. For each endoscopic finding, ECS-based biopsy had higher sensitivity than that of WLI in the diagnosis of edema (33.1 vs. 11.3%, P = 0.007) and linear furrows (75.8 vs. 52%, P = 0.005). CONCLUSION This study showed that adding ECS to WLI improved the biopsy sensitivity and eosinophil detection in patients with EE.
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Affiliation(s)
- Koichi Muroi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
- Department of Gastroenterology, Graduate School of Medicine, Tokyo University, Tokyo, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Satoshi Furune
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Nobuhito Ito
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takashi Hirose
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Emiko Hida
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Tomohiko Suzuki
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takahiro Suzuki
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Keiko Hirai
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroyuki Shibata
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Tsunaki Sawada
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Keiko Maeda
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
- Department of Gastroenterology, Graduate School of Medicine, Tokyo University, Tokyo, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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Kinoshita Y, Yahata S, Oouchi S. Eosinophilic Gastrointestinal Diseases: The Pathogenesis, Diagnosis, and Treatment. Intern Med 2023; 62:1-10. [PMID: 34670903 PMCID: PMC9876718 DOI: 10.2169/internalmedicine.8417-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic gastrointestinal diseases are delayed-type chronic allergic disorders that show gastrointestinal eosinophil dense infiltration, with an exaggerated Th2-type immune reaction considered to be an important mechanism. These diseases can be roughly divided into two types: eosinophilic esophagitis, mainly found in young and middle-aged men, and eosinophilic gastroenteritis, which is found in both genders equally. A diagnosis of eosinophilic esophagitis is suspected when characteristic endoscopic findings, including longitudinal furrows and rings, are noted. However, characteristic endoscopic abnormalities are rarely found in cases with eosinophilic gastroenteritis, so multiple biopsy sampling from the apparently normal gastrointestinal mucosal surface is important for making an accurate diagnosis. The administration of systemic glucocorticoid is the standard treatment for eosinophilic gastroenteritis, while acid inhibitors and topical glucocorticoid swallowing therapy are effective for eosinophilic esophagitis. Anti-cytokine therapies for eosinophilic gastrointestinal diseases are currently under development.
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Affiliation(s)
- Yoshikazu Kinoshita
- Department of Medicine, Hyogo-Brain and Heart Center at Himeji, Japan
- Department of Medicine, Steel Memorial Hirohata Hospital, Japan
| | - Shinsuke Yahata
- Department of Medicine, Steel Memorial Hirohata Hospital, Japan
| | - Sachiko Oouchi
- Department of Medicine, Steel Memorial Hirohata Hospital, Japan
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Aceves SS, Alexander JA, Baron TH, Bredenoord AJ, Day L, Dellon ES, Falk GW, Furuta GT, Gonsalves N, Hirano I, Konda VJA, Lucendo AJ, Moawad F, Peterson KA, Putnam PE, Richter J, Schoepfer AM, Straumann A, McBride DL, Sharma P, Katzka DA. Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference. Gastrointest Endosc 2022; 96:576-592.e1. [PMID: 35965102 DOI: 10.1016/j.gie.2022.05.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
Endoscopy plays a critical role in caring for and evaluating the patient with eosinophilic esophagitis (EoE). Endoscopy is essential for diagnosis, assessment of response to therapy, treatment of esophageal strictures, and ongoing monitoring of patients in histologic remission. To date, less-invasive testing for identifying or grading EoE severity has not been established, whereas diagnostic endoscopy as integral to both remains the criterion standard. Therapeutic endoscopy in patients with adverse events of EoE may also be required. In particular, dilation may be essential to treat and attenuate progression of the disease in select patients to minimize further fibrosis and stricture formation. Using a modified Delphi consensus process, a group of 20 expert clinicians and investigators in EoE were assembled to provide guidance for the use of endoscopy in EoE. Through an iterative process, the group achieved consensus on 20 statements yielding comprehensive advice on tissue-sampling standards, gross assessment of disease activity, use and performance of endoscopic dilation, and monitoring of disease, despite an absence of high-quality evidence. Key areas of controversy were identified when discussions yielded an inability to reach agreement on the merit of a statement. We expect that with ongoing research, higher-quality evidence will be obtained to enable creation of a guideline for these issues. We further anticipate that forthcoming expert-generated and agreed-on statements will provide valuable practice advice on the role and use of endoscopy in patients with EoE.
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Affiliation(s)
- Seema S Aceves
- Division of Allergy, Immunology, Departments of Pediatrics and Medicine, University of California San Diego and Rady Children's Hospital, San Diego, California, USA
| | - Jeffrey A Alexander
- Departments of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Arjan J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Lukejohn Day
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Gary W Falk
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Fouad Moawad
- Scripps Health Uniformed Services, La Jolla, California, USA
| | - Kathryn A Peterson
- Division of Gastroenterology, Hepatology, and Nutrition, University of Utah Health, Salt Lake City, Utah, USA
| | - Philip E Putnam
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joel Richter
- University of South Florida Health, Tampa, Florida, USA
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausannel, Lausanne, Switzerland
| | - Alex Straumann
- Facharzt FMH fur Gastroenterologie u Innere Medizin, Olten, Switzerland
| | | | - Prateek Sharma
- Division of Gastroenterology, Hepatology, and Motility, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - David A Katzka
- Division of Gastroenterology, Columbia University Medical Center, New York, New York, USA
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10
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Wechsler JB, Bolton SM, Gray E, Kim KY, Kagalwalla AF. Defining the Patchy Landscape of Esophageal Eosinophilia in Children With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2022; 20:1971-1976.e2. [PMID: 34954340 PMCID: PMC9552248 DOI: 10.1016/j.cgh.2021.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/30/2021] [Accepted: 12/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) is a patchy disease of the esophagus with significant variability in intraepithelial eosinophilia. Three biopsies each from distal and proximal esophagus are recommended for identification of active EoE. Recent work suggests 3 biopsy sites are more optimal. We sought to evaluate 2-site vs 3-site esophageal biopsy combinations for utility to identify active EoE. METHODS We prospectively obtained 3-site esophageal biopsies based on rigorous endoscopic measurements of the proximal, mid, and distal esophagus and gastroesophageal junction. Biopsies were reviewed by a pathologist, and those with at least 15 eosinophils per high-power field were considered active EoE. The sensitivity of one or more sites to identify active EoE was determined, and endoscopic measurements were correlated to height and age. RESULTS Five hundred ninety-six endoscopies were performed in 217 patients; of these, 304 endoscopies in 167 patients had active EoE. Among the initial esophagogastroduodenoscopies with active EoE, distal biopsies had greater than 80% sensitivity, whereas mid and proximal biopsies had sensitivity of 65% and 62%, respectively, and distal + proximal biopsies had the highest diagnostic sensitivity for a 2-site combination. Among the 304 endoscopies with active EoE, 9 had focal eosinophilia restricted to the mid esophagus, and 8 were restricted to the proximal esophagus. For patients with multiple endoscopies with active EoE, nearly one fourth had reduced sites with eosinophilia at the second time point. Endoscopic measurements strongly correlated with height and age. CONCLUSIONS This study supports endoscopic measurement-guided 3-site biopsies for optimal disease assessment of active EoE in children.
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Affiliation(s)
- Joshua B Wechsler
- Northwestern University Feinberg School of Medicine, Chicago, Illinois; Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Scott M Bolton
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Elizabeth Gray
- Department of Preventive Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Kwang-Youn Kim
- Department of Preventive Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Amir F Kagalwalla
- Northwestern University Feinberg School of Medicine, Chicago, Illinois; Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; John H. Stroger Hospital of Cook County, Chicago, Illinois
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11
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Characterization of Eosinophilic Esophagitis From the European Pediatric Eosinophilic Esophagitis Registry (pEEr) of ESPGHAN. J Pediatr Gastroenterol Nutr 2022; 75:325-333. [PMID: 35706095 DOI: 10.1097/mpg.0000000000003530] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Few pediatric data on phenotypic aspects of eosinophilic esophagitis (EoE) are available. The pEEr registry was developed to prospectively characterize children with EoE from Europe and Israel. METHODS pEEr is an ongoing prospective registry enrolling children with esophageal eosinophilia (≥15 eos/HPF). Anonymized data were collected from 19 pediatric centers. Data regarding demographics, clinical manifestations, endoscopy, histology, and therapies were collected. RESULTS A total of 582 subjects (61% male) were analyzed. The median age at diagnosis was 10.5 years [interquartile range (IQR): 5.7-17.7], whereas the age at symptom onset was 9.2 years (IQR: 4.3-16.4), resulting in a median diagnostic delay of 1.2 years (IQR: 0.7-2.3). The diagnostic delay was longer below age <6 years. Shorter diagnostic delays were associated with the presence of food allergy or a family history for EoE. Symptoms varied by age with dysphagia and food impaction more common in adolescents, while vomiting and failure to thrive more common in younger children ( P < 0.001). Among endoscopic findings, esophageal rings were more common in adolescents, whereas exudates were more frequent in younger children( P < 0.001). Patients who responded to proton pump inhibitors (PPIs) were more likely to be older, males, and less often presented severe endoscopic findings. Patients unresponsive to PPIs received topical steroids (40%), elimination diet (41%), or a combined therapy (19%). CONCLUSIONS EoE findings vary according to age in pediatric EoE. Young children are commonly characterized by non-specific symptoms, atopic dermatitis, food allergy, and inflammatory endoscopic lesions. Adolescents usually have dysphagia or food impaction, fibrostenotic lesions, and a better PPI response.
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12
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Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R, Morris D, Epstein J, Novelli MR, Hunter H, Cordell A, Hall S, Hayat JO, Kapur K, Moore AR, Read C, Sami SS, Turner PJ, Trudgill NJ. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022; 71:1459-1487. [PMID: 35606089 PMCID: PMC9279848 DOI: 10.1136/gutjnl-2022-327326] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE. METHODS The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance. RESULTS Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research. CONCLUSIONS These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.
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Affiliation(s)
- Anjan Dhar
- Gastroenterology, Darlington Memorial Hospital, Darlington, UK .,Teesside University, Middlesbrough, UK
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea University, Swansea, UK,Department of Gastroenterology, University Hospital Llandough, Llandough, UK
| | | | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
| | - Jason M Dunn
- Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
| | - Rami Sweis
- Research Department of Tissue and Energy, Division of Surgery & Interventional Science, University College London, London, UK
| | - Danielle Morris
- Department of Gastroenterology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Hannah Hunter
- Department of Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Amanda Cordell
- Trustee & Chair, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sharon Hall
- Department of Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Jamal O Hayat
- Gastroenterology, St George's Healthcare NHS Trust, London, UK
| | - Kapil Kapur
- Gastroenterology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Andrew Robert Moore
- Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Carol Read
- Medical advisor/Patient advocate, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sarmed S Sami
- Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul J Turner
- National Heart and Lung Institute Section of Allergy and Clinical Immunology, London, UK,Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
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13
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An artificial intelligence algorithm is highly accurate for detecting endoscopic features of eosinophilic esophagitis. Sci Rep 2022; 12:11115. [PMID: 35778456 PMCID: PMC9249895 DOI: 10.1038/s41598-022-14605-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/09/2022] [Indexed: 11/17/2022] Open
Abstract
The endoscopic features associated with eosinophilic esophagitis (EoE) may be missed during routine endoscopy. We aimed to develop and evaluate an Artificial Intelligence (AI) algorithm for detecting and quantifying the endoscopic features of EoE in white light images, supplemented by the EoE Endoscopic Reference Score (EREFS). An AI algorithm (AI-EoE) was constructed and trained to differentiate between EoE and normal esophagus using endoscopic white light images extracted from the database of the University Hospital Augsburg. In addition to binary classification, a second algorithm was trained with specific auxiliary branches for each EREFS feature (AI-EoE-EREFS). The AI algorithms were evaluated on an external data set from the University of North Carolina, Chapel Hill (UNC), and compared with the performance of human endoscopists with varying levels of experience. The overall sensitivity, specificity, and accuracy of AI-EoE were 0.93 for all measures, while the AUC was 0.986. With additional auxiliary branches for the EREFS categories, the AI algorithm (AI-EoE-EREFS) performance improved to 0.96, 0.94, 0.95, and 0.992 for sensitivity, specificity, accuracy, and AUC, respectively. AI-EoE and AI-EoE-EREFS performed significantly better than endoscopy beginners and senior fellows on the same set of images. An AI algorithm can be trained to detect and quantify endoscopic features of EoE with excellent performance scores. The addition of the EREFS criteria improved the performance of the AI algorithm, which performed significantly better than endoscopists with a lower or medium experience level.
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14
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Miller TL, Desai AD, Garrison MM, Lee D, Muir A, Lion KC. Drivers of Variation in Diagnosis and Management of Eosinophilic Esophagitis: A Survey of Pediatric Gastroenterologists. Dig Dis Sci 2022; 67:2029-2038. [PMID: 33974186 DOI: 10.1007/s10620-021-07039-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/05/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Widespread variation in the diagnosis and treatment of eosinophilic esophagitis (EoE) has previously been reported among adult gastroenterologists; however, variation in EoE practice in among pediatric populations is poorly characterized. The study objectives were to describe guideline adherence and understand reasons for variation in EoE practice among pediatric gastroenterologists following publication of the updated 2018 international EoE guidelines. METHODS We developed and administered a 28-item survey to pediatric gastroenterologists via an email listserv using the PEDGI Bulletin Board from 03/2019 to 04/2019. The survey was developed using evidence-based review, expert validation, and cognitive interviews. Survey domains included respondent knowledge of and adherence to published guidelines, diagnostic and management approach and rationale, and participant demographics. Analysis included descriptive statistics and tests for association. RESULTS A total of 288 pediatric gastroenterologists completed the survey, most of whom practiced in an academic center (73%). More than half (63%) reported knowledge of the 2018 updated guidelines; however, only 52% agreed with them and 50% reported adherence. Respondents who reported not agreeing with updated guidelines cited concerns regarding increasing number of endoscopies (72%), misdiagnosing eosinophilia from reflux (56%), and insufficient data (23%). The most common drivers of decision making with respect to therapy choice were patient/family preference, evidence/guidelines, and symptom burden. CONCLUSIONS Many physicians are not adherent to current guidelines for reasons which include lack of knowledge of updated guidelines and concern regarding the strength of the supporting evidence. This study elucidates several areas to enhance education regarding these guidelines to promote widespread adherence.
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Affiliation(s)
- Talya L Miller
- Department of Pediatrics, University of North Carolina, 101 Manning Drive, N.C. Children's Hospital, Ground Floor, Chapel Hill, NC, 27514, USA.
| | - Arti D Desai
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, 4800 Sand Point Way NE, OB.9.620.1-Gastroenterology and Hepatology, Seattle, WA, 98105, USA
- Seattle Children's Research Institute, M/S CS8-6, 2001 Eighth Ave, PO BOX 5371, Seattle, WA, 98121, USA
| | - Michelle M Garrison
- Seattle Children's Research Institute, M/S CS8-6, 2001 Eighth Ave, PO BOX 5371, Seattle, WA, 98121, USA
- Department of Health Services, University of Washington, M/S CS8-6, 2001 Eighth Ave, PO BOX 5371, Seattle, WA, 98121, USA
| | - Dale Lee
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, 4800 Sand Point Way NE, OB.9.620.1-Gastroenterology and Hepatology, Seattle, WA, 98105, USA
| | - Amanda Muir
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - K Casey Lion
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, 4800 Sand Point Way NE, OB.9.620.1-Gastroenterology and Hepatology, Seattle, WA, 98105, USA
- Seattle Children's Research Institute, M/S CS8-6, 2001 Eighth Ave, PO BOX 5371, Seattle, WA, 98121, USA
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15
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Okimoto E, Ishimura N, Adachi K, Kinoshita Y, Ishihara S, Tada T. Application of Convolutional Neural Networks for Diagnosis of Eosinophilic Esophagitis Based on Endoscopic Imaging. J Clin Med 2022; 11:jcm11092529. [PMID: 35566653 PMCID: PMC9105792 DOI: 10.3390/jcm11092529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/17/2022] [Accepted: 04/29/2022] [Indexed: 02/04/2023] Open
Abstract
Subjective symptoms associated with eosinophilic esophagitis (EoE), such as dysphagia, are not specific, thus the endoscopic identification of suggestive EoE findings is quite important for facilitating endoscopic biopsy sampling. However, poor inter-observer agreement among endoscopists regarding diagnosis has become a complicated issue, especially with inexperienced practitioners. Therefore, we constructed a computer-assisted diagnosis (CAD) system using a convolutional neural network (CNN) and evaluated its performance as a diagnostic utility. A CNN-based CAD system was developed based on ResNet50 architecture. The CNN was trained using a total of 1192 characteristic endoscopic images of 108 patients histologically proven to be in an active phase of EoE (≥15 eosinophils per high power field) as well as 1192 normal esophagus images. To evaluate diagnostic accuracy, an independent test set of 756 endoscopic images from 35 patients with EoE and 96 subjects with a normal esophagus was examined with the constructed CNN. The CNN correctly diagnosed EoE in 94.7% using a diagnosis per image analysis, with an overall sensitivity of 90.8% and specificity of 96.6%. For each case, the CNN correctly diagnosed 37 of 39 EoE cases with overall sensitivity and specificity of 94.9% and 99.0%, respectively. These findings indicate the usefulness of CNN for diagnosing EoE, especially for aiding inexperienced endoscopists during medical check-up screening.
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Affiliation(s)
- Eiko Okimoto
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo 693-8501, Japan; (E.O.); (S.I.)
| | - Norihisa Ishimura
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo 693-8501, Japan; (E.O.); (S.I.)
- Correspondence: ; Tel.: +81-853-20-2190
| | - Kyoichi Adachi
- Health Center, Shimane Environment and Health Public Corporation, Matsue 690-0012, Japan;
| | - Yoshikazu Kinoshita
- Department of Medicine, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji 670-8560, Japan;
| | - Shunji Ishihara
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo 693-8501, Japan; (E.O.); (S.I.)
| | - Tomohiro Tada
- AI Medical Service Inc., Toshima, Tokyo 170-0013, Japan;
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16
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Kim SJ, Choi CW, Hwang CS. [Diagnosis and Treatment of Eosinophilic Esophagitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:99-108. [PMID: 35342167 DOI: 10.4166/kjg.2021.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/07/2021] [Accepted: 09/15/2021] [Indexed: 11/03/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. The diagnostic criteria for EoE have changed with our growing knowledge over the past two decades. Esophageal eosinophilia, which responds histologically to a proton pump inhibitor (PPI) is not a distinct disease but a subset of EoE. An endoscopic scoring system that relies on the assessment of exudates, rings, edema, furrows, and strictures is a useful tool for assessing endoscopic severity. PPIs are regarded as safe and effective first-line treatments for EoE. Oral topical corticosteroids or dietary therapy are also options for first-line treatment. Endoscopic dilation is effective for relieving the dysphagia symptoms of a patient with an esophageal stricture.
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Affiliation(s)
- Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheong Su Hwang
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Pathology, Pusan National University School of Medicine, Busan, Korea
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17
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Campora M, Mastracci L, Carlin L, Unti E, Parente P, Fassan M, Ferro J, Errico ME, Donofrio V, Grillo F. Pathologist's approach to paediatric and neonatal eosinophilic gastrointestinal disorders. Pathologica 2022; 114:79-88. [PMID: 35212318 PMCID: PMC9040541 DOI: 10.32074/1591-951x-734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 12/23/2021] [Indexed: 11/30/2022] Open
Abstract
Children are not simply miniature adults. The evaluation of their gastrointestinal disorders is therefore different from that in full-grown adults and requires a particular clinical/pathologic approach. Different studies have tried to assess the normal eosinophil distribution in the gastrointestinal tract in adults while very few studies have investigated the paediatric population, consequently complicating the pathologist’s ability in identifying an abnormal number of eosinophils in this setting of patients. When evaluating gastrointestinal tract biopsies with eosinophilia, eosinophilic count must be considered along with other histological features like eosinophil distribution in the gastrointestinal wall, their degranulation, cryptitis and crypt abscesses, other accompanying inflammatory cells, apoptotic bodies, foreign material or microorganisms; these findings, although rarely specific, may be a useful aid for diagnosis. Reports should not include a diagnosis of primary eosinophilic gastrointestinal disorders (EoGID) if clinical data and test results do not rule out other forms of gastrointestinal eosinophilia. A more descriptive definition like “with eosinophilic pattern” should be favoured over a specific diagnosis of “eosinophilic disorder” in order to avoid potential confusion between different entities.
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Affiliation(s)
| | - Luca Mastracci
- Anatomic Pathology, Ospedale Policlinico San Martino IRCCS, Genova, Italy.,Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
| | - Luca Carlin
- Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
| | - Elettra Unti
- Unit of Pathology, Civico-Di Cristina-Benfratelli Hospitals, Palermo, Italy
| | - Paola Parente
- Unit of Pathology, Fondazione IRCCS Casa Sollievo della Sofferenza, Viale Cappuccini 1, 71013 San Giovanni Rotondo, FG, Italy
| | - Matteo Fassan
- Department of Medicine (DIMED), Surgical Pathology & Cytopathology Unit, University of Padua, Padua, Italy.,Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Jacopo Ferro
- Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
| | - Maria Elena Errico
- Anatomia Patologica, Unit of Pathology, AORN Santobono Pausilipon, Ospedale Pausilipon, Naples, Italy
| | - Vittoria Donofrio
- Anatomia Patologica, Unit of Pathology, AORN Santobono Pausilipon, Ospedale Pausilipon, Naples, Italy
| | - Federica Grillo
- Anatomic Pathology, Ospedale Policlinico San Martino IRCCS, Genova, Italy.,Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genova, Italy
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18
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Ruffner MA, Juste L, Muir AB. Medical Management of Eosinophilic Esophagitis in Pediatric Patients. Pediatr Clin North Am 2021; 68:1191-1204. [PMID: 34736584 DOI: 10.1016/j.pcl.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis is an immune-mediated allergic disease of the esophagus that affects pediatric patients of all ages. The diagnosis is made by esophagogastroduodenoscopy demonstrating eosinophilic infiltrate of the esophagus. Approaches to treatment involve proton pump inhibitors (PPIs), swallowed topical steroid preparations, as well as dietary elimination. In this review we discuss the evidence and efficacy of each of these approaches.
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Affiliation(s)
- Melanie A Ruffner
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th and Civic Center Boulevard, Wood Building 3rd Floor, Philadelphia, PA 19104, USA
| | - Linola Juste
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Abramson Research Center 902E, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Abramson Research Center 902E, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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19
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Fernandez-Becker NQ. Eosinophilic Esophagitis: Incidence, Diagnosis, Management, and Future Directions. Gastroenterol Clin North Am 2021; 50:825-841. [PMID: 34717873 DOI: 10.1016/j.gtc.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Eosinophilic esophagitis (EoE) is an antigen-mediated esophageal disease defined by the presence of esophageal eosinophilia and symptoms of esophageal dysfunction. The pathophysiology involves an allergen-driven Th2 T cell response that triggers infiltration of eosinophils into the esophagus leading to inflammation, remodeling, and fibrosis. This results in disruption of esophageal function and accompanying symptoms - most notably dysphagia. Effective therapies target inflammation or fibrostenotic complications and include proton pump inhibitors, swallowed topical steroids, dietary exclusion, and dilation. Clinical trials testing promising biologic therapies are ongoing.
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20
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Pouw RE, Barret M, Biermann K, Bisschops R, Czakó L, Gecse KB, de Hertogh G, Hucl T, Iacucci M, Jansen M, Rutter M, Savarino E, Spaander MCW, Schmidt PT, Vieth M, Dinis-Ribeiro M, van Hooft JE. Endoscopic tissue sampling - Part 1: Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:1174-1188. [PMID: 34535035 DOI: 10.1055/a-1611-5091] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
1: ESGE recommends that, where there is a suspicion of eosinophilic esophagitis, at least six biopsies should be taken, two to four biopsies from the distal esophagus and two to four biopsies from the proximal esophagus, targeting areas with endoscopic mucosal abnormalities. Distal and proximal biopsies should be placed in separate containers.Strong recommendation, low quality of evidence. 2: ESGE recommends obtaining six biopsies, including from the base and edge of the esophageal ulcers, for histologic analysis in patients with suspected viral esophagitis.Strong recommendation, low quality of evidence. 3: ESGE recommends at least six biopsies are taken in cases of suspected advanced esophageal cancer and suspected advanced gastric cancer.Strong recommendation, moderate quality of evidence. 4: ESGE recommends taking only one to two targeted biopsies for lesions in the esophagus or stomach that are potentially amenable to endoscopic resection (Paris classification 0-I, 0-II) in order to confirm the diagnosis and not compromise subsequent endoscopic resection.Strong recommendation, low quality of evidence. 5: ESGE recommends obtaining two biopsies from the antrum and two from the corpus in patients with suspected Helicobacter pylori infection and for gastritis staging.Strong recommendation, low quality of evidence. 6: ESGE recommends biopsies from or, if endoscopically resectable, resection of gastric adenomas.Strong recommendation, moderate quality of evidence. 7: ESGE recommends fine-needle aspiration (FNA) and fine-needle biopsy (FNB) needles equally for sampling of solid pancreatic masses.Strong recommendation, high quality evidence. 8: ESGE suggests performing peroral cholangioscopy (POC) and/or endoscopic ultrasound (EUS)-guided tissue acquisition in indeterminate biliary strictures. For proximal and intrinsic strictures, POC is preferred. For distal and extrinsic strictures, EUS-guided sampling is preferred, with POC where this is not diagnostic.Weak recommendation, low quality evidence. 9: ESGE suggests obtaining possible non-neoplastic biopsies before sampling suspected malignant lesions to prevent intraluminal spread of malignant disease.Weak recommendation, low quality of evidence. 10: ESGE suggests dividing EUS-FNA material into smears (two per pass) and liquid-based cytology (LBC), or the whole of the EUS-FNA material can be processed as LBC, depending on local experience.Weak recommendation, low quality evidence.
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Cancer Center Amsterdam, Amsterdam University Medical Centers location VUmc, Amsterdam, The Netherlands
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital and University of Paris, Paris, France
| | - Katharina Biermann
- Department of Pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location AMC, Amsterdam, The Netherlands
| | - Gert de Hertogh
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Tomas Hucl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Marietta Iacucci
- Institute of Translational Medicine, Institute of Immunology and Immunotherapy and NIHR Birmingham Biomedical Research Centre, University Hospitals NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Marnix Jansen
- Department of Histopathology, University College London Hospital, London, UK
| | - Matthew Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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21
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Lehman HK, Lam W. Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2021; 41:587-598. [PMID: 34602230 DOI: 10.1016/j.iac.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis is a recently defined condition that has dramatically increased in prevalence in the last several decades. It may occur at any age, but the clinical presentation in young children is often more vague than the classic solid food dysphagia and food impacting that are the major presenting symptoms of eosinophilic esophagitis in adults and adolescents. Successful therapies exist, including medications and dietary modifications, but disease typically recurs when the intervention is discontinued.
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Affiliation(s)
- Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 1001 Main Street, Buffalo, NY 14203, USA.
| | - Weyman Lam
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 1001 Main Street, Buffalo, NY 14203, USA
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22
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Kerdsirichairat T, Shin EJ. Important Quality Metrics and Standardization in Endoscopy. Gastrointest Endosc Clin N Am 2021; 31:727-742. [PMID: 34538412 DOI: 10.1016/j.giec.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Quality metrics and standardization has become critical as the Affordable Care Act mandates that the Center for Medicare and Medicaid Services change reimbursement from volume to a value-based system. While the most commonly used quality indicators are related to that of colonoscopy, quality metrics for other procedures and endoscopy units have been developed mainly by the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy. Data to show that these quality metrics, especially in the field of advanced endoscopy as well as in the era of COVID-19 pandemic, can improve patient outcomes, are anticipated.
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Affiliation(s)
- Tossapol Kerdsirichairat
- Digestive Disease Center, Bumrungrad International Hospital, Bangkok, Thailand 33 Soi Sukhumvit 3, Wattana, Bangkok 10110 Thailand
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower, Suite 7125H, Baltimore, MD 21287, USA.
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23
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Tukan A, Biank VF. Eosinophilic Esophagitis for the General Pediatrician. Pediatr Ann 2021; 50:e325-e329. [PMID: 34398712 DOI: 10.3928/19382359-20210721-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This article reviews pediatric eosinophilic esophagitis (EoE), a clinicopathologic disorder with symptoms related to esophageal dysfunction and characterized by eosinophil-predominant inflammation present on esophageal biopsy. As part of this review, we outline the pathophysiology, clinical features, diagnostic criteria, approved treatment options, and emerging therapies of EoE. Although previously considered a rare condition, EoE has emerged primarily in Western countries, with an estimated incidence of 4 per 100,000 persons. Understanding disease manifestation, diagnosis, and treatment options are critical for primary care physicians and specialists alike as EoE presentation varies by patient age. Several treatment options are approved for first-line management and can be used interchangeably based on symptoms and patient preference. Additionally, the collaboration of gastroenterologists, allergist-immunologists, and nutritionists is recommended for a multidisciplinary approach to long-term EoE management. [Pediatr Ann. 2021;50(8):e325-e329.].
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24
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Ishimura N, Okimoto E, Shibagaki K, Nagano N, Ishihara S. Similarity and difference in the characteristics of eosinophilic esophagitis between Western countries and Japan. Dig Endosc 2021; 33:708-719. [PMID: 32623781 DOI: 10.1111/den.13786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/28/2020] [Indexed: 12/15/2022]
Abstract
Over the past two decades, the incidence and prevalence of eosinophilic esophagitis (EoE) have risen rapidly, especially in Western countries, with cases in Japan also showing a gradual increase in recent years. However, similarities and differences regarding the characteristics of EoE between Western countries and Japan remain to be clearly elucidated. The current clinical guidelines for diagnosis include symptoms related to esophageal dysfunction and dense eosinophilic infiltration in the esophageal epithelium. Most affected patients in Japan are diagnosed incidentally during a medical health check-up and asymptomatic cases with typical endoscopic findings suggestive of EoE are frequently encountered. Clinical characteristics of EoE in Japanese are similar to those seen in Western populations. The predominant symptom is dysphagia, with food impaction extremely rare in Japanese cases. Linear furrows are the most frequently reported characteristic endoscopic finding, while an esophageal stricture or narrow caliber is rarely observed. Treatment strategies for EoE include drugs, dietary restrictions, and endoscopic dilation when the disease is advanced with stricture formation. Although single therapy using a proton-pump inhibitor has been shown to achieve symptomatic and histological response in the majority of patients in Japan, no prospective randomized control studies that evaluated drug or elimination diet therapy have been presented. Overall, EoE has similar clinical characteristics between Japanese and Western populations, while disease severity seems to be milder in Japan. Additional studies are necessary to determine genetic factors, natural history of the disease, and treatment efficacy of drugs and elimination diet as compared to Western populations.
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Affiliation(s)
- Norihisa Ishimura
- Second Department of Internal Medicine, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Eiko Okimoto
- Second Department of Internal Medicine, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Kotaro Shibagaki
- Division of Gastrointestinal Endoscopy, Shimane University Hospital, Shimane, Japan
| | - Nahoko Nagano
- Department of Clinical Pathology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Shunji Ishihara
- Second Department of Internal Medicine, Faculty of Medicine, Shimane University, Shimane, Japan
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25
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Sarbinowska J, Wiatrak B, Waśko-Czopnik D. Searching for Noninvasive Predictors of the Diagnosis and Monitoring of Eosinophilic Esophagitis-The Importance of Biomarkers of the Inflammatory Reaction Involving Eosinophils. Biomolecules 2021; 11:biom11060890. [PMID: 34203871 PMCID: PMC8232675 DOI: 10.3390/biom11060890] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Invasive and costly endoscopic diagnosis is obligatory for the diagnosis and monitoring of eosinophilic esophagitis (EoE). This study aims to evaluate the usefulness of serum biomarkers involved in eosinophil-mediated inflammation in the management of EoE. Methods: A prospective cohort study was conducted in 58 patients with dysphagia. Each participant completed a health questionnaire, underwent esophagogastroduodenoscopy with esophageal biopsy for histopathological examination and assessment of total, inflammatory and fibrostenotic Eosinophilic Esophagitis Reference Score (EREFS). Serum levels of interleukin 5 (IL-5), interleukin 13 (IL-13), transforming growth factor β1 (TGF-β1), major basic protein (MBP), and eotaxin 3 were determined by enzyme immunoassays. Total of 16 patients meeting the histological criteria for EoE were treated with proton pump inhibitors for 8 weeks, and then the same diagnostics was performed again. Results: Statistically significantly higher concentrations of MBP and TGF-β1 were demonstrated in the group of patients with EoE, while MBP and eotaxin 3 correlated with the peak eosinophil count (PEC). Baseline MBP levels and eotaxin 3 after treatment significantly positively correlated with EREFS. There was a negative correlation between IL-13 and fibrostenotic EREFS. Additionally, after treatment, a negative correlation TGF-β1 was noted with the inflammatory EREFS and a positive correlation with the fibrostenotic EREFS. Conclusions: The potential role of MBP in predicting the diagnosis of EoE, eotaxin 3 in predicting the advancement and correlation of IL-13 and TGF-β1 in differentiating the inflammatory and fibrotic course of the disease may facilitate the management and individualization of EoE therapy.
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Affiliation(s)
- Joanna Sarbinowska
- Department of Gastroenterology and Hepatology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (J.S.); (D.W.-C.)
| | - Benita Wiatrak
- Department of Pharmacology, Wroclaw Medical University, Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland
- Correspondence: ; Tel.: +48-717-841-438
| | - Dorota Waśko-Czopnik
- Department of Gastroenterology and Hepatology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (J.S.); (D.W.-C.)
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26
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Wright BL, Fernandez-Becker NQ, Kambham N, Purington N, Cao S, Tupa D, Zhang W, Sindher SB, Rank MA, Kita H, Katzka DA, Shim KP, Bunning BJ, Doyle AD, Jacobsen EA, Tsai M, Boyd SD, Manohar M, Chinthrajah RS. Gastrointestinal Eosinophil Responses in a Longitudinal, Randomized Trial of Peanut Oral Immunotherapy. Clin Gastroenterol Hepatol 2021; 19:1151-1159.e14. [PMID: 32434067 PMCID: PMC8445108 DOI: 10.1016/j.cgh.2020.05.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Gastrointestinal side effects are common during oral immunotherapy (OIT) and eosinophilic esophagitis (EoE) is a potential complication. We aimed to characterize eosinophilic gastrointestinal responses to peanut OIT, in which peanut protein is given orally, with incremental increases in dose over time. METHODS Twenty adults with IgE-mediated peanut allergy were randomly assigned to groups given peanut OIT (n = 15) or placebo (n = 5); 1 additional subject withdrew before randomization. Serial gastrointestinal biopsies were collected at baseline (n = 21, 0 weeks), following dose escalation (n = 10, 52 weeks), and during the maintenance phase (n = 11, 104 weeks). Endoscopic findings were characterized using the EoE endoscopic reference score. Biopsies were assessed for eosinophils per high-power field (eos/hpf) and other pathology features using EoE histologic scoring system scores. We performed immunohistochemical analyses of eosinophil peroxidase deposition, quantified using automated image analysis. RESULTS At baseline, no subjects reported current gastrointestinal symptoms. However, 3 of the 21 subjects (14%) had esophageal peak eosinophil counts ≥15 eos/hpf and all subjects had dilated intercellular spaces (DIS). OIT induced or exacerbated esophageal eosinophilia (EE) at 52 weeks in most subjects (peak eosinophil counts >5 eos/hpf in 6 of 7 patients [86%]; peak eosinophil counts ≥15 eos/hpf in 4 of 7 patients [57%]). One subject met clinicopathologic criteria for EoE and withdrew; no significant changes in esophageal peak eosinophil counts were observed in the placebo group. EE in the OIT group corresponded with significant increases in EoE histologic scoring system scores and deposition of eosinophil peroxidase. In 4 of 6 participants (67%), OIT-induced EE and gastrointestinal eosinophilia resolved by the end of the maintenance phase. Gastrointestinal symptoms were not clearly associated with EE or gastrointestinal eosinophilia. CONCLUSIONS In this pilot study, we found that peanut OIT-induced EE and gastrointestinal eosinophilia are usually transient and are not always associated with gastrointestinal symptoms. Clinicaltrials.gov no: NCT02103270.
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Affiliation(s)
- Benjamin L. Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Division of Pulmonology, Phoenix Children’s Hospital, Phoenix, AZ, United States
| | - Nielsen Q. Fernandez-Becker
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Neeraja Kambham
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Natasha Purington
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Shu Cao
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Dana Tupa
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Wenming Zhang
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Sayantani B. Sindher
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Matthew A. Rank
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Division of Pulmonology, Phoenix Children’s Hospital, Phoenix, AZ, United States
| | - Hirohito Kita
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN. United States
| | - Kelly P. Shim
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Division of Pulmonology, Phoenix Children’s Hospital, Phoenix, AZ, United States
| | - Bryan J. Bunning
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Alfred D. Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Elizabeth A. Jacobsen
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Mindy Tsai
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Scott D. Boyd
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Monali Manohar
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - R. Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
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27
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Are biopsies always necessary in upper and lower gastrointestinal endoscopy in children? A retrospective 10-year analysis. Eur J Pediatr 2021; 180:1089-1098. [PMID: 33064219 DOI: 10.1007/s00431-020-03838-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/15/2020] [Accepted: 10/09/2020] [Indexed: 10/23/2022]
Abstract
Little attention has been given to the efficiency and validity of performing routine endoscopic biopsies in normal areas in children. This study aimed to investigate the need to perform routine biopsies in upper gastrointestinal endoscopy (UDE) and colonoscopy in normal areas by comparing macroscopy and histology. It was a 10-year retrospective analysis with the inclusion of 761 UDEs and 177 colonoscopies. Considering all segments, UDEs showed false-positive result rates of 73.11% and false-negative result rates of 14.34%. The histological results modified the initial management in 53.95% of patients. Considering all segments, colonoscopies showed false-positive result rates of 63.64% and false-negative result rates of 30.97%. The histological results modified the initial management in 34.45% of patients.Conclusion: If biopsies were obtained only in abnormal areas, the diagnosis would be lost in 53.95% of the patients in upper endoscopies and 85.7% of the colonoscopies, which justifies routine maintenance of biopsies in macroscopically normal areas in children. What is Known: • Little attention has been given to the efficiency and validity of endoscopic biopsies of normal areas during pediatric exams. • Only a few pediatric studies have correlated macroscopic and histological findings from endoscopic biopsies, and low sensitivity and specificity, as well as poor agreement, were reported. What is New: • Our study confirms the evidence that routine biopsies from macroscopically normal areas during upper and lower digestive endoscopies can lead to histopathological diagnoses and different medical management. • This is the first research on this topic in a Latin population, from a developing country, reassuring the results obtained in previous papers from other countries.
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28
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Image Analysis of Eosinophil Peroxidase Immunohistochemistry for Diagnosis of Eosinophilic Esophagitis. Dig Dis Sci 2021; 66:775-783. [PMID: 32248390 PMCID: PMC7541435 DOI: 10.1007/s10620-020-06230-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diagnosis of eosinophilic esophagitis (EoE) requires manual quantification of tissue eosinophils. Eosinophil peroxidase (EPX) is an eosinophil-specific, cytoplasmic granule protein released during degranulation. AIMS The objective of this study was to evaluate image analysis of EPX immunohistochemistry as an automated method for histologic diagnosis of EoE. METHODS We performed a secondary analysis of prospectively collected esophageal biopsies obtained from adult subjects with EoE and controls. Tissue sections were stained with hematoxylin and eosin (H&E) and evaluated for peak eosinophils per high power field (eos/hpf). The same slides were de-stained and re-stained to detect EPX for direct comparison. Slides were digitized, and EPX staining area/mm2 was quantified using image analysis. Paired samples were compared for changes in EPX staining in treatment responders and non-responders. RESULTS Thirty-eight EoE cases and 49 controls were analyzed. Among EoE subjects, matched post-treatment biopsies were available for 21 responders and 10 non-responders. Baseline EPX/mm2 was significantly increased in EoE subjects and decreased in treatment responders. EPX quantification correlated strongly with eos/hpf (r = 0.84, p < 0.0001) and identified EoE subjects with high diagnostic accuracy (AUC 0.95, p < 0.0001). The optimal diagnostic EPX-positive pixel/area threshold was 17,379 EPX/mm2. Several controls (5/49) with < 15 eos/hpf on H&E staining exceeded this cutoff. CONCLUSIONS EPX/mm2 correlates strongly with eos/hpf, accurately identifies subjects with EoE, and decreases in treatment responders. Automated quantification of intact eosinophils and their degranulation products may enhance pathologic assessment. Future studies are needed to correlate EPX/mm2 with symptoms, endoscopic findings, and esophageal distensibility.
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29
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Adorno W, Catalano A, Ehsan L, Vitzhum von Eckstaedt H, Barnes B, McGowan E, Syed S, Brown DE. Advancing Eosinophilic Esophagitis Diagnosis and Phenotype Assessment with Deep Learning Computer Vision. BIOMEDICAL ENGINEERING SYSTEMS AND TECHNOLOGIES, INTERNATIONAL JOINT CONFERENCE, BIOSTEC ... REVISED SELECTED PAPERS. BIOSTEC (CONFERENCE) 2021; 2021:44-55. [PMID: 34046649 PMCID: PMC8144887 DOI: 10.5220/0010241900440055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Eosinophilic Esophagitis (EoE) is an inflammatory esophageal disease which is increasing in prevalence. The diagnostic gold-standard involves manual review of a patient's biopsy tissue sample by a clinical pathologist for the presence of 15 or greater eosinophils within a single high-power field (400× magnification). Diagnosing EoE can be a cumbersome process with added difficulty for assessing the severity and progression of disease. We propose an automated approach for quantifying eosinophils using deep image segmentation. A U-Net model and post-processing system are applied to generate eosinophil-based statistics that can diagnose EoE as well as describe disease severity and progression. These statistics are captured in biopsies at the initial EoE diagnosis and are then compared with patient metadata: clinical and treatment phenotypes. The goal is to find linkages that could potentially guide treatment plans for new patients at their initial disease diagnosis. A deep image classification model is further applied to discover features other than eosinophils that can be used to diagnose EoE. This is the first study to utilize a deep learning computer vision approach for EoE diagnosis and to provide an automated process for tracking disease severity and progression.
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Affiliation(s)
- William Adorno
- Dept. of Engineering Systems and Environment, University of Virginia, Charlottesville, VA, U.S.A
| | - Alexis Catalano
- College of Dental Medicine, Columbia University, New York City, NY, U.S.A
- School of Medicine, University of Virginia, Charlottesville, VA, U.S.A
| | - Lubaina Ehsan
- School of Medicine, University of Virginia, Charlottesville, VA, U.S.A
| | | | - Barrett Barnes
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, U.S.A
| | - Emily McGowan
- Department of Medicine, University of Virginia, Charlottesville, VA, U.S.A
| | - Sana Syed
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, U.S.A
| | - Donald E Brown
- School of Data Science, University of Virginia, Charlottesville, VA, U.S.A
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30
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Attwood S, Epstein J. Eosinophilic oesophagitis: recent advances and practical management. Frontline Gastroenterol 2020; 12:644-649. [PMID: 34917322 PMCID: PMC8640383 DOI: 10.1136/flgastro-2019-101313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/14/2020] [Accepted: 08/15/2020] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic oesophagitis (EoE) is a disease identified just over 30 years ago. The main symptom is dysphagia. EoE is initially inflammatory and progresses to fibrosis. There are differences in clinical presentation between young children and adults. Diagnosis is by endoscopy and six biopsies at varying positions of the oesophageal lining. Blood tests are of no diagnostic value as the condition is mediated by IgG4 local mucosal pathology. Endoscopic signs are distinct from those of gastro-oesophageal reflux. Histological signs of EoE are >15 eosinophils/high-power field on a background of hyperplastic mucosa. Options of therapy include diet restriction, proton pump inhibitors therapy and topical steroids but there is a dearth of randomised control trials to define the optimum approach. The only licenced therapy for EoE is budesonide orodispersible tablet, a specific formulation for oesophageal topical steroid therapy. EoE is the most common cause of spontaneous perforation in the oesophagus. Stricture formation occurs in up to 10% and may require therapeutic dilatation.
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Affiliation(s)
| | - Jenny Epstein
- Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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31
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Lisovsky M. Inflammatory conditions of the esophagus: an update. Ann N Y Acad Sci 2020; 1481:5-10. [PMID: 32783223 DOI: 10.1111/nyas.14450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/24/2022]
Abstract
A variety of inflammatory disorders involve the esophagus. This commentary discusses the pathology of some forms of esophagitis, with an emphasis on recent developments. The initial section focuses on some common forms of nonreflux esophagitis, including lymphocytic esophagitis and eosinophilic esophagitis. Recent studies suggest that lymphocytic esophagitis may be associated with esophageal motility disorders and gastroesophageal reflux disease. Immunophenotypic features of intraepithelial lymphocytes may be helpful in distinguishing these conditions. Updates on the criteria and the limitations of histologic approach to the diagnosis of eosinophilic esophagitis are presented and new diagnostic adjuncts are discussed. In the remaining section, novel entities, such as IgG4-related esophagitis, are discussed. IgG4-related esophagitis has been recognized as a cause of esophageal lymphoplasmacytic inflammation. Increased understanding of esophageal inflammation remains an important goal that likely will lead to new approaches in the therapy of inflammatory esophageal diseases.
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Affiliation(s)
- Mikhail Lisovsky
- Department of Pathology, Dartmouth-Hitchcock Medical Center and Geisel Medical School at Dartmouth, Lebanon, New Hampshire
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32
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Fernandez-Becker NQ, Raja S, Scarpignato C, Lynch KL, Ahuja NK, Horsley-Silva JL. Eosinophilic esophagitis: updates on key unanswered questions. Ann N Y Acad Sci 2020; 1481:30-42. [PMID: 32762154 DOI: 10.1111/nyas.14421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/25/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022]
Abstract
Eosinophilic esophagitis (EoE) is a clinicopathologic disease characterized by symptoms of esophageal dysfunction and esophageal eosinophilia. In the last decade, there has been a dramatic increase in its prevalence for reasons that are not completely understood. The underlying pathophysiology involves an antigen-mediated TH 2 immune response that draws eosinophils to the esophagus, causing mucosal inflammation, esophageal remodeling, and fibrosis. This ultimately leads to esophageal dysfunction that most commonly manifests as dysphagia. In this review, we will discuss updates on key questions regarding the diagnosis and treatment of EoE.
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Affiliation(s)
| | - Shreya Raja
- Department of Medicine, Emory University, Atlanta, Georgia
| | - Carmelo Scarpignato
- Department of Health Sciences, United Campus of Malta, Msida, Malta.,Faculty of Medicine, Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Kristle L Lynch
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nitin K Ahuja
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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33
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Clarke JO, Ahuja NK, Chan WW, Gyawali CP, Horsley-Silva JL, Kamal AN, Vela MF, Xiao Y. Mucosal impedance for esophageal disease: evaluating the evidence. Ann N Y Acad Sci 2020; 1481:247-257. [PMID: 32588457 DOI: 10.1111/nyas.14414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/21/2020] [Accepted: 05/28/2020] [Indexed: 12/13/2022]
Abstract
Impedance has traditionally been employed in esophageal disease as a means to assess bolus flow and reflux episodes. Recent and ongoing research has provided new and novel applications for this technology. Measurement of esophageal mucosal impedance, via either multichannel intraluminal impedance catheters or specially designed endoscopically deployed impedance catheters, provides a marker of mucosal integrity. Mucosal impedance has been shown to segregate gastroesophageal reflux disease (GERD) and eosinophilic esophagitis from non-GERD controls and may play a role in predicting response to reflux intervention. More data are needed with regard to other esophageal subgroups, outcome studies, and functional disease. Our paper reviews the history of impedance in esophageal disease, the means of assessing baseline and mucosal impedance, data with regard to the newly developed mucosal impedance probes, the clinical utility of mucosal impedance in specific clinical conditions, and limitations in our existing knowledge, along with suggestions for future studies.
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Affiliation(s)
- John O Clarke
- Department of Medicine, Stanford University, Redwood City, California
| | - Nitin K Ahuja
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walter W Chan
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Afrin N Kamal
- Department of Medicine, Stanford University, Redwood City, California
| | - Marcelo F Vela
- Gastroenterology Division, the Mayo Clinic, Scottsdale, Arizona
| | - Yinglian Xiao
- Department of Gastroenterology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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34
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High-resolution manometry in diagnostics and evaluation of therapy effectiveness in patients with eosinophilic esophagitis - underestimated breakthrough or dead end? GASTROENTEROLOGY REVIEW 2020; 15:22-26. [PMID: 32215123 PMCID: PMC7089858 DOI: 10.5114/pg.2019.83793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 03/15/2019] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic disease with non-specific symptoms, among which dysphagia is a prevailing one. The observed increase of EoE rate, its chronic and recurrent character, as well as invasive follow-up examination (periodical panendoscopy with specimen collection for histopathology), compel optimization of both the diagnostics algorithm and disease monitoring through searching for new, unique methods and tools so far not applied, including high-resolution manometry (HRM). Mentioned investigations result from advances in comprehension of disease pathogenesis, in which it is suggested that development of a chronic inflammatory reaction of the esophageal wall may lead to consecutive fibrosis and motility disorders. In research published to date one manometric pattern characteristic for EoE was not obtained, whereas the obtained inconsistent and at times contradictory results do not correlate either with symptoms exacerbation or endoscopic scan. Numerous constraints of discussed studies as well as current knowledge in disease etiopathology and esophagus biomechanics prompt further investigation of HRM significance in diagnostics and therapy monitoring of patients with EoE.
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35
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Wright BL, Kita H. Noninvasive Diagnosis of Eosinophilic Esophagitis: The Nuclear Medicine Option. Mayo Clin Proc 2020; 95:432-434. [PMID: 32138872 PMCID: PMC7289193 DOI: 10.1016/j.mayocp.2020.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 01/26/2023]
Affiliation(s)
- Benjamin L Wright
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ; Division of Pulmonology, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ.
| | - Hirohito Kita
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ
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36
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De Matteis A, Pagliaro G, Corleto VD, Pacchiarotti C, Di Giulio E, Villa MP, Parisi P, Vassallo F, Ziparo C, Di Nardo G. Eosinophilic Esophagitis in Children: Clinical Findings and Diagnostic Approach. Curr Pediatr Rev 2020; 16:206-214. [PMID: 31584371 PMCID: PMC8193808 DOI: 10.2174/1573396315666191004110549] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/02/2019] [Accepted: 09/02/2019] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is an emerging chronic immune and antigen-mediated clinicopathologic disease. During the last 2 decades, the incidence of this condition in children has increased significantly, thanks to practitioners for creating the awareness and higher use of diagnostic endoscopy. We have analysed paediatric literature on EoE focusing on the epidemiology, pathophysiology, clinical findings and diagnostic approach. EoE is pathogenically related to a Th2 inflammation characterized by a mixed IgE and non-IgEmediated reaction to food and/or environmental agents. This leads to esophageal dysfunction and remodeling accompanied by subepithelial fibrosis. EoE can be presented with several range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or feeding refusal in infants and toddlers, as well as heartburn, dysphagia and food bolus impaction in older children and adults. The diagnostic suspicion is based on the presence of chronic symptoms of esophgeal dysfunction and esophageal eosinophilia characterised histologically by a significant eosinophilic infiltration of the oesophageal mucosa (>15 eosinophils per high powered field). In this review, we will provide an update on clinical presentation and diagnostic approach to EoE in children. We emphasized on the relevant aspects of the new clinical condition termed "PPI responsive esophageal eosinophilia", as entities distinct from EoE and the role of PPI trial in the diagnostic workup, therefore we proposed a new diagnostic algorithm.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Giovanni Di Nardo
- Address correspondence to this author at the Chair of Pediatrics, NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 - Rome, Italy; Tel: +393397267637; E-mail:
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37
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Sharma P, Parasa S, Shaheen N. Developing Quality Metrics For Upper Endoscopy. Gastroenterology 2020; 158:9-13. [PMID: 31626753 DOI: 10.1053/j.gastro.2019.09.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/21/2019] [Accepted: 09/24/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Prateek Sharma
- Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas
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38
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Kinoshita Y, Oouchi S, Fujisawa T. Eosinophilic gastrointestinal diseases - Pathogenesis, diagnosis, and treatment. Allergol Int 2019; 68:420-429. [PMID: 31000445 DOI: 10.1016/j.alit.2019.03.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic gastrointestinal diseases (EGIDs) are divided into eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE), depending on the involved gastrointestinal tract, though both are considered to be chronic Th2-type allergic diseases caused by food or environmental allergens. In development of EoE, refluxed gastric acid may also have an important role. For diagnosis of EGIDs, the presence of symptoms possibly originating from the involved gastrointestinal tract and dense eosinophil infiltration are important factors. Imaging studies, including endoscopy and computed tomography, along with histopathological examinations of biopsy specimens are useful for diagnosis, whereas laboratory testing of blood, urine, and stool samples has limited value. Three useful options for treating EoE patients are acid inhibitors, swallowed topical corticosteroids, and an elimination diet, while systemic administration of glucocorticoids is the standard treatment of EGE, though information is limited. Since the prevalence of EGIDs is increasing in Western countries as well as Japan, development of effective treatments based on sufficient evidence is becoming an urgent need.
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Abstract
Eosinophilic esophagitis is a recently defined condition that has dramatically increased in prevalence in the last several decades. It may occur at any age, but the clinical presentation in young children is often more vague than the classic solid food dysphagia and food impacting that are the major presenting symptoms of eosinophilic esophagitis in adults and adolescents. Successful therapies exist, including medications and dietary modifications, but disease typically recurs when the intervention is discontinued.
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Affiliation(s)
- Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 1001 Main Street, Buffalo, NY 14203, USA.
| | - Weyman Lam
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 1001 Main Street, Buffalo, NY 14203, USA
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40
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Cook D, Zala A, Bollipo S, Potter MDE, Walker MM, Talley NJ. Oesophageal food bolus obstruction and eosinophilic oesophagitis. Intern Med J 2019; 49:1032-1034. [PMID: 31387146 DOI: 10.1111/imj.14389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 12/22/2018] [Accepted: 01/13/2019] [Indexed: 01/08/2023]
Abstract
Eosinophilic oesophagitis (EoE) is now a well-recognised cause of dysphagia and food bolus obstruction (FBO). The diagnosis requires histologic confirmation, and the yield is greatest when at least 4 to 6 oesophageal biopsies are taken from different sites. Previous case reports of FBO have demonstrated a low biopsy rate, and as such cases of EoE may have been missed. In this review, the medical records of 123 patients aged 18 years or older, who had presented with FBO over a 2 year period, were reviewed. EoE was the most common diagnosis, and was found in 81.3% of patients with FBO aged 40 years or less. 45.5% of patients with FBO were biopsied, and of those, 33.9% were confirmed to have had at least 4 biopsies. EoE is a common cause of FBO and requires appropriate oesophageal sampling to confirm the diagnosis. Cases of EoE may otherwise be missed.
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Affiliation(s)
- Dane Cook
- Department of Gastroenterology and Endoscopy, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Australian Gastroenterology Research Alliance (AGIRA), Hunter Medical Research Institute (HMRI), Newcastle, New South Wales, Australia
| | - Alkesh Zala
- Department of Gastroenterology and Endoscopy, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Australian Gastroenterology Research Alliance (AGIRA), Hunter Medical Research Institute (HMRI), Newcastle, New South Wales, Australia
| | - Steven Bollipo
- Department of Gastroenterology and Endoscopy, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Australian Gastroenterology Research Alliance (AGIRA), Hunter Medical Research Institute (HMRI), Newcastle, New South Wales, Australia
| | - Michael D E Potter
- Department of Gastroenterology and Endoscopy, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Australian Gastroenterology Research Alliance (AGIRA), Hunter Medical Research Institute (HMRI), Newcastle, New South Wales, Australia
| | - Marjorie M Walker
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Australian Gastroenterology Research Alliance (AGIRA), Hunter Medical Research Institute (HMRI), Newcastle, New South Wales, Australia.,Department of Anatomical Pathology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Nicholas J Talley
- Department of Gastroenterology and Endoscopy, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Australian Gastroenterology Research Alliance (AGIRA), Hunter Medical Research Institute (HMRI), Newcastle, New South Wales, Australia
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41
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Radicic K, Stokes RF. Analysis of Midesophageal Biopsies Increases Sensitivity of Detection of Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2019; 17:1408-1409. [PMID: 30240892 DOI: 10.1016/j.cgh.2018.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/04/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is defined by the presence of abundant eosinophils in the squamous epithelium of the esophagus. There has been remarkable progress recently in the understanding of the pathogenesis, diagnosis, and treatment of EoE.1 Because undiagnosed EoE leads to an increase in fibrostenotic complications including strictures, timely diagnosis is critical.2.
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Affiliation(s)
- Kasey Radicic
- Department of Internal Medicine, Southwestern Endoscopy Center, Uniontown, Pennsylvania.
| | - R Fraser Stokes
- Department of Gastroenterology, Southwestern Endoscopy Center, Uniontown, Pennsylvania
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42
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Carr S, Chan ES, Watson W. Correction to: Eosinophilic esophagitis. Allergy Asthma Clin Immunol 2019; 15:22. [PMID: 31007687 PMCID: PMC6456987 DOI: 10.1186/s13223-019-0336-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an atopic condition of the esophagus that has become increasingly recognized over the last 15 years. Diagnosis of the disorder is dependent on the patient’s clinical manifestations, and must be confirmed by histologic findings on esophageal mucosal biopsies. Patients with EoE should be referred to an allergist for optimal management, which may include dietary modifications and pharmacologic agents such as proton pump inhibitors (PPI) and corticosteroids, and for the diagnosis and management of comorbid atopic conditions. Mechanical dilation of the esophagus may also be necessary. The epidemiology, pathophysiology, diagnosis, treatment, and prognosis of EoE are discussed in this review.
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Affiliation(s)
- Stuart Carr
- 1Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - Edmond S Chan
- 2Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC Canada.,3EoE Clinic, BC Children's Hospital, Vancouver, BC Canada
| | - Wade Watson
- 4Division of Allergy, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, NS Canada
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Affiliation(s)
- Stephen E Attwood
- Professor of Health Services Research, Department of Health Services Research, Durham University, Durham
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44
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Arias Á, Lucendo AJ. Molecular basis and cellular mechanisms of eosinophilic esophagitis for the clinical practice. Expert Rev Gastroenterol Hepatol 2019; 13:99-117. [PMID: 30791784 DOI: 10.1080/17474124.2019.1546120] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, allergen-driven inflammatory esophageal disease characterized by predominantly eosinophilic inflammation leading to esophageal dysfunction. Recent efforts to understand EoE have increased our knowledge of the disease. Areas covered: Multiple cells, molecules, and genes interplay with early life environmental factors in the pathophysiology of EoE to converge in the esophageal epithelium at the center of disease pathogenesis. Epithelial cells constitute a mayor cytokine source for TSLP and Calpain-14; an impaired epithelial barrier function allowing penetration of food and microbiota-derived antigens is involved in triggering and maintaining inflammation. Eosinophil and mast cell-derived products, including TGFβ, together with IL-1β and TNFα, promote epithelial mesenchymal transition in EoE, contributing to tissue remodeling by synthetizing and depositing extracellular matrix in subepithelial layers. This article aims to provide a state-of-the-art update on the pathophysiology of EoE applied to clinical practice, and latest research and developments with potential interest to improve the diagnosis and treatment of patients with EoE are revised. Expert commentary: Preliminary approaches have provided promising results toward incorporating minimally invasive methods for patient diagnosis and monitoring in clinical practice. Early diagnosis and optimized therapies will allow for personalized medicine in EoE.
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Affiliation(s)
- Ángel Arias
- a Research Unit , Hospital General La Mancha Centro , Alcázar de San Juan , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
| | - Alfredo J Lucendo
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,c Department of Gastroenterology , Hospital General de Tomelloso , Ciudad Real , Spain
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45
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Saeed A, Assiri AM, Al Asmi M, Ullah A. Trend, clinical presentations and diagnosis of eosinophilic esophagitis in Saudi children. Saudi Med J 2018; 39:668-673. [PMID: 29968888 PMCID: PMC6146256 DOI: 10.15537/smj.2018.7.22425] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Objectives: To observe the frequency of eosinophilic esophagitis (EoE), pattern of clinical presentation and diagnosis among Saudi children at 2 tertiary care hospitals in Riyadh, Saudi Arabia. Methods: The database of children admitted or seen, and aged less than 18 years over 5 years period and diagnosed with EoE was collected and reviewed. Patients with esophagitis other than EoE were excluded. Patients who had eosinophils count more than 15/high power field (HPF) on esophageal biopsies were given the diagnosis of EoE. Demographic database, clinical parameters, and diagnostic modalities were analyzed by using the Statistical Package for Social Sciences version 22. Results: A total of 37 children with the diagnosis of EoE were gathered from 398 upper gastrointestinal endoscopic procedures with the frequency of 9.3%. There were 22 (59.4%) males with a mean±SD age of 9.6±2.3 years and all were Saudi nationals. Dysphagia was the leading presentation in 21 (56.7%) children followed by vomiting in 18 (48.6%), impaction of food bolus in 8 (21.6%) and foreign body in 3 (8.1%). Allergic symptoms were present in 13 (35.1%) children in the form of asthma, 11 (29.7%) multiple food allergies and 5 (13.5%) eczema. Peripheral eosinophil count and immunoglobulin E were raised more than normal in 6 and 5 children respectively. The pH measurements were carried out in 16 (43.2%) and ruled out the reflux. Contrast studies with barium (n=6; 16.2%) and endoscopic findings were significant (n=27; 72.9%). Conclusion: Eosinophilic esophagitis is an emerging disease and have a rising trend in Saudi children. Dysphagia, vomiting, and food impaction are the more common presenting features in older children and recurrent vomiting in younger children in addition to associated allergic conditions.
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Affiliation(s)
- Anjum Saeed
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatric Medicine, College of Medicine, King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia. E-mail.
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Ma C, van Rhijn BD, Jairath V, Nguyen TM, Parker CE, Aceves SS, Furuta GT, Gupta SK, Katzka DA, Safroneeva E, Schoepfer AM, Straumann A, Spergel JM, Pai RK, Feagan BG, Hirano I, Dellon ES, Bredenoord AJ. Heterogeneity in Clinical, Endoscopic, and Histologic Outcome Measures and Placebo Response Rates in Clinical Trials of Eosinophilic Esophagitis: A Systematic Review. Clin Gastroenterol Hepatol 2018; 16:1714-1729.e3. [PMID: 29908360 DOI: 10.1016/j.cgh.2018.06.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Agents are being developed for treatment of eosinophilic esophagitis (EoE). However, it is not clear what outcome measures would best determine the efficacy and safety of these agents in clinical trials. We performed a systematic review of outcomes used in randomized placebo-controlled trials of EoE and we estimate the placebo response and rates of remission. METHODS We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and the EU Clinical Trials Register from inception through February 20, 2018 for randomized controlled trials of pharmacologic therapies for EoE. Efficacy outcome definitions, measurement tools, and the proportion of patients responding to placebo were collected and stratified by based on histologic, endoscopic, and patient-reported outcomes. RESULTS We analyzed data from 22 placebo-controlled trials, comprising 1112 patients with EoE. Ten additional active registered trials were identified. Most published trials evaluated topical corticosteroid therapy (13/22, 59.1%). Histologic outcomes measuring eosinophil density and patient-reported outcomes were reported in 21/22 published trials (95.5%). No consistently applied definitions of histologic or patient-reported response or remission were identified. Endoscopic outcomes were described in 60% (12/20) of published trials. The EoE Endoscopic Reference Score is the most commonly applied tool for describing changes in endoscopic appearance. The median histologic response to placebo was 3.7% (range, 0%-31.6%) and the median rate of remission in patients given placebo was 0.0% (range, 0%-11.0%). The median patient-reported response to placebo was 14.4% (range, 8.6%-77.8%) and rate of remission in patients given placebo was 26.2% (range, 13.2%-35.7%). CONCLUSIONS In a systematic review of the literature, we found that no standardized definitions of histologic, endoscopic, or patient-reported outcomes are used to determine whether pharmacologic agents produce a response or remission in patients with EoE. A core outcome set is needed to reduce heterogeneity in outcome reporting and facilitate trial interpretation and comparison of results from trials.
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Affiliation(s)
- Christopher Ma
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada; Robarts Clinical Trials Inc, London, Ontario, Canada
| | - Bram D van Rhijn
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vipul Jairath
- Robarts Clinical Trials Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Tran M Nguyen
- Robarts Clinical Trials Inc, London, Ontario, Canada
| | | | - Seema S Aceves
- Division of Allergy and Immunology, Department of Pediatrics, University of California San Diego, La Jolla, California; Division of Allergy and Immunology, Department of Medicine, University of California San Diego, La Jolla, California; Rady Children's Hospital San Diego, San Diego, California
| | - Glenn T Furuta
- Division of Gastroenterology, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine, Peoria, Illinois
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Alex Straumann
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Jonathan M Spergel
- Department of Pediatrics, Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rish K Pai
- Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Brian G Feagan
- Robarts Clinical Trials Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Evan S Dellon
- Center for Esophageal Disease and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands.
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47
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Abstract
Eosinophilic esophagitis (EoE) is an atopic condition of the esophagus that has become increasingly recognized over the last 15 years. Diagnosis of the disorder is dependent on the patient’s clinical manifestations, and must be confirmed by histologic findings on esophageal mucosal biopsies. Patients with EoE should be referred to an allergist for optimal management, which may include dietary modifications and pharmacologic agents such as corticosteroids, and for the diagnosis and management of comorbid atopic conditions. Mechanical dilation of the esophagus may also be necessary. The epidemiology, pathophysiology, diagnosis, treatment, and prognosis of EoE are discussed in this review.
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Hommeida S, Grothe RM, Hafed Y, Lennon RJ, Schleck CD, Alexander JA, Katzka DA, Absah I. Assessing the incidence trend and characteristics of eosinophilic esophagitis in children in Olmsted County, Minnesota. Dis Esophagus 2018; 31:5049295. [PMID: 29982568 PMCID: PMC6279968 DOI: 10.1093/dote/doy062] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Previous studies reported increased eosinophilic esophagitis (EoE) incidence in children. It is unclear whether this reported increased EoE incidence is true or due to increased recognition and diagnostic endoscopy among children. A population-based study that evaluated EoE incidence in OC, Minnesota, from 1976 to 2005 concluded that EoE incidence increased significantly over the past three 5-year intervals (from 0.35 [range: 0-0.87] per 100,000 person-years for 1991-1995 to 9.45 [range: 7.13-11.77] per 100,000 person-years for 2001-2005). The aim of this study is to assess the change of incidence and characteristics of EoE in children in the same population between 2005 and 2015 and compare the findings to those reported in the previous study. We retrospectively reviewed the electronic medical records from Olmsted Medical Center and Mayo Clinic between 2005 and 2015, using Rochester Epidemiology Project (REP) resources. All children with EoE diagnosis based on the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines were included. The incidence and characteristics of children with EoE during the study period were compared to those diagnosed between 1995 and 2005. The incidence of EoE in children adjusted for age and sex was 5.31 per 100,000 population person-years in 1995, 15.2 in 2005, and 19.2 in 2015. Change in annual incidence and seasonal variation were not significant, (P = .48) and (P = .32), respectively. Between 2005 and 2015, 73 children received an EoE diagnosis (boys 49; 67%) compared to 16 children (boys 10; 62.5) between 1995 and 2005. Mean (SD) age at diagnosis was 7.5 (5.2) and 12.8 (4.3) years, respectively. Symptoms differed by age of presentation, with vomiting the most common in children younger than 5 years (41.1% and 43.5%) and dysphagia in those older than 5 years (35.6% and 60.9%). The incidence of EoE was not increased for any specific age-group during the study period (P = .49). This study showed increased incidence of EoE in children in Olmsted County between 2005 and 2015 compared to the incidence between 1995 and 2005 (5.31 per 100,000 population person-years in 1995, 15.2 in 2005, and 19.2 in 2015). However, between 2005 and 2015, the change of incidence was not statically significant, (P = .48) despite the steady increase of EGD performed during the same time frame (64 in 2005 to 144 in 2015). By comparing children diagnosed between 2005 and 2015 to those diagnosed between 1995 and 2005, the mean age at diagnosis was younger in the former group, 7.5 versus 12.8 years. Vomiting replaced dysphagia as the most common clinical presentation. Otherwise, the presenting symptom of EoE in children remained consistent across specific age groups.
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Affiliation(s)
- S Hommeida
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA,Address correspondence to: Salim Hommeida, M.D., Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail:
| | - R M Grothe
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA,Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Y Hafed
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - R J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - C D Schleck
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - J A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - I Absah
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA,Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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Lucendo AJ, Arias Á, Molina-Infante J, Arias-González L. The role of endoscopy in eosinophilic esophagitis: from diagnosis to therapy. Expert Rev Gastroenterol Hepatol 2017; 11:1135-1149. [PMID: 28803528 DOI: 10.1080/17474124.2017.1367664] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Eosinophilic esophagitis (EoE) has arisen as a common disorder in current clinical and endoscopic gastroenterology practice. Areas covered: A comprehensive review of the literature to summarize and update different aspects related with the use of endoscopy in the diagnostic workout and treatment of pediatric and adult EoE patients is conducted. Expert commentary: Endoscopic features in EoE are frequently subtle, so were inadverted in some initial reports of the disease. Literature has described a wide number of EoE-associated features, systematized in the EREFS classification, which standardized the grade and severity of exudates, rings, edema, furrows, and strictures. The insufficient reliability of these features to predict eosinophilic inflammation still makes biopsies essential in diagnosing or monitoring EoE. EoE causes half of the food impactions requiring endoscopy; food impaction leads to EoE diagnosis in up to half of cases. Long term consequences of EoE include esophageal remodeling leading to strictures and narrowing, thus impairing symptoms and needs dilation. Recognizing the risks from dilation in EoE required carrying out a safe technique to avoid the high complication rate reported in the early literature. Endoscopic dilation should be considered in patients with esophageal narrowing and dysphagia/food impaction unresponsive to diet or drugs-based anti-inflammatory treatment.
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Affiliation(s)
- Alfredo J Lucendo
- a Department of Gastroenterology , Hospital General de Tomelloso , Tomelloso , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
| | - Ángel Arias
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,c Research Support Unit , Hospital General Mancha Centro , Alcázar de San Juan , Spain
| | - Javier Molina-Infante
- b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain.,d Department of Gastroenterology , Hospital San Pedro de Alcántara , Cáceres , Spain
| | - Laura Arias-González
- a Department of Gastroenterology , Hospital General de Tomelloso , Tomelloso , Spain.,b Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid , Spain
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Panarelli NC. Other Forms of Esophagitis: It Is Not Gastroesophageal Reflux Disease, So Now What Do I Do? Surg Pathol Clin 2017; 10:765-779. [PMID: 29103532 DOI: 10.1016/j.path.2017.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Esophagitis results from diverse causes, including gastroesophageal reflux, immune-mediated or allergic reactions, therapeutic complications, and infections. The appropriate clinical management differs in each of these situations and is often guided by pathologic interpretation of endoscopic mucosal biopsy specimens. This review summarizes the diagnostic features of unusual forms of esophagitis, including eosinophilic esophagitis, lymphocytic esophagitis, esophagitis dissecans superficialis, drug-induced esophageal injury, and bullous disorders. Differential diagnoses and distinguishing features are emphasized.
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Affiliation(s)
- Nicole C Panarelli
- Department of Pathology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10467, USA.
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