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Shaker A. Esophageal remodeling in eosinophilic esophagitis. Curr Opin Gastroenterol 2024; 40:291-298. [PMID: 38661722 PMCID: PMC11156539 DOI: 10.1097/mog.0000000000001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW Eosinophilic esophagitis (EoE) is a Th2 immune/antigen-mediated disorder characterized by esophageal dysfunction and eosinophilic inflammation. Worsening dysphagia and food impactions are significant complications associated with esophageal remodeling and fibrostenotic disease. This review highlights the most recent research findings pertaining to mechanisms of sub-epithelial fibrosis in EoE, current diagnostic tools, and therapeutic approaches. RECENT FINDINGS Recent studies leveraging publicly available single cell sequencing databases and comparative proteomics have furthered our understanding of the mechanisms mediating fibrosis. Fibroblast crosstalk with the extracellular matrix and with epithelial, endothelial, and T cells have been implicated, with the likely existence of multiple fibroblast sub-types. Accurate diagnosis of remodeling with biopsies remains a challenge due to inadequate depth of sampling. Web-based tools incorporating epithelial findings show promise in predicting subepithelial fibrosis. Impedance planimetry with esophageal distensibility measurements are increasingly utilized tools to assess fibrostenotic severity. Immunostaining and luminal captured proteins associated with remodeling show promise as potential molecular markers of fibrosis. Anti-inflammatory therapy may improve esophageal fibrosis and distensibility, although specific fibrosis-targeted therapy is lacking. SUMMARY Recent studies highlight novel mechanisms of fibrosis in EoE. Improved understanding of these mechanisms may lead to novel diagnostic strategies and therapies, and thereby inform treatment decisions.
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Affiliation(s)
- Anisa Shaker
- University of Southern California, Keck School of Medicine of USC, Department of Medicine, Division of Gastrointestinal and Liver Diseases, Swallowing and Esophageal Disorders Center, Los Angeles, California, USA
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Sorge A, Coletta M, Elli L, Bredenoord AJ. Clinical practices and adherence to guidelines for eosinophilic esophagitis: A European survey. Dig Liver Dis 2024; 56:1196-1203. [PMID: 38290961 DOI: 10.1016/j.dld.2023.12.011] [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: 09/11/2023] [Revised: 11/17/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND We aimed to assess the clinical practices and adherence to guidelines for adult Eosinophilic Esophagitis (EoE) patients in Europe. METHODS A cross-sectional web survey containing 23 questions was distributed to members of the European Consortium for Eosinophilic Diseases of the Gastrointestinal Tract (EUREOS) and the Italian Association of Hospital Gastroenterologists and digestive endoscopists (AIGO). We conducted a subgroup analysis to assess the impact of EoE expertise and practice setting on clinical practices. RESULTS 228 physicians from 18 European countries participated. Adherence to guidelines varied from 72% to 98.6%. 83.4% of total respondents obtained ≥ 6 esophageal biopsies in suspected EoE. 42% of total respondents, 82.5% of EoE experts (vs. non-experts 33%; P < 0.0001), and 55% of academics (vs. 29.1 non-academics; P < 0.0001) routinely used the EREFS score. Regarding first-line therapy, 82.9% of total respondents prescribed proton pump inhibitors, 41.6% topical steroids, 20.6% elimination diets, and 9.2% combination therapies. Only 72% of respondents used symptoms and endoscopy with <15 Eosinophils/HPF to define treatment response. 21.5% of all respondents did not prescribe maintenance therapies and 12.7% discontinued therapy before response evaluation endoscopy. CONCLUSION Our findings revealed significant heterogeneity in practice patterns and suboptimal adherence to EoE guidelines across Europe. Expertise in EoE and working in an academic hospital positively influenced clinical practices and adherence to guidelines.
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Affiliation(s)
- Andrea Sorge
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Marina Coletta
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Elli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Chehade M, Dellon ES, Spergel JM, Collins MH, Rothenberg ME, Pesek RD, Hirano I, Liu R, Laws E, Mortensen E, Martincova R, Shabbir A, McCann E, Kamal MA, Kosloski MP, Hamilton JD, Samuely C, Lim WK, Wipperman MF, Farrell A, Patel N, Yancopoulos GD, Glotfelty L, Maloney J. Dupilumab for Eosinophilic Esophagitis in Patients 1 to 11 Years of Age. N Engl J Med 2024; 390:2239-2251. [PMID: 38924731 DOI: 10.1056/nejmoa2312282] [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: 06/28/2024]
Abstract
BACKGROUND Dupilumab is a human monoclonal antibody that blocks interleukin-4 and interleukin-13 pathways and has shown efficacy in five different atopic diseases marked by type 2 inflammation, including eosinophilic esophagitis in adults and adolescents. METHODS In this phase 3 trial, we randomly assigned, in a 2:2:1:1 ratio, patients 1 to 11 years of age with active eosinophilic esophagitis who had had no response to proton-pump inhibitors to 16 weeks of a higher-exposure or lower-exposure subcutaneous dupilumab regimen or to placebo (two groups) (Part A). At the end of Part A, eligible patients in each dupilumab group continued the same regimen and those in the placebo groups were assigned to higher-exposure or lower-exposure dupilumab for 36 weeks (Part B). At each level of exposure, dupilumab was administered in one of four doses tiered according to baseline body weight. The primary end point was histologic remission (peak esophageal intraepithelial eosinophil count, ≤6 per high-power field) at week 16. Key secondary end points were tested hierarchically. RESULTS In Part A, histologic remission occurred in 25 of the 37 patients (68%) in the higher-exposure group, in 18 of the 31 patients (58%) in the lower-exposure group, and in 1 of the 34 patients (3%) in the placebo group (difference between the higher-exposure regimen and placebo, 65 percentage points [95% confidence interval {CI}, 48 to 81; P<0.001]; difference between the lower-exposure regimen and placebo, 55 percentage points [95% CI, 37 to 73; P<0.001]). The higher-exposure dupilumab regimen led to significant improvements in histologic, endoscopic, and transcriptomic measures as compared with placebo. The improvements in histologic, endoscopic, and transcriptomic measures between baseline and week 52 in all the patients were generally similar to the improvements between baseline and week 16 in the patients who received dupilumab in Part A. In Part A, the incidence of coronavirus disease 2019, nausea, injection-site pain, and headache was at least 10 percentage points higher among the patients who received dupilumab (at either dose) than among those who received placebo. Serious adverse events were reported in 3 patients who received dupilumab during Part A and in 6 patients overall during Part B. CONCLUSIONS Dupilumab resulted in histologic remission in a significantly higher percentage of children with eosinophilic esophagitis than placebo. The higher-exposure dupilumab regimen also led to improvements in measures of key secondary end points as compared with placebo. (Funded by Sanofi and Regeneron Pharmaceuticals; EoE KIDS ClinicalTrials.gov number, NCT04394351.).
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Affiliation(s)
- Mirna Chehade
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Evan S Dellon
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Jonathan M Spergel
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Margaret H Collins
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Marc E Rothenberg
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Robert D Pesek
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Ikuo Hirano
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Ruiqi Liu
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Elizabeth Laws
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Eric Mortensen
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Renata Martincova
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Arsalan Shabbir
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Eilish McCann
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Mohamed A Kamal
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Matthew P Kosloski
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Jennifer D Hamilton
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Carin Samuely
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Wei Keat Lim
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Matthew F Wipperman
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Annamaria Farrell
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Naimish Patel
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - George D Yancopoulos
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Lila Glotfelty
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Jennifer Maloney
- From the Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (R.L., E. Mortensen, A.S., E. McCann, M.A.K., M.P.K., J.D.H., C.S., W.K.L., M.F.W., A.F., G.D.Y., J.M.) - both in New York; the Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); the Division of Allergy and Immunology, Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania - both in Philadelphia (J.M.S.); the Divisions of Pathology and Laboratory Medicine (M.H.C.) and Allergy and Immunology (M.E.R.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati; the Section of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (R.D.P.); the Kenneth Griffin Esophageal Center, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago (I.H.); Sanofi, Bridgewater, NJ (E.L., L.G.); Sanofi, Prague, Czech Republic (R.M.); and Sanofi, Cambridge, MA (N.P.)
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4
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Amil-Dias J, Oliva S, Papadopoulou A, Thomson M, Gutiérrez-Junquera C, Kalach N, Orel R, Auth M, Nijenhuis-Hendriks D, Strisciuglio C, Bauraind O, Chong S, Ortega GD, Férnandez SF, Furman M, Garcia-Puig R, Gottrand F, Homan M, Huysentruyt K, Kostovski A, Otte S, Rea F, Roma E, Romano C, Tzivinikos C, Urbonas V, Velde SV, Zangen T, Zevit N. Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2024. [PMID: 38923067 DOI: 10.1002/jpn3.12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus characterized by symptoms of esophageal dysfunction and histologically by predominantly eosinophilic infiltration of the squamous epithelium. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published a guideline in 2014; however, the rapid evolution of knowledge about pathophysiology, diagnostic criteria, and therapeutic options have made an update necessary. METHODS A consensus group of pediatric gastroenterologists from the ESPGHAN Working Group on Eosinophilic Gastrointestinal Diseases (ESPGHAN EGID WG) reviewed the recent literature and proposed statements and recommendations on 28 relevant questions about EoE. A comprehensive electronic literature search was performed in MEDLINE, EMBASE, and Cochrane databases from 2014 to 2022. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of evidence and formulate recommendations. RESULTS A total of 52 statements based on the available evidence and 44 consensus-based recommendations are available. A revision of the diagnostic protocol, options for initial drug treatment, and the new concept of simplified empiric elimination diets are now available. Biologics are becoming a part of the potential armamentarium for refractory EoE, and systemic steroids may be considered as the initial treatment for esophageal strictures before esophageal dilation. The importance and assessment of quality of life and a planned transition to adult medical care are new areas addressed in this guideline. CONCLUSION Research in recent years has led to a better understanding of childhood EoE. This guideline incorporates the new findings and provides a practical guide for clinicians treating children diagnosed with EoE.
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Affiliation(s)
- Jorge Amil-Dias
- Pediatric Gastroenterology, Hospital Lusíadas, Porto, Portugal
| | - Salvatore Oliva
- Maternal and Child Health Department, University Hospital - Umberto I, Sapienza - University of Rome, Rome, Italy
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, Children's hospital Agia Sofia, University of Athens, Athens, Greece
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, International Academy for Paediatric Endoscopy Training, Sheffield Children's Hospital, UK
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro Majadahonda, Universidad Autónoma de Madrid, Spain
| | - Nicolas Kalach
- Department of Pediatrics, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University, Lille, France
| | - Rok Orel
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marcus Auth
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialized Surgery of the University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Sonny Chong
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - Gloria Dominguez Ortega
- Pediatric Gastroenterology and Nutrition Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sonia Férnandez Férnandez
- Pediatric Gastroenterology Unit, Department of Pediatrics, Severo Ochoa University Hospital, Madrid, Spain
| | - Mark Furman
- Royal Free London NHS Foundation Trust, London, UK
| | - Roger Garcia-Puig
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Pediatrics Department, Hospital Universitari MútuaTerrassa, Universitat de Barcelona, Barcelona, Spain
| | | | - Matjaz Homan
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Koen Huysentruyt
- Kindergastro-enterologie, hepatologie en nutritie, Brussels Centre for Intestinal Rehabilitation in Children (BCIRC), Belgium
| | - Aco Kostovski
- University Children's Hospital Skopje, Faculty of Medicine, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Sebastian Otte
- Childrens' Hospital, Helios Mariahilf Hospital, Hamburg, Germany
| | - Francesca Rea
- Endoscopy and Surgey Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Eleftheria Roma
- First Department of Pediatrics, University of Athens and Pediatric Gastroenterology Unit Mitera Children's Hospital, Athens, Greece
| | - Claudio Romano
- Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Christos Tzivinikos
- Paediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Dubai, UAE
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Vaidotas Urbonas
- Vilnius University Medical Faculty Clinic of Children's Diseases, Vilnius, Lithuania
| | | | - Tsili Zangen
- Pediatric Gastroenterology Unit, Wolfson Medical Center, Holon, Israel
| | - Noam Zevit
- Eosinophilic Gastrointestinal Disease Clinic, Institute of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Israel
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Laky K, Frischmeyer-Guerrerio PA. Development and dysfunction of structural cells in eosinophilic esophagitis. J Allergy Clin Immunol 2024; 153:1485-1499. [PMID: 38849184 DOI: 10.1016/j.jaci.2024.04.006] [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: 12/18/2023] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 06/09/2024]
Abstract
Eosinophilic esophagitis (EoE) is a disorder characterized by dysfunction and chronic local inflammation of the esophagus. The incidence and prevalence of EoE are increasing worldwide. The mechanisms responsible are poorly understood, and effective treatment options are limited. From the lumen outward, the esophagus comprises stratified squamous epithelium, lamina propria, and muscle. The tissue-specific nature of EoE strongly suggests that structural cells in the esophagus are involved in the EoE diathesis. Epithelial basal cell hyperplasia and dilated intercellular spaces are cardinal features of EoE. Some patients with EoE develop lamina propria fibrosis, strictures, or esophageal muscle dysmotility. Clinical symptoms of EoE are only weakly correlated with peak eosinophil count, implying that other cell types contribute to EoE pathogenesis. Epithelial, endothelial, muscle, and fibroblast cells can each initiate inflammation and repair, regulate tissue resident immune cells, recruit peripheral leukocytes, and tailor adaptive immune cell responses. A better understanding of how structural cells maintain tissue homeostasis, respond to cell-intrinsic and cell-extrinsic stressors, and exacerbate and/or resolve inflammatory responses in the esophagus is needed. This knowledge will facilitate the development of more efficacious treatment strategies for EoE that can restore homeostasis of both hematopoietic and structural elements in the esophagus.
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Affiliation(s)
- Karen Laky
- Food Allergy Research Section, Laboratory of Allergic Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Pamela A Frischmeyer-Guerrerio
- Food Allergy Research Section, Laboratory of Allergic Diseases, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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6
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Rawson R, Duong L, Tkachenko E, Chiang AWT, Okamoto K, Dohil R, Lewis NE, Kurten R, Abud EM, Aceves SS. Mechanotransduction-induced interplay between phospholamban and yes-activated protein induces smooth muscle cell hypertrophy. Mucosal Immunol 2024; 17:315-322. [PMID: 38423390 PMCID: PMC11195688 DOI: 10.1016/j.mucimm.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
The gastrointestinal system is a hollow organ affected by fibrostenotic diseases that cause volumetric compromise of the lumen via smooth muscle hypertrophy and fibrosis. Many of the driving mechanisms remain unclear. Yes-associated protein-1 (YAP) is a critical mechanosensory transcriptional regulator that mediates cell hypertrophy in response to elevated extracellular rigidity. In the type 2 inflammatory disorder, eosinophilic esophagitis (EoE), phospholamban (PLN) can induce smooth muscle cell hypertrophy. We used EoE as a disease model for understanding a mechanistic pathway in which PLN and YAP interact in response to rigid extracellular substrate to induce smooth muscle cell hypertrophy. PLN-induced YAP nuclear sequestration in a feed-forward loop caused increased cell size in response to a rigid substrate. This mechanism of rigidity sensing may have previously unappreciated clinical implications for PLN-expressing hollow systems such as the esophagus and heart.
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Affiliation(s)
- Renee Rawson
- Department of Pediatrics, University of California, San Diego, California; Division of Allergy Immunology, University of California, San Diego, California
| | - Loan Duong
- Department of Pediatrics, University of California, San Diego, California; Division of Allergy Immunology, University of California, San Diego, California
| | - Eugene Tkachenko
- Department of Pediatrics, University of California, San Diego, California; Division of Allergy Immunology, University of California, San Diego, California; Department of Medicine, University of California, San Diego, California
| | - Austin W T Chiang
- Department of Pediatrics, University of California, San Diego, California; Department of Bioengineering, University of California, San Diego, California
| | - Kevin Okamoto
- Department of Pediatrics, University of California, San Diego, California; Division of Allergy Immunology, University of California, San Diego, California
| | - Ranjan Dohil
- Department of Pediatrics, University of California, San Diego, California; Division of Gastroenterology, University of California, San Diego, California; XXX, Rady Children's Hospital, San Diego, California
| | - Nathan E Lewis
- Department of Pediatrics, University of California, San Diego, California; Department of Bioengineering, University of California, San Diego, California
| | - Richard Kurten
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital Research Institute, Little Rock, Arkansas; Department of Pediatrics, University of California, San Diego, California; Division of Allergy Immunology, University of California, San Diego, California
| | - Edsel M Abud
- Department of Pediatrics, University of California, San Diego, California; Division of Allergy Immunology, University of California, San Diego, California; XXX, Scripps Research Translational Institute, Scripps Research, San Diego, California
| | - Seema S Aceves
- Department of Pediatrics, University of California, San Diego, California; Division of Allergy Immunology, University of California, San Diego, California; XXX, Rady Children's Hospital, San Diego, California; Department of Medicine, University of California, San Diego, California.
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7
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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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8
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van Klink ML, Bredenoord AJ. Health-Related Quality of Life in Patients with Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:265-280. [PMID: 38575222 DOI: 10.1016/j.iac.2023.12.011] [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] [Indexed: 04/06/2024]
Abstract
Measuring health-related quality of life (HRQOL) gained relevance in research and clinical practice in patients with eosinophilic esophagitis. The physical discomfort and social and psychological consequences of this food-related disease substantially affect HRQOL. Determinant of an impaired HRQOL include symptom severity, disease duration, biological disease activity, and psychological factors. Patients prioritize symptom relief and improved HRQOL as treatment objectives. Available treatment options can address these goals; however, there is a suboptimal adherence to treatment. There is a need for enhanced patient guidance and education. The assessment of HRQOL will help to prioritize patient's needs in management.
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Affiliation(s)
- Maria L van Klink
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; Amsterdam UMC, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; Amsterdam UMC, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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9
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Menard-Katcher C, Aceves S. Pathophysiology and Clinical Impact of Esophageal Remodeling and Fibrosis in Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:129-143. [PMID: 38575213 DOI: 10.1016/j.iac.2023.12.002] [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] [Indexed: 04/06/2024]
Abstract
Most of the major clinical signs and consequences of eosinophilic esophagitis seem to be related to tissue remodeling. Important data on remodeling activity in patients with eosinophilic esophagitis are provided by a range of current and new biologic markers and diagnostics. To completely clarify the possible advantages and restrictions of therapeutic approaches, clinical studies should take into consideration the existence and reversibility of esophageal remodeling. The degree of mucosal or submucosal disease activity may not be reflected by epithelial eosinophilic inflammation, which is used to define one criterion of disease activity".
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Affiliation(s)
- Calies Menard-Katcher
- Departments of Pediatrics, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Digestive Health Institute, Childrens Hospital Colorado, Anschutz Medical Campus, 13123 East 16th Avenue, Aurora, CO 80045, USA.
| | - Seema Aceves
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of California, Biomedical Research Facility 2, 4A17, 3147 Biomedical Sciences Way, La Jolla, CA, USA
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10
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Biedermann L, Straumann A. Clinical Evaluation of the Adult with Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:185-196. [PMID: 38575217 DOI: 10.1016/j.iac.2023.12.006] [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] [Indexed: 04/06/2024]
Abstract
Adult patients with eosinophilic esophagitis (EoE) typically present with a history of dysphagia for solids, sometimes with additional reflux-like pain and a history of prior food impactions. In contrast to these alarming symptoms, the general appearance and physical examination of adult patients with EoE is in line with apparently healthy individuals. Therefore, the diagnosis is based on a history of solid-food dysphagia and eosinophilic tissue infiltration. Importantly, the increasing prevalence of EoE variants, that is, typical EoE symptoms in the absence of a relevant eosinophilia, and several studies with eosinophil-targeting drugs, call the pathogenic role of eosinophils into question.
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Affiliation(s)
- Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrassse 100, CH-8091 Zurich, Switzerland.
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrassse 100, CH-8091 Zurich, Switzerland
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11
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Bauer M, Nguyen N, Liacouras CA. Clinical Evaluation of the Child with Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:157-171. [PMID: 38575215 DOI: 10.1016/j.iac.2023.12.004] [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] [Indexed: 04/06/2024]
Abstract
The diagnosis of eosinophilic esophagitis (EoE) is based on clinical symptoms of esophageal dysfunction and eosinophil predominant esophageal inflammation. Clinical symptoms in children with EoE vary based on age and may be nonspecific. EoE has a male predominance with the majority having comorbid atopic disorders. At present, treatment options include medications (proton pump inhibition, swallowed topical steroids), dietary therapy or biologic therapy (dupilumab, approved for those ≥12 years of age). Outside of EoE in the context of oral immunotherapy, EoE is typically chronic requiring lifelong therapy. Long-term complications including feeding difficulties, malnutrition, and fibrostenotic disease.
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Affiliation(s)
- Maureen Bauer
- Department of Pediatric Allergy & Immunology, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA.
| | - Nathalie Nguyen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Gastrointestinal Eosinophilic Diseases Program, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA
| | - Chris A Liacouras
- Department of Gastroenterology, Hepatology and Nutrition, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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12
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Barchi A, Vespa E, Passaretti S, Dell’Anna G, Fasulo E, Yacoub MR, Albarello L, Sinagra E, Massimino L, Ungaro F, Danese S, Mandarino FV. The Dual Lens of Endoscopy and Histology in the Diagnosis and Management of Eosinophilic Gastrointestinal Disorders-A Comprehensive Review. Diagnostics (Basel) 2024; 14:858. [PMID: 38667503 PMCID: PMC11049211 DOI: 10.3390/diagnostics14080858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/13/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Eosinophilic Gastrointestinal Disorders (EGIDs) are a group of conditions characterized by abnormal eosinophil accumulation in the gastrointestinal tract. Among these EGIDs, Eosinophilic Esophagitis (EoE) is the most well documented, while less is known about Eosinophilic Gastritis (EoG), Eosinophilic Enteritis (EoN), and Eosinophilic Colitis (EoC). The role of endoscopy in EGIDs is pivotal, with applications in diagnosis, disease monitoring, and therapeutic intervention. In EoE, the endoscopic reference score (EREFS) has been shown to be accurate in raising diagnostic suspicion and effective in monitoring therapeutic responses. Additionally, endoscopic dilation is the first-line treatment for esophageal strictures. For EoG and EoN, while the literature is more limited, common endoscopic findings include erythema, nodules, and ulcerations. Histology remains the gold standard for diagnosing EGIDs, as it quantifies eosinophilic infiltration. In recent years, there have been significant advancements in the histological understanding of EoE, leading to the development of diagnostic scores and the identification of specific microscopic features associated with the disease. However, for EoG, EoN, and EoC, precise eosinophil count thresholds for diagnosis have not yet been established. This review aims to elucidate the role of endoscopy and histology in the diagnosis and management of the three main EGIDs and to analyze their strengths and limitations, their interconnection, and future research directions.
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Affiliation(s)
- Alberto Barchi
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Edoardo Vespa
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Sandro Passaretti
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Giuseppe Dell’Anna
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Ernesto Fasulo
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Mona-Rita Yacoub
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Luca Albarello
- Pathology Unit, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto S. Raffaele—G. Giglio, 90015 Cefalu, Italy;
| | - Luca Massimino
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Federica Ungaro
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Silvio Danese
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Francesco Vito Mandarino
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
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13
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Lee SY, Nahm JH, Kim MJ, Kim Y, Kim JH, Youn YH, Park H. Expression of Immunoglobulin G4 in Eosinophilic Esophagitis. J Clin Med 2024; 13:2175. [PMID: 38673448 PMCID: PMC11050440 DOI: 10.3390/jcm13082175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Eosinophilic esophagitis (EoE) is a disease that has been subcategorized into two endoscopic phenotypes: inflammatory and fibrostenotic. Moreover, studies have shown a link between EoE and immunoglobulin G4 (IgG4), a subclass of the immunoglobulin G (IgG) antibody. In this study, we aimed to evaluate the relationship between histologic IgG4 expression and endoscopic phenotypes in patients with EoE. Methods: This case-control study included patients diagnosed with EoE (n = 19) and patients with non-obstructive dysphagia without abnormal findings as controls (NOD; n = 12). The EoE group was further divided into three subgroups based on endoscopic phenotype: inflammatory, fibrostenotic, or combined. Retrospective examination of endoscopic findings and pathological slides was performed to analyze IgG4 staining. Results: Histological analysis revealed a significant difference in IgG4 cell count (15.00 vs. 0.58, p = 0.003) and eosinophil cell count (84.67 vs. 0.08, p < 0.001) between the EoE and NOD groups. Symptom manifestation and blood test results were similar across all three endoscopic EoE phenotypes. However, histological analysis revealed a significant difference in IgG4 cell count between the inflammatory, fibrostenotic, and combined phenotypes (4.13 vs. 17.6 vs. 59.7, p = 0.030). Conclusions: IgG4 expression was higher in EoE patients than in those with NOD, the highest being in the combined phenotype subgroup. These findings emphasize the important role of endoscopic and histological examination in diagnosing EoE and the need for further research in this area.
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Affiliation(s)
- See-Young Lee
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea; (S.-Y.L.); (M.-J.K.); (Y.K.); (J.-H.K.); (Y.-H.Y.)
| | - Ji-Hae Nahm
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea;
| | - Min-Jae Kim
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea; (S.-Y.L.); (M.-J.K.); (Y.K.); (J.-H.K.); (Y.-H.Y.)
| | - Yuna Kim
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea; (S.-Y.L.); (M.-J.K.); (Y.K.); (J.-H.K.); (Y.-H.Y.)
| | - Jie-Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea; (S.-Y.L.); (M.-J.K.); (Y.K.); (J.-H.K.); (Y.-H.Y.)
| | - Young-Hoon Youn
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea; (S.-Y.L.); (M.-J.K.); (Y.K.); (J.-H.K.); (Y.-H.Y.)
| | - Hyojin Park
- Division of Gastroenterology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06229, Republic of Korea; (S.-Y.L.); (M.-J.K.); (Y.K.); (J.-H.K.); (Y.-H.Y.)
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14
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Ramanan SP, Singh B, Gandhamaneni SH, Sange I. Eosinophilic Esophagitis: The Role of Steroids and the Dose, Duration, and Delivery of Steroid Therapy. Cureus 2024; 16:e58343. [PMID: 38756322 PMCID: PMC11097238 DOI: 10.7759/cureus.58343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 04/08/2024] [Indexed: 05/18/2024] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition characterized by the eosinophil infiltration of the esophagus (>15 per high power field). Recently, there has been an increase in both the incidence and prevalence of the disease. The common modalities of treatment are dietary modification, proton pump inhibitors, and steroids. However, the United States Food and Drug Administration has not approved any drugs for the treatment of EoE. This review has discussed the role of steroids in the treatment of EoE, focusing on the various formulations of the drug, its dosage, drug delivery, and duration of therapy. The study also covers the common outcomes of steroid therapy and its side effects.
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Affiliation(s)
- Sruthi Priyavadhana Ramanan
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Medicine/Surgery, Saveetha Medical College, Chennai, IND
- Internal Medicine, Henry Ford Health System, Jackson, USA
| | - Bipneet Singh
- Internal Medicine, Henry Ford Health System, Jackson, USA
| | | | - Ibrahim Sange
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Karamshibhai Jethabhai Somaiya Medical College, Hospital & Research Center, Mumbai, IND
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15
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Carlson DA, Hirano I, Gonsalves N, Kahrilas PJ, Araujo IK, Yang M, Tetreault MP, Pandolfino JE. Composite score of physiomechanical esophageal function using functional lumen imaging probe panometry in eosinophilic esophagitis. Gastrointest Endosc 2024; 99:499-510.e1. [PMID: 37890596 PMCID: PMC11090643 DOI: 10.1016/j.gie.2023.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/16/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND AND AIMS The evaluation provided by functional lumen imaging probe (FLIP) panometry includes esophageal distensibility/compliance (mechanics) of the esophageal body and esophagogastric junction (EGJ) and esophageal motility (secondary peristalsis). We developed a composite score using these parameters to characterize physiomechanical function in patients with eosinophilic esophagitis (EoE). METHODS Two hundred fifteen adult patients with EoE who completed FLIP panometry during sedated endoscopy with esophageal biopsy sampling were included. FLIP metrics of esophageal body Compliance, Contractile response, Distensibility plateau, and maximum EGJ Diameter (C2D2) were scored as 0 for normal versus 1 or 2 for increasing degree of abnormality. Scores were summed to calculate the composite C2D2 score. RESULTS The C2D2 score had a significant positive correlation with mucosal eosinophil count (ρ = .241) and total Endoscopic EoE Reference Score (ρ = .467). Among 46 patients off treatment at the baseline evaluation, future proton pump inhibitor (PPI) responders (ie, achieved mucosal eosinophil count <15 per high-powered field after PPI treatment) had lower C2D2 scores than PPI nonresponders (median, 2 [interquartile range, 1-3] vs 4 [interquartile range, 2-6], respectively; P = .003). A regression model (that controlled for age, sex, and baseline eosinophil count) showed a C2D2 score ≤3 had an odds ratio of 14.5 (95% confidence interval, 2.6-85) to predict future PPI response. However, total Endoscopic EoE Reference Scores (P = .142) and baseline eosinophil count (P = .480) did not differ between PPI responders and PPI nonresponders. CONCLUSIONS This composite score of FLIP panometry metrics, the C2D2 score, may facilitate characterizing physiomechanical function in EoE and serve as an objective outcome measure.
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Affiliation(s)
- Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ikuo Hirano
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nirmala Gonsalves
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Isis K Araujo
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Mira Yang
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Marie-Pier Tetreault
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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16
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Snyder DL, Dellon ES. Flipping the Script: Diagnostic Delay, Distensibility, and EoE Progression. Clin Gastroenterol Hepatol 2024; 22:484-485. [PMID: 37453594 DOI: 10.1016/j.cgh.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Diana L Snyder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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17
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Araujo IK, Shehata C, Hirano I, Gonsalves N, Kahrilas PJ, Tetreault MP, Schauer JM, Farina D, Peterson S, Kou W, Pandolfino JE, Carlson DA. The Severity of Reduced Esophageal Distensibility Parallels Eosinophilic Esophagitis Disease Duration. Clin Gastroenterol Hepatol 2024; 22:513-522.e1. [PMID: 37164112 PMCID: PMC10630533 DOI: 10.1016/j.cgh.2023.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/13/2023] [Accepted: 04/24/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND & AIMS Chronic inflammation of eosinophilic esophagitis (EoE) results in progressive, fibrostenotic remodeling of the esophageal wall. This study aimed to demonstrate objective changes in esophageal distensibility relative to duration of EoE disease using a functional lumen imaging probe (FLIP). METHODS Adult patients with EoE who completed a 16-cm FLIP protocol during endoscopy were evaluated in a cross-sectional study. FLIP analysis focused on distensibility plateau (DP) of the esophageal body. The time from onset of symptoms to time of endoscopy with FLIP was assessed, as was time from symptom onset to EoE diagnosis (ie, diagnostic delay). RESULTS A total of 171 patients (mean age 38 ± 12 years; 31% female) were included; the median symptom duration was 8 (interquartile range, 3-15) years and diagnostic delay was 4 (interquartile range, 1-12) years. At the time of endoscopy with FLIP, there were 54 patients (39%) in histologic remission (<15 eosinophils per high-power field [eos/hpf]). Symptom duration and diagnostic delay were negatively correlated with DP (rho = -0.326 and -0.309; P values < .001). Abnormal esophageal distensibility (DP ≤17 mm) was more prevalent with increased duration of symptoms (P < .004): 23% at <5 years to 64% at ≥25 years. When stratifying the cohort based on mucosal eosinophil density, patients with ≥15 eos/hpf had significantly lower DP with greater symptom duration (P = .004), while there was not a significant difference among patients with <15 eos/hpf (P = .060). CONCLUSIONS Esophageal distensibility objectively measured with FLIP was reduced in EoE patients with greater symptom duration and diagnostic delay. This supports that EoE is a progressive, fibrostenotic disease and that FLIP may be a useful tool to monitor disease progression in EoE.
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Affiliation(s)
- Isis K Araujo
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Gastroenterology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Cristina Shehata
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nimala Gonsalves
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Marie-Pier Tetreault
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jacob M Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Domenico Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stephanie Peterson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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18
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Awadhi SA, Miqdady M, Abuzakouk M, Yousef O, Tzivinikos C, Georgopoulos F, Carr S, Sultan A, Bitar R, Dajani AI, Taha M, Alakrad E, Jazzar A, Banama M, Bamakhrama K, Alnahdi N, Elghoudi AA, Azaz A, Gutta R, Fahmy M, Raghib B, Murad S, Abdelmallek M. Expert Recommendations on the Diagnosis of Eosinophilic Esophagitis in the United Arab Emirates. Cureus 2024; 16:e56062. [PMID: 38618346 PMCID: PMC11009821 DOI: 10.7759/cureus.56062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/16/2024] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory esophageal disease presenting as dysphagia to solid food and non-obstructive food impaction. Knowledge gaps exist in its diagnosis and management. These expert recommendations focused on the diagnosis of EoE in the United Arab Emirates. An electronic search of PubMed and Embase databases was used to gather evidence from systematic reviews, randomized controlled trials, consensus papers, and expert opinions from the last five years on the diagnosis of EoE. The evidence was graded using the Oxford system. Literature search findings were shared with the expert panel. A 5-point scale (strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree) was used, and a concordance rate of >75% among experts indicated agreement. Using a modified Delphi technique, 18 qualified experts provided 17 recommendations. Eleven statements achieved high agreement, four got moderate agreement, and two got low agreement. Challenges exist in diagnosing EoE, particularly in children. Esophageal biopsies were crucial in diagnosis, irrespective of visible mucosal changes. Further research on diagnostic tools like endoscopic mucosal impedance and biomarkers is needed. Diagnosis relies on esophageal biopsies and symptom-histology correlation; however, tools like EoE assessment questionnaires and endoscopic mucosal impedance could enhance the accuracy and efficiency of EoE diagnosis. The diagnosis of EoE is challenging since the symptoms seldom correlate with the histological findings. Currently, diagnosis is based on patient symptoms and endoscopic and histological findings. Further research into mucosal impedance tests and the role of biomarkers is needed to facilitate diagnosis.
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Affiliation(s)
- Sameer Al Awadhi
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | - Mohamad Miqdady
- Pediatric Gastroenterology, Hepatology, and Nutrition, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, ARE
- Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, ARE
| | - Mohamed Abuzakouk
- Allergy and Immunology, Respiratory Institute, Cleveland Clinic, Abu Dhabi, ARE
| | - Osama Yousef
- Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, ARE
| | - Christos Tzivinikos
- Pediatric Gastroenterology, Al Jalila Children's Speciality Hospital, Dubai, ARE
- Pediatric Gastroenterology, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, ARE
| | | | - Stuart Carr
- Immunology and Allergy, Snö Clinics, Abu Dhabi, ARE
| | - Ahmed Sultan
- Gastroenterology and Hepatology, Mediclinic Airport Road Hospital, Abu Dhabi, ARE
| | - Rana Bitar
- Pediatric Gastroenterology, Hepatology, and Nutrition, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, ARE
- Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, ARE
| | | | - Mazen Taha
- Gastroenterology and Hepatology, Tawam Hospital, Abu Dhabi, ARE
| | - Eyad Alakrad
- Gastroenterology and Hepatology, Sheikh Shakhbout Medical City, Abu Dhabi, ARE
| | - Ahmad Jazzar
- Gastroenterology and Hepatology, Burjeel Day Surgery Center, Abu Dhabi, ARE
| | - Mohammed Banama
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | - Khaled Bamakhrama
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | - Nawal Alnahdi
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | | | - Amer Azaz
- Pediatric Gastroenterology, Hepatology, and Nutrition, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, ARE
- Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, ARE
| | - Ravi Gutta
- Immunology, Mediclinic City Hospital, Dubai, ARE
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19
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Muir AB, Karakasheva TA, Whelan KA. Epithelial-Fibroblast Crosstalk in Eosinophilic Esophagitis. Cell Mol Gastroenterol Hepatol 2024; 17:713-718. [PMID: 38316214 PMCID: PMC10957450 DOI: 10.1016/j.jcmgh.2024.01.020] [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: 11/10/2023] [Revised: 01/24/2024] [Accepted: 01/24/2024] [Indexed: 02/07/2024]
Abstract
Eosinophilic esophagitis (EoE) is an emerging form of food allergy that exerts a significant clinical and financial burden worldwide. EoE is clinically characterized by eosinophil-rich inflammatory infiltrates in esophageal mucosa and esophageal dysfunction. Remodeling events in esophageal epithelium and lamina propria also frequently occur in patients with EoE. Because subepithelial fibrosis is associated with esophageal stricture, the most severe consequence of EoE, there exists an urgent need for a deeper understanding of the molecular mechanisms mediating fibrosis in EoE. Here, we review emerging evidence from experimental model systems that implicates crosstalk between esophageal epithelial cells and underlying stromal cells in EoE fibrosis. We further discuss implications for epithelial-stromal interaction with regard to EoE patient care and propose future directions that may be pursued to further the understanding of epithelial-stromal crosstalk in EoE pathobiology.
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Affiliation(s)
- Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Tatiana A Karakasheva
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelly A Whelan
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania; Department of Cancer & Cellular Biology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania.
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20
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Jones SM, Anvari S, Coleman A, Pesek RD, Kloepfer KM, Perry TT, Jefferson AA, Doan D, Andres A, Doderer M, Hilbun A, Solomon R, Scurlock AM. Food insecurity and allergic diseases: A call to collective action. J Allergy Clin Immunol 2024; 153:359-367. [PMID: 37926122 DOI: 10.1016/j.jaci.2023.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/13/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
Food security encompassess the concept of access by all people at all times to enough food for an active, healthy life. Conversely, food insecurity (FI) refers to household-level economic and social conditions of limited or uncertain access to adequate food. FI is a key social determinant of health that can negatively affect nutrition and health outcomes, as it is estimated that 10.2% of the US population meets criteria for FI. Recognizing the impact of FI on our patients and families is critical to promote health equity and optimize health outcomes. This review focuses on FI and allergic disease from the perspective of key multisector stakeholders within the field of allergy and immunology as well as from the larger health care arena, highlighting key resources and initiatives important to patients. Collectively, as specialists in allergy and immunology, and within the medical field more broadly, we must leverage our unique roles as we interface with patients and families and serve as committed advocates for change. Developing innovative strategies to promote health equity can provide a pathway forward for all children, adults, and families to gain access to healthy, nutritious food as part of their routine lifestyle. This is a call to action.
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Affiliation(s)
- Stacie M Jones
- University of Arkansas for Medical Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark.
| | - Sara Anvari
- Baylor College of Medicine and Texas Children's Hospital, Houston, Tex
| | - Amaziah Coleman
- National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Robert D Pesek
- University of Arkansas for Medical Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark
| | - Kirsten M Kloepfer
- Indiana University School of Medicine and Riley Children's Hospital at IU Health, Indianapolis, Ind
| | - Tamara T Perry
- University of Arkansas for Medical Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark
| | - Akilah A Jefferson
- University of Arkansas for Medical Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark
| | - Dieu Doan
- University of Arkansas for Medical Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark
| | - Aline Andres
- University of Arkansas for Medical Sciences, Little Rock, Ark; Arkansas Children's Nutrition Center, Little Rock, Ark
| | - Marcy Doderer
- Arkansas Children's Hospital, Little Rock, Ark; Arkansas Children's Health System, Little Rock, Ark
| | - Ashlie Hilbun
- Arkansas Children's Hospital, Little Rock, Ark; Arkansas Children's Health System, Little Rock, Ark
| | - Ryan Solomon
- Arkansas Children's Hospital, Little Rock, Ark; Arkansas Children's Health System, Little Rock, Ark
| | - Amy M Scurlock
- University of Arkansas for Medical Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark
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21
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Chehade M, McGowan EC, Wright BL, Muir AB, Klion AD, Furuta GT, Jensen ET, Bailey DD. Barriers to Timely Diagnosis of Eosinophilic Gastrointestinal Diseases. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:302-308. [PMID: 38110118 PMCID: PMC10988285 DOI: 10.1016/j.jaip.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023]
Abstract
Although eosinophilic gastrointestinal diseases, including eosinophilic esophagitis, have been described over the past 2 to 3 decades, barriers to diagnosis and treatment are common and compounded by issues related to social determinants of health, race, ethnicity, and access to care. These barriers contribute to delays in diagnosis, resulting in persistent inflammation in the gastrointestinal tract, which can have significant consequences, including fibrostenotic complications in adults, failure to thrive in children, and decreased quality of life in all affected patients. In this commentary, we summarize gaps in knowledge regarding the epidemiology of eosinophilic gastrointestinal diseases, highlight barriers to diagnosis, discuss potential approaches based on best practices in other atopic and chronic gastrointestinal diseases, and provide recommendations for reducing barriers to timely diagnosis of eosinophilic gastrointestinal diseases in underserved populations.
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Affiliation(s)
- Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Departments of Pediatrics and Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville, Va
| | - Benjamin L Wright
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ; Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ
| | - Amanda B Muir
- Department of Pediatrics, Division of Gastroenterology, the Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Amy D Klion
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo; Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colo
| | - Elizabeth T Jensen
- Departments of Epidemiology and Prevention and Internal Medicine, Gastroenterology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Dominique D Bailey
- Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
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22
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Muftah M, Bernstein D, Patel A. Eosinophilic Esophagitis: Lessons Learned from Its Evolution. Dig Dis Sci 2024; 69:318-319. [PMID: 37968558 DOI: 10.1007/s10620-023-08166-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/18/2023] [Indexed: 11/17/2023]
Affiliation(s)
- Mayssan Muftah
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Daniel Bernstein
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA
| | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, DUMC Box 3913, Durham, NC, 27710, USA.
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23
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Massironi S, Elvevi A, Panceri R, Mulinacci G, Colella G, Biondi A, Invernizzi P, Danese S, Vespa E. Eosinophilic esophagitis: does age matter? Expert Rev Clin Immunol 2024; 20:211-223. [PMID: 37870118 DOI: 10.1080/1744666x.2023.2274940] [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: 07/22/2023] [Accepted: 10/20/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus with increasing prevalence worldwide. It is a multifactorial disease caused by a combination of immunologic, genetic, and environmental factors. The clinical presentation of EoE varies largely, especially between different age groups. While diagnostic criteria and therapeutic goals are similar in children and adults, there are differences in treatment, with a more cautious approach in children to avoid growth disturbances. In addition, close monitoring and follow-up are essential in children to ensure uninterrupted growth. AREAS COVERED A search in PubMed/MEDLINE, EMBASE, and SCOPUS databases was conducted to identify relevant studies published between January 2010 and January 2023 to give an overview of the state-of-the-art of EoE epidemiology, diagnosis, and treatment while focusing on similarities and differences between the adult and the pediatric population. EXPERT OPINION The current state of research indicates that while significant progress has been made in understanding and treating EoE, further research and advances are needed to optimize diagnostic strategies, tailored treatment approaches, monitoring, and follow-up, and improve long-term outcomes for patients. With further innovation, the management of EoE can become more precise and tailored, leading to better patient outcomes and improved quality of life.
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Affiliation(s)
- Sara Massironi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Alessandra Elvevi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Roberto Panceri
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Giacomo Mulinacci
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giacomo Colella
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Andrea Biondi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Pietro Invernizzi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy, and Vita-Salute, San Raffaele University, Milan, Italy
| | - Edoardo Vespa
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy, and Vita-Salute, San Raffaele University, Milan, Italy
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24
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Kiran A, Cameron BA, Xue Z, LaFata S, Ocampo AA, McCallen J, Lee CJ, Borinsky SA, Redd WD, Cotton CC, Eluri S, Reed CC, Dellon ES. Increasing Age at the Time of Diagnosis and Evolving Phenotypes of Eosinophilic Esophagitis Over 20 Years. Dig Dis Sci 2024; 69:521-527. [PMID: 37968556 DOI: 10.1007/s10620-023-08165-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/18/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND The presentation of eosinophilic esophagitis (EoE) is heterogeneous, but trends over time are not known. AIM To determine whether clinical and endoscopic phenotypes at EoE diagnosis have changed over the past 2 decades. METHODS In this retrospective cohort study, adults and children with newly diagnosed EoE were phenotyped as follows: (1) inflammatory vs fibrostenotic vs mixed on endoscopy; (2) atopic vs non-atopic; (3) age at symptom onset; (4) age at diagnosis; (5) presence of autoimmune or connective tissue disease; and (6) responsive to steroids. The prevalence of different phenotypes was categorized by 5-year intervals. Multivariate analysis was performed to assess for changes in patient features over time. RESULTS Of 1187 EoE patients, age at diagnosis increased over time (from 22.0 years in 2002-2006 to 31.8 years in 2017-2021; p < 0.001) as did the frequency of dysphagia (67% to 92%; p < 0.001). Endoscopic phenotypes were increasingly mixed (26% vs 68%; p < 0.001) and an increasing proportion of patients had later onset of EoE. However, there were no significant trends for concomitant autoimmune/connective tissue disease or steroid responder phenotypes. On multivariate analysis, after accounting for age, dysphagia, and food impaction, the increase in the mixed endoscopic phenotype persisted (aOR 1.51 per each 5-year interval, 95% CI 1.31-1.73). CONCLUSION EoE phenotypes have changed over the past two decades, with increasing age at diagnosis and age at symptom onset. The mixed endoscopic phenotype also increased, even after controlling for age and symptomatology. Whether this reflects changes in provider recognition or disease pathophysiology is yet to be elucidated.
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Affiliation(s)
- Akshatha Kiran
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Brenderia A Cameron
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Zeyun Xue
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sean LaFata
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Adolfo A Ocampo
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Justin McCallen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Christopher J Lee
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Stephanie A Borinsky
- Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Walker D Redd
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Cary C Cotton
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Swathi Eluri
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Craig C Reed
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, CB#7080 Bioinformatics Building, 130 Mason Farm Rd., UNC-CH, Chapel Hill, NC, 27599-7080, USA.
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25
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Lee CJ, Dellon ES. Real-World Efficacy of Dupilumab in Severe, Treatment-Refractory, and Fibrostenotic Patients With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2024; 22:252-258. [PMID: 37660770 DOI: 10.1016/j.cgh.2023.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/22/2023] [Accepted: 08/10/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND & AIMS Dupilumab is approved for treatment of eosinophilic esophagitis (EoE), but real-world data are lacking. We aimed to determine the real-world efficacy of dupilumab in patients with severe, treatment-refractory, and fibrostenotic EoE. METHODS We conducted a retrospective cohort study of EoE patients prescribed dupilumab and who were treatment-refractory to standard modalities. Patient demographics, clinical characteristics, EoE history, and procedural data (including the histologically worst, predupilumab, and postdupilumab endoscopies) were extracted from medical records. Symptomatic, endoscopic, and histologic responses were assessed for the worst and predupilumab endoscopies compared with the postdupilumab endoscopy. RESULTS We identified 46 patients with refractory fibrostenotic EoE who were treated with dupilumab. Patients showed endoscopic, histologic, and symptomatic improvement on dupilumab compared with both the worst and the predupilumab esophagogastroduodenoscopies. The peak eosinophil counts decreased markedly, and postdupilumab histologic response rates were 80% and 57% for fewer than 15 eosinophils per high-power field and 6 or fewer eosinophils per high-power field, respectively, and the Endoscopic Reference Score decreased from 5.01 to 1.89 (P < .001 for all). Although the proportion of strictures was stable, there was a significant increase in the predilation esophageal diameter (from 13.9 to 16.0 mm; P < .001). Global symptom improvement was reported in 91% (P < .001). CONCLUSIONS In this population of severe, refractory, and fibrostenotic EoE patients, most achieved histologic, endoscopic, and symptom improvement with a median of 6 months of dupilumab, and esophageal stricture diameter improved. Dupilumab has real-world efficacy for a severe EoE population, most of whom would not have qualified for prior clinical trials.
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Affiliation(s)
- Christopher J Lee
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
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Ishii A, Shibata T, Tsunoda Y, Kayukawa T, Kobayashi M, Orinaka M, Miyamatsu S, Ryuge Y, Asano S, Tanaka I. Benralizumab treatment in an elderly patient with eosinophilic esophagitis resulted in remission: a case report. BMC Geriatr 2024; 24:92. [PMID: 38267847 PMCID: PMC10809539 DOI: 10.1186/s12877-024-04683-1] [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: 06/23/2023] [Accepted: 01/08/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Interleukin-5 (IL-5) has recently been shown to play a crucial role in eosinophil-mediated diseases, implying that an IL-5 receptor alpha chain (IL-5Rα) antibody (benralizumab) can be effective against eosinophilic esophagitis (EoE). Here, we present a case in which benralizumab significantly improved the symptoms and signs of an elderly Asian woman with EoE who had inadequate response to existing treatments. Case presentation A 73-year-old woman with an 8-year history of bronchial asthma (BA) and a 7-year history of dysphagia presented to our hospital with worsening dysphagia, vomiting, chest pain, and difficulty in eating. Blood biochemical findings revealed an increase in the eosinophil fraction of white blood cells (42.2%), and a conventional chest computed tomography scan revealed esophageal wall thickening. An upper gastrointestinal endoscopy revealed mucosal edema as well as multiple esophageal rings, and esophageal biopsy specimens showed an eosinophilic infiltrate of more than 15 cells/ high power field. Based on these findings, she was diagnosed as EoE complicated by BA. We firstly administrated 20 mg/day of prednisolone, rabeprazole sodium and liquid budesonide oral suspension for 5 months; however, they were ineffective and her dysphagia worsened over time. Then, benralizumab treatment in combination with these drugs was started. Her dysphagia completely disappeared 2 weeks after starting benralizumab, and an upper endoscopy showed that the clinical findings had completely disappeared after another 6 weeks. Benralizumab was then given to her for 41 months, and her symptoms remained in remission. In addition, she had no EoE recurrence for more than 12 months after discontinuing benralizumab. CONCLUSIONS Benralizumab in combination with other multiple drugs significantly improved the symptoms and examination findings of an elderly patients with EoE. Furthermore, she experienced no recurrence even after discontinuing benralizumab withdrawal, suggesting that benralizumab could be an appropriate therapeutic option for EoE.
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Affiliation(s)
- Azusa Ishii
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Tomofumi Shibata
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Yohei Tsunoda
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Takafumi Kayukawa
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Masahiro Kobayashi
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Masami Orinaka
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Shoko Miyamatsu
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Yoshio Ryuge
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Shuichi Asano
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Ichidai Tanaka
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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27
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Terkelsen JH, Hollænder M, Bredal K, Nielsen SM, Thomsen KVK, Baggerman A, Ofverlind E, Koc AM, Pakes H, Mahdi MB, Larsen SØ, Gonzalez VP, Riis J, Frandsen LT, Melgaard D, Krarup AL. A retrospective cohort study on oesophageal food bolus obstruction in the North Denmark region in 2021-two thirds were never diagnosed with a cause. BMC Gastroenterol 2024; 24:3. [PMID: 38166672 PMCID: PMC10759704 DOI: 10.1186/s12876-023-03077-8] [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: 06/19/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Food bolus obstruction (FBO) leading to hospital treatment is often associated with eosinophilic oesophagitis (EoE), stenosis, or oesophageal cancer (1). Danish national guidelines recommend that patients with FBO undergo a diagnostic upper endoscopy within two weeks of presentation to exclude possible malignancy, and histological evaluation of eight biopsies (2, 3). AIMS The aims of this study were to (1) report the incidence and describe the causes and treatment of FBO in the North Denmark Region (NDR), (2) determine the proportion of patients who underwent upper endoscopy and biopsy according to regional and national guidelines, and (3) identify International Classification of Diseases 10th Revision (ICD-10) diagnosis and procedure codes applied to the hospital visits due to FBO in the NDR. METHODS Among all acute hospital visits in the NDR in 2021, all visits with ICD-10 codes possibly reflecting FBO, as well as a random sample of 14,400 visits with unspecific ICD-10 codes (R and Z codes), were screened manually for possible FBO. Diagnosis, follow-up, and treatment of all patients with FBO were recorded. RESULTS The median patient age was 66.0 (Q1-Q3: 49.8-81.0) years, and half of the patients had experienced FBO before. Two thirds of patients (66.0%) were never diagnosed with a cause of FBO, followed by 17.3% with EoE. 30% of patients did not undergo upper endoscopy within two weeks of the hospital visit, and 50.7% were never biopsied in the oesophagus. Of 1886 hospital visits with registry ICD-10 codes that possibly reflected FBO, 8.4% were due to FBO, while FBO was present in 0.028% of the random sample of unspecific ICD-10 codes. CONCLUSIONS Most hospitalized FBO patients in the NDR in 2021 were never diagnosed with a cause. In these patients there is a high risk of overlooked EoE or upper gastrointestinal cancers. The area needs immediate focus and changed routines to improve treatment and prevent new FBO.
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Affiliation(s)
| | - Martin Hollænder
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Kasper Bredal
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | | | - Kristoffer Vittrup Koed Thomsen
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Amanda Baggerman
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Emilia Ofverlind
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Alptug Mertcan Koc
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Hannah Pakes
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Marco Bassam Mahdi
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Sanne Ørnfeldt Larsen
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Vanessa Parra Gonzalez
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Johannes Riis
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Line Tegtmeier Frandsen
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
- Department of Gastroenterology, North Denmark Regional Hospital, Hjørring, Denmark
| | - Dorte Melgaard
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Lund Krarup
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark.
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.
- Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Casabona Francés S, Ruiz de León San Juan A, Sanz García A, Ortega Rabbione GJ, Majano P, Pérez Fernández MT, Lucendo AJ, Santander C. Esophageal biomechanics assessed by impedance planimetry (EndoFLIPTM) in healthy subjects and in patients with eosinophilic esophagitis. Normality values. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:693-699. [PMID: 37449498 DOI: 10.17235/reed.2023.9560/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND active eosinophilic esophagitis is associated with esophageal caliber, distensibility and motility changes that may be reversed with treatment. OBJECTIVES to study esophageal diameter, distensibility and contractility in healthy subjects compared to patients with eosinophilic esophagitis, both before and after treatment. METHODS a quasi-experimental study, EndoFLIP™, was used to analyze the esophageal body and esophago-gastric junction (EGJ) in all three groups, and a program was designed to obtain esophageal diameter, distensibility and contractility values. RESULTS ten healthy volunteers (24-61 years, six men) and nine patients with eosinophilic esophagitis (21-52 years, seven men) were included. The esophagogastric junction distensibility index was 5.07 mm2/Hg in the control subjects, 2.40 mm2/Hg in the subjects with eosinophilic esophagitis before treatment and 2.46 mm2/Hg after treatment. The distensibility plateau was 20.02 mm, 15.43 mm and 17.41 mm, respectively, and the diameter was 21.90 mm, 17.73 mm and 18.30 mm, showing significant differences (p < 0.05), except between control subjects and patients after treatment (p = 0.079). Repetitive antegrade contractions developed in 90 % of control subjects, 66.7 % of eosinophilic esophagitis patients before treatment and 88.9 % of the latter after treatment (p > 0.05). CONCLUSIONS esophago-gastric junction distensibility index, distensibility plateau and diameter values were higher in controls than in patients, although six weeks of treatment seems a short period to observe significant changes in esophageal biomechanics. Repetitive antegrade contractions are the predominant pattern in healthy subjects and eosinophilic esophagitis. We provide normality values for esophageal biomechanics, measured by impedance planimetry in our setting.
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Affiliation(s)
| | | | - Ancor Sanz García
- Unidad de Análisis de Datos, Instituto de Investigación Sanitaria Princesa (IIS-IP)
| | | | - Pedro Majano
- Aparato Digestivo, Hospital Universitario de La Princesa
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Maslenkina K, Mikhaleva L, Mikhalev A, Kaibysheva V, Atiakshin D, Motilev E, Buchwalow I, Tiemann M. Assessment of the Severity and the Remission Criteria in Eosinophilic Esophagitis. Biomedicines 2023; 11:3204. [PMID: 38137426 PMCID: PMC10740698 DOI: 10.3390/biomedicines11123204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/19/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is an immune-mediated disease that manifests with dysphagia and is characterized by the predominantly eosinophilic infiltration of the esophageal mucosa. Several instruments have been developed to assess the symptoms of EoE: the Daily Symptom Questionnaire (DSQ), EoE Activity Index (EEsAI), Pediatric EoE Symptom Severity (PEESSv2), etc. The use of the EREFS is a gold standard for endoscopic diagnosis. The EoE histologic scoring system (EoEHSS) was elaborated for the assessment of histological features in EoE. However, the remission criteria are not clearly defined and vary greatly in different studies. Gastroenterologists establish the severity of EoE mainly based on endoscopic findings. At the same time, EoE requires a multidisciplinary approach. The recently developed Index of Severity of Eosinophilic Esophagitis (I-SEE) that is built on symptoms, endoscopic findings, and histological features is promising.
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Affiliation(s)
- Ksenia Maslenkina
- A.P. Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119991 Moscow, Russia; (K.M.); (L.M.); (E.M.)
| | - Liudmila Mikhaleva
- A.P. Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119991 Moscow, Russia; (K.M.); (L.M.); (E.M.)
| | - Alexander Mikhalev
- Laboratory of Surgical Gastroenterology and Endoscopy, Pirogov Russian National Research University, 117997 Moscow, Russia; (A.M.); (V.K.)
| | - Valeria Kaibysheva
- Laboratory of Surgical Gastroenterology and Endoscopy, Pirogov Russian National Research University, 117997 Moscow, Russia; (A.M.); (V.K.)
| | - Dmitri Atiakshin
- Research and Educational Resource Center for Immunophenotyping, Digital Spatial Profiling and Ultrastructural Analysis Innovative Technologies, RUDN University, 6 Miklukho-Maklaya St., 117198 Moscow, Russia;
| | - Eugeny Motilev
- A.P. Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119991 Moscow, Russia; (K.M.); (L.M.); (E.M.)
| | - Igor Buchwalow
- Research and Educational Resource Center for Immunophenotyping, Digital Spatial Profiling and Ultrastructural Analysis Innovative Technologies, RUDN University, 6 Miklukho-Maklaya St., 117198 Moscow, Russia;
- Institute for Hematopathology, Fangdieckstr. 75a, 22547 Hamburg, Germany;
| | - Markus Tiemann
- Institute for Hematopathology, Fangdieckstr. 75a, 22547 Hamburg, Germany;
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Sharlin CS, Mukkada VA, Putnam PE, Bolton SM. Treatment of Pediatric Eosinophilic Esophagitis: Traditional and Novel Therapies. Curr Gastroenterol Rep 2023; 25:289-298. [PMID: 37658151 DOI: 10.1007/s11894-023-00893-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/03/2023]
Abstract
PURPOSE OF REVIEW This review presents and summarizes the existing studies on the treatment goals and options for pediatric eosinophilic esophagitis utilizing rigorous peer-reviewed literature. RECENT FINDINGS In addition to traditional treatments, emerging biologic therapies continue to evolve the approach to treating pediatric eosinophilic esophagitis. Well defined treatment goals will aid the continued development of new therapies. Further, innovative assessment tools have changed how the clinician is able to assess the effectiveness of therapies with a trend toward less invasive options. The management of pediatric eosinophilic esophagitis continues to evolve with the advent of both novel treatment options and assessment tools. Treatment choices, with benefits and risks involved, should be presented to families upon diagnosis and tailored towards the individual patient and likelihood of adherence and success. Biologic therapy for EoE presents an exciting option for both first line therapy and escalation for those with severe or unresponsive disease.
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Affiliation(s)
- Colby S Sharlin
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott M Bolton
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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31
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Pehrsson M, de Rooij WE, Bay-Jensen AC, Karsdal MA, Mortensen JH, Bredenoord AJ. Extracellular matrix remodeling proteins as biomarkers for clinical assessment and treatment outcomes in eosinophilic esophagitis. BMC Gastroenterol 2023; 23:357. [PMID: 37845632 PMCID: PMC10577915 DOI: 10.1186/s12876-023-02977-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/26/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic progressive inflammatory disease of the esophagus, characterized by extracellular matrix remodeling and fibrotic stricture formation. Disease monitoring requires multiple re-endoscopies with esophageal biopsies. Hence non-invasive methods for determining tissue fibrosis and treatment efficacy are warranted. AIMS To investigate the ability of extracellular matrix proteins in serum as potential biomarkers of tissue remodeling and clinical, endoscopic, and histological disease outcomes in adult EoE patients. METHODS Protein-fingerprint assays were used to measure neo-epitope specific fragments of collagen remodeling, human-neutrophil elastase degraded calprotectin, and citrullinated or non-citrullinated vimentin in the serum of an adult EoE-cohort. Biomarker analysis, symptoms, endoscopic features and histological disease activity (eosinophils(eos) per high-power-field(hpf)) were evaluated at baseline and after six weeks of dietary intervention. RESULTS Patients with a baseline (Endoscopic Reference score) EREFS fibrosis subscore ≥ 2 presented with increased fibrolysis of cross-linked type III collagen (CTX-III) (p < 0.01), whereas low CTX-III levels were observed in patients achieving histological remission (< 15 eos/hpf) (vs. no histological remission (p < 0.05). Progression of endoscopic fibrosis after intervention was associated with increased levels of type-III (PRO-C3) and -VI collagen (PRO-C6) formation (all; p < 0.05). A baseline EREFS inflammatory subscore ≥ 2 correlated with higher neutrophilic activity (Cpa9-HNE) at week 6 (p < 0.05). Moreover, increased degradation of type-III (C3M) and -IV (C4M/PRO-C4) collagens were associated with remission of food impaction after intervention (all; p < 0.05). CONCLUSION Serum extracellular matrix remodeling proteins demonstrated potential as surrogate biomarkers for assessing histological disease remission, endoscopic fibrosis, and remission of symptoms of food impaction after diet intervention in adult EoE patients.
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Affiliation(s)
- Martin Pehrsson
- Biomarkers and Research, Nordic Bioscience A/S, Herlev, Denmark
| | - Willemijn E de Rooij
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Center, Amsterdam, Netherlands.
| | | | | | | | - Albert Jan Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Center, Amsterdam, Netherlands
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32
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Hofstaedter CE, Watkins R, Kotwal N. Asymptomatic Esophageal Eosinophilia in an 11-Year-Old with Severe Persistent Asthma. Case Rep Pediatr 2023; 2023:6678918. [PMID: 37868770 PMCID: PMC10586919 DOI: 10.1155/2023/6678918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/18/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023] Open
Abstract
Asymptomatic esophageal eosinophilia (aEE) is a rare presentation, where patients have increased eosinophils in esophageal mucosa but lack any esophagus-related symptoms. Cases of aEE have only been documented in adults, and little is known about its clinical significance and whether treatment is warranted. We report a case of an 11-year-old patient with uncontrolled severe persistent asthma who underwent flexible bronchoscopy and upper endoscopy as a part of complete aerodigestive evaluation. Elevated intraepithelial eosinophils in the esophageal mucosa were noted, suggesting an aEE-like presentation. This case documents a pediatric patient with aEE and highlights the importance of combined aerodigestive assessment with pulmonology and gastroenterology teams for the evaluation of severe asthma.
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Affiliation(s)
- Casey E. Hofstaedter
- Medical Scientist Training Program, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
| | - Runa Watkins
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
| | - Nidhi Kotwal
- Division of Pulmonology and Allergy, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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Cotton CC, Moist SE, McGee SJ, Furuta GT, Aceves SS, Dellon ES. A Newly Proposed Severity Index for Eosinophilic Esophagitis is Associated With Baseline Clinical Features and Successful Treatment Response. Clin Gastroenterol Hepatol 2023; 21:2534-2542.e1. [PMID: 37061110 PMCID: PMC10524581 DOI: 10.1016/j.cgh.2023.03.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/15/2023] [Accepted: 03/27/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND AND AIMS The Index of Severity for EoE (I-SEE) was recently developed. We aimed to determine the relationship between features of eosinophilic esophagitis and disease severity, and assess change in disease severity with topical corticosteroid treatment, using I-SEE. METHODS We performed a post hoc analysis of an 8-week randomized trial comparing 2 topical corticosteroid formulations in newly diagnosed patients with eosinophilic esophagitis. I-SEE was calculated at baseline and posttreatment, and patients were classified as mild (1-6 points), moderate (7-14 points), severe (≥15 points), or inactive (0 points). We analyzed clinical, endoscopic, and histologic features at baseline by disease severity, and examined the change in severity before and after treatment, and by histologic response (<15 eosinophils per high-power field). RESULTS Of 111 subjects randomized, 20 (18%) were classified as mild, 75 (68%) as moderate, and 16 (14%) as severe at baseline. Increasing severity was associated with lower body mass index (30 for mild, 27 for moderate, 24 for severe; P = .01), longer duration of dysphagia symptoms before diagnosis (9 years for mild, 9 for moderate, and 20 for severe; P < .001), and decreasing esophageal diameter (15 mm for mild, 13 for moderate, and 10 for severe; P < .001). Mean severity score decreased after treatment (11 vs 4; P < .001), with lower scores in histologic responders compared with nonresponders (2 vs 9; P < .001). The severity score at baseline predicted need for dilation at follow-up (C statistic, 0.81). CONCLUSIONS The newly developed I-SEE correlates with many clinical features at diagnosis, and severity improves with successful topical corticosteroid treatment. Additional investigations in other populations can further confirm its utility.
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Affiliation(s)
- Cary C Cotton
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Susan E Moist
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Sarah J McGee
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- University of California, San Diego and Rady Children's Hospital, San Diego, California
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
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Arnim UV, Biedermann L, Aceves SS, Bonis PA, Collins MH, Dellon ES, Furuta GT, Gonsalves N, Gupta S, Hirano I, Lucendo AJ, Miehlke S, Oliva S, Schlag C, Schoepfer A, Straumann A, Vieth M, Bredenoord AJ. Monitoring Patients With Eosinophilic Esophagitis in Routine Clinical Practice - International Expert Recommendations. Clin Gastroenterol Hepatol 2023; 21:2526-2533. [PMID: 36572109 DOI: 10.1016/j.cgh.2022.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND & AIMS There are no studies or recommendations on optimal monitoring strategies for patients with eosinophilic esophagitis (EoE). Our objective was to develop guidance on how to monitor patients with EoE in routine clinical practice, on the basis of available clinical evidence and expert opinion. METHODS A multidisciplinary, international group of EoE experts identified the following important 3 questions during several consensus meetings: why, by what means, and when to monitor patients with EoE. A steering committee was named, and 3 teams were formed to review literature and to formulate statements for each topic. In a Delphi survey, a level of agreement of ≥75% was defined as threshold value for acceptance. In a final conference, results were presented, critical points and comments on the statements were discussed, and statements were rephrased/rewritten if necessary. RESULTS Eighteen EoE experts (14 adult and pediatric gastroenterologists, 2 pathologists and 2 allergists) with a median of 21.7 years in clinical practice, mostly academic or university-based, completed the Delphi survey, which included 11 statements and a proposed algorithm for monitoring patients with EoE. Each statement attained ≥75% agreement. Participants discussed and debated mostly about the statement concerning surveillance intervals for EoE patients with stable disease. CONCLUSIONS It was concluded that effective maintenance treatment probably reduces the development of EoE complications, and regular, structured, and, under certain conditions, individualized clinical follow-up is recommended to assess disease activity while opening a window to monitoring side effects, adjusting therapy, and encouraging adherence to treatment. Follow-up should comprise symptom assessment and periodic or repeated endoscopy with histological assessment in specific EoE settings.
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Affiliation(s)
- Ulrike von Arnim
- Department of Gastroenterology, Hepatology, and Infectious Diseases, University Hospital, Magdeburg, Germany.
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zurich, Switzerland
| | - Seema S Aceves
- Eosinophilic Gastrointestinal Disorders Clinic, Division of Allergy Immunology, Rady Children's Hospital, San Diego University of California, San Diego, California
| | | | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Glenn T Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado; Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University - Feinberg School of Medicine, Chicago, Illinois
| | - Sandeep Gupta
- Community Hospital Network, Division of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ikuo Hirano
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, Tomelloso, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Stephan Miehlke
- Centre for Digestive Diseases, Internal Medicine Centre Eppendorf, Hamburg, Germany
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Christoph Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zurich, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zurich, Switzerland
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Netherlands
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Carlson DA, Hirano I, Gonsalves N, Kahrilas PJ, Araujo IK, Yang M, Tetreault MP, Pandolfino JE. A PhysioMechanical Model of Esophageal Function in Eosinophilic Esophagitis. Gastroenterology 2023; 165:552-563.e4. [PMID: 37263308 PMCID: PMC10527622 DOI: 10.1053/j.gastro.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) is characterized by eosinophilic inflammation, but also heterogeneous presentations involving fibrostenotic esophageal remodeling and esophageal dysmotility. We aimed to define and evaluate phenotypes of EoE using functional lumen imaging probe (FLIP) panometry (ie, a PhysioMechanical classification of EoE). METHODS Patients with EoE who completed FLIP during endoscopy were included in a cross-sectional study. FLIP studies were analyzed for distensibility plateau and compliance of the esophageal body, maximum esophagogastric junction diameter, and contractile response pattern. These FLIP features were then applied to define PhysioMechanical classifications. RESULTS A total of 215 patients with EoE (mean [standard deviation] age 38 [12] years; 31% female) were included. Seven PhysioMechanical classifications were identified that differed by various clinical characteristics, including symptom duration (P < .001) and Endoscopic EoE Reference Scores (EREFS) (P < .001). In particular, patients with "nonreactive fibrostenosis" (n = 14), had greater symptom duration (median [interquartile range] 20 [10-30] years) and more frequently had EREFS grade 2 or 3 ring scores (14 of 14 patients) than patients with a "normal" PhysioMechanical classification (symptom duration: 3 [1-8] years; 4 of 50 [8%] had EREFS grade 2 or 3 rings). In addition, among patients off treatment at cross-sectional evaluation (n = 46), there was a difference between PhysioMechanical classifications in future proton pump inhibitor (PPI) response rates (ie, achieving peak mucosal eosinophil count <15 per high-powered field after PPI treatment); P = .009. PPI response ranged from 87% (13 of 15 patients) with "isolated esophagogastric junction outflow obstruction" to 11% (1 of 9 patients) with "spastic-reactive fibrostenosis." CONCLUSIONS Classifying PhysioMechanical esophageal function in EoE based on FLIP panometry features may facilitate defining disease severity and directing management in EoE.
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Affiliation(s)
- Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Ikuo Hirano
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nirmala Gonsalves
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Isis K Araujo
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Gastroenterology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Mira Yang
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Marie-Pier Tetreault
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Visaggi P, Solinas I, Baiano Svizzero F, Bottari A, Barberio B, Lorenzon G, Ghisa M, Maniero D, Marabotto E, Bellini M, de Bortoli N, Savarino EV. Non-Invasive and Minimally Invasive Biomarkers for the Management of Eosinophilic Esophagitis beyond Peak Eosinophil Counts: Filling the Gap in Clinical Practice. Diagnostics (Basel) 2023; 13:2806. [PMID: 37685343 PMCID: PMC10486562 DOI: 10.3390/diagnostics13172806] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic esophageal disease that needs lifelong management and follow-up. The diagnosis requires an upper endoscopy with at least one esophageal biopsy demonstrating >15 eosinophils/high-power field, and often occurs with a diagnostic delay of up to ten years, partly due to the absence of valid non-invasive screening tools. In addition, serial upper endoscopies with esophageal biopsies are mandatory to assess the efficacy of any ongoing treatment in patients with EoE. These procedures are invasive, costly, and, when performed without sedation, are often poorly tolerated by patients. Therefore, there is the clinical need to identify reliable non-invasive or minimally invasive biomarkers that could be used to assess disease activity in clinical practice as a surrogate of peak eosinophil counts on esophageal biopsies. This review summarizes evidence on investigational non-invasive or minimally invasive biomarkers for the diagnosis and follow-up of EoE to report on the state of the art in the field and support future research. We discussed eosinophil-derived mediators including eosinophil cationic protein (ECP), eosinophil-derived neurotoxin (EDN, also known as eosinophil protein X), eosinophil peroxidase (EPO), and major basic protein (MBP) as well as other promising non-eosinophil-derived biomarkers. Although several studies have shown the utility of most biomarkers collected from the serum, esophageal luminal secretions, and feces of EoE patients, numerous limitations currently hamper the integration of such biomarkers in clinical practice. Future studies should aim at validating the utility of non-invasive and minimally invasive biomarkers using rigorous protocols and updated consensus criteria for EoE.
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Affiliation(s)
- Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56125 Pisa, Italy
| | - Irene Solinas
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56125 Pisa, Italy
| | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56125 Pisa, Italy
| | - Andrea Bottari
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56125 Pisa, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Italy
- Gastroenterology Unit, Azienda Ospedale University of Padua, 35128 Padua, Italy
| | - Greta Lorenzon
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Italy
- Gastroenterology Unit, Azienda Ospedale University of Padua, 35128 Padua, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Italy
- Gastroenterology Unit, Azienda Ospedale University of Padua, 35128 Padua, Italy
| | - Daria Maniero
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Italy
- Gastroenterology Unit, Azienda Ospedale University of Padua, 35128 Padua, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
| | - Massimo Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56125 Pisa, Italy
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56125 Pisa, Italy
| | - Edoardo V. Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Italy
- Gastroenterology Unit, Azienda Ospedale University of Padua, 35128 Padua, Italy
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Oshima T. How should we interpret the data of eosinophilic esophagitis patients from an academic institution? JGH Open 2023; 7:525-526. [PMID: 37649857 PMCID: PMC10463014 DOI: 10.1002/jgh3.12962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Tadayuki Oshima
- Department of GastroenterologyOkazaki City Medical Association Public Health CenterOkazakiJapan
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Murray FR, Kreienbühl A, Straumann A, Biedermann L, Schreiner P. Natural History of Patients Lost to Follow-up After Esophageal Food Impaction. Clin Gastroenterol Hepatol 2023; 21:2413-2414. [PMID: 35868442 DOI: 10.1016/j.cgh.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Fritz Ruprecht Murray
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland; Department of Gastroenterology & Hepatology, Stadtspital Triemli Zurich, Zurich, Switzerland
| | - Andrea Kreienbühl
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Alex Straumann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Luc Biedermann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland.
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Ketchem CJ, Ocampo AA, Xue Z, Chang NC, Thakkar KP, Reddy S, Greenberg SB, Lee CJ, Redd WD, Eluri S, Reed CC, Dellon ES. Higher Body Mass Index Is Associated With Decreased Treatment Response to Topical Steroids in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2023; 21:2252-2259.e3. [PMID: 36410644 DOI: 10.1016/j.cgh.2022.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND & AIMS Understanding which eosinophilic esophagitis (EoE) patients will respond to treatment with topical corticosteroids (tCS) remains challenging, and it is unknown whether obesity impacts treatment response. This study aimed to determine whether treatment outcomes to tCS in EoE patients vary by body mass index (BMI). METHODS This retrospective cohort study of the University of North Carolina EoE Clinicopathologic database assessed subjects age 14 years or older with a new diagnosis of EoE. Their BMI was calculated and histologic, symptom, and endoscopic responses were recorded after tCS treatment. The treatment response of obese (BMI, ≥30 kg/m2) and nonobese EoE status was compared using bivariate and multivariate analyses. RESULTS We identified 296 EoE patients treated with tCS. Baseline characteristics were similar, although obese EoE patients had more heartburn and hiatal hernias. Histologic response was higher for those who were nonobese compared with obese at fewer than 15 (61% vs 47%; P = .049) and 6 or fewer (54% vs 38%; P = .02) eosinophils per high-power field, respectively. In addition, nonobese patients had significantly greater endoscopic and symptomatic responses. On multivariate analysis, increasing BMI was associated independently with decreased histologic response after accounting for age, heartburn, dilation, and hiatal hernia whether BMI was assessed as a continuous variable (adjusted odds ratio [aOR], 0.93; 95% CI, 0.89-0.98), as nonobese vs obese (aOR, 0.38; 95% CI, 0.21-0.68), or in 4 categories (overweight vs normal [aOR, 0.46; 95% CI, 0.26-0.84] or obese vs normal [aOR, 0.26; 95% CI, 0.13-0.51]). CONCLUSIONS As BMI increases in EoE patients, the odds of histologic, symptomatic, and endoscopic responses to tCS decreases, with obese patients having an approximately 40% decrease in odds of response.
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Affiliation(s)
- Corey J Ketchem
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Adolfo A Ocampo
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Zeyun Xue
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Nicole C Chang
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kisan P Thakkar
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sumana Reddy
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sydney B Greenberg
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Christopher J Lee
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Walker D Redd
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Swathi Eluri
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Craig C Reed
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
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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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Walgraeve S, Vanuytsel T. Novel corticosteroid formulations in the treatment of eosinophilic esophagitis: what is the evidence? Acta Gastroenterol Belg 2023; 86:437-448. [PMID: 37814560 DOI: 10.51821/86.3.11757] [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] [Indexed: 10/11/2023]
Abstract
Background and study aims Eosinophilic esophagitis (EoE) is a food allergen-induced disease of the esophagus. Chronic, eosinophil-predominant inflammation eventually leads to fibrosis, esophageal dysfunction and severe morbidity. Swallowed topical corticosteroids (STCs) are a mainstay of anti-inflammatory therapy in the treatment of active EoE. Data on the efficacy of novel corticosteroid formulations, developed specifically for esophageal delivery, have recently become available. Methods A comprehensive review was performed aiming to summarize evidence on the role of STCs in the treatment of EoE. Two biomedical bibliographic databases (PubMED, EMBASE) were searched for articles providing original information on the efficacy and safety of STCs in adult EoE patients. Results Budesonide orodispersible tablet (BOT) and budesonide oral suspension (BOS) both surpassed placebo formulations regarding the efficacy of inducing and maintaining histologic, symptomatic and endoscopic remission. Overall, BOT displayed the highest grade of efficacy with clinico-histologic remission rates up to 75% after 1 year. Fluticasone propionate (APT-1011) achieved and maintained histologic and endoscopic responses in the majority of patients, whereas only a positive trend was demonstrated for symptomatic improvement. Mometasone and ciclesonide were studied in a limited number of smaller-scale trials and placebo-controlled data are required to substantiate the promising findings. All STCs displayed a similar side effects profile and were generally considered safe and well-tolerated. Conclusions Current evidence supports long-term treatment with novel corticosteroid formulations, challenging the established treatment paradigm of EoE. BOT appears to be the most effective steroid therapy, although head-to-head comparative trials between STCs are needed.
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Affiliation(s)
- S Walgraeve
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - T Vanuytsel
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Miehlke S, Arnim UV, Schlag C, Labenz J, Madisch A. [Treatment of eosinophilic esophagitis - advancements and perspectives]. Laryngorhinootologie 2023; 102:339-348. [PMID: 37141876 DOI: 10.1055/a-1861-7152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
In recent years significant progress has been made in the treatment of eosinophilic esophagitis (EoE), especially in the area of topical corticosteroids. Novel EoE-specific formulations have been developed and first approvals have been obtained for induction and maintenance of remission in adult EoE patients with the orodispersible budesonide tablet in Germany and other European and non-EU countries. A novel budesonide oral suspension is currently under priority review by the FDA for first approval in the U.S. In contrast, the scientific evidence on the efficacy of proton pump inhibitors remains limited. Moreover, new biologicals have been identified which showed promising results in phase 2 trials and are now being studied in phase 3. This article aims to summarize and discuss recent advances and perspectives in the treatment of EoE.
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Affiliation(s)
- Stephan Miehlke
- Magen-Darm-Zentrum, Facharztzentrum Eppendorf, Hamburg, Germany
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology and Infectious diseases, Universitätsklinikum Magdeburg AöR, Magdeburg, Germany
| | - Christoph Schlag
- Second medical department, Klinikum rechts der Isar der Technischen Universität München, Munchen, Germany
| | - Joachim Labenz
- Medizinische Klinik, Ev. Jung-Stilling Krankenhaus, Siegen, Germany
| | - Ahmed Madisch
- Department of Internal Medicine, Siloah Hospital, Hannover, Germany
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Abe Y, Sasaki Y, Yagi M, Mizumoto N, Onozato Y, Kon T, Shoji M, Sakuta K, Sakai T, Umehara M, Ito M, Nakamura S, Tsuchida H, Ueno Y. Linked color imaging improves the diagnostic accuracy of eosinophilic esophagitis. DEN OPEN 2023; 3:e146. [PMID: 35898847 PMCID: PMC9310047 DOI: 10.1002/deo2.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/03/2022] [Accepted: 06/10/2022] [Indexed: 11/25/2022]
Abstract
Objectives To assess the usefulness of linked color imaging (LCI), a recently developed image‐enhanced endoscopy technique, in the endoscopic diagnosis of eosinophilic esophagitis (EoE). Methods Thirty white light images (WLIs) and 30 WLI+LCI images collected from patients with and without EoE were randomly and blindly reviewed by 10 endoscopists, including four experts (Exs) and six non‐Exs. Edema, ring, exudate furrows, and strictures were rated on the adjusted EoE endoscopic reference score; the diagnosis of EoE was assessed. Using the kappa value, inter‐ and intra‐observer agreements were analyzed among endoscopists. Results WLI+LCI images had a higher diagnostic accuracy for EoE than WLIs (0.85 vs. 0.70, respectively), especially in non‐Exs or endoscopists with no experience with EoE patients. Inter‐observer agreement for WLI+LCI images statistically surpassed WLIs for furrows (kappa, 0.73 vs. 0.67, respectively; p = 0.0013), stricture (kappa, 0.51 vs. 0.39, respectively; p = 0.0072), and diagnosis (kappa, 0.67 vs. 0.57, respectively; p < 0.0001) of EoE. The increase in inter‐observer agreement in WLI+LCI images allowed for a reduction in the differences between the Exs and non‐Ex endoscopists. Intra‐observer agreement for WLI+LCI images surpassed WLIs for a ring (kappa, 0.62 vs. 0.43, p = 0.0052), and a similar trend was found in exudates, furrows, and diagnosis irrespective of the Exs or non‐Exs. Conclusions LCI can contribute to the improvement of the endoscopic diagnosis for EoE, with “moderate” to “substantial” consistency, by enhancing the visibility of abnormal findings, leading to reduced diagnostic disparities among endoscopists.
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Affiliation(s)
- Yasuhiko Abe
- Division of Endoscopy Yamagata University Hospital Yamagata Japan
| | - Yu Sasaki
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Makoto Yagi
- Division of Endoscopy Yamagata University Hospital Yamagata Japan
| | - Naoko Mizumoto
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Yusuke Onozato
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Takashi Kon
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Masakuni Shoji
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Kazuhiro Sakuta
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Takayuki Sakai
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Matsuki Umehara
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Minami Ito
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Shuhei Nakamura
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Hidemoto Tsuchida
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
| | - Yoshiyuki Ueno
- Department of Gastroenterology Faculty of Medicine Yamagata University Yamagata Japan
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Proton Pump Inhibitor Therapy in Pediatric Eosinophilic Esophagitis: Predictive Factors and Long-Term Step-Down Efficacy. J Pediatr Gastroenterol Nutr 2023; 76:191-198. [PMID: 36416845 DOI: 10.1097/mpg.0000000000003660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the short- and long-term efficacy of proton pump inhibitor (PPI) therapy for pediatric eosinophilic esophagitis (EoE) in real-world practice with a step-down strategy, and to evaluate factors predictive of PPI responsiveness. METHODS We collected data regarding the efficacy of PPIs during this cross-sectional analysis of the prospective nationwide RENESE registry. Children with EoE treated with PPI monotherapy were included. Histological remission was defined as a peak eosinophilic count of <15 eosinophils (eos)/high-power field (hpf). Factors associated with PPI responsiveness were identified using multivariate logistic regression analysis. RESULTS After induction therapy, histological and clinico-histological remission were observed in 51.4% (n = 346) and 46.5% of children, respectively. Normal endoscopic appearance of the esophagus was associated with a higher possibility [odds ratio (OR), 9.20; 95% confidence interval (CI), 2.10-40.16], and fibrostenotic phenotype was associated with a lower possibility (OR, 0.36; 95% CI, 0.18-0.74) of histological remission. Long-term therapy with a step-down strategy effectively maintained histological remission in 68.5% and 85.3% of children at 7 months (n = 108) and 16 months (n = 34), respectively. Complete initial histological remission (≤5 eos/hpf) was associated with a higher possibility of sustained histological remission (OR, 5.08; 95% CI, 1.75-14.68). Adverse events were infrequent and mild. CONCLUSIONS We confirmed the efficacy of PPIs for a large cohort of children with EoE with sustained histological remission using a step-down strategy. Children with fibrostenotic phenotypes are less likely to respond to induction therapy. Furthermore, patients with complete initial histological remission are more likely to experience long-term histological remission.
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Ocampo AA, Dellon ES. Worsened Fibrostenotic Outcomes in Eosinophilic Esophagitis Patients Due to COVID-19-Related Endoscopy Cancellations. Dig Dis Sci 2023; 68:396-403. [PMID: 35790699 PMCID: PMC9255524 DOI: 10.1007/s10620-022-07610-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/27/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Indirect consequences of COVID-19 in eosinophilic esophagitis (EoE) are not known. AIM To determine the impact of COVID-19-related endoscopy cancellations on outcomes in EoE patients. METHODS In this retrospective cohort study, we assessed whether adult EoE patients who had routine endoscopy scheduled from mid-March 2020 to May 2020 (pandemic start) were canceled or proceeded, and if canceled, ultimately returned. We extracted clinical, endoscopic, and histologic data for their pre-COVID procedure as well as the next procedure performed, if a patient returned. Outcomes included histologic response (< 15 eos/hpf) and endoscopic severity. Those with delayed care were compared to those who returned as scheduled. RESULTS Of 102 patients identified, 75 had procedures canceled, and 20 (27%) never returned. For the 55 who were canceled but returned, mean time between procedures was 1.1 ± 0.7 years with a delay of 0.5 ± 0.3 years. While treatment rates were similar between the pre- and delayed post-COVID EGD, more patients required a dilation after their return (71% vs 58%; p = 0.05) and their esophageal diameter had significantly decreased (16.8 mm to 15.0 mm; p < 0.001). Of 17 individuals who did not have stricture, narrowing, or dilation pre-pandemic, during their next endoscopy 5 (29%) had a stricture, 1 (6%) had a narrowing, and 7 (41%) required dilation. CONCLUSION Of EoE patients with canceled endoscopies during the beginning of the COVID-19 pandemic, > 25% never returned for care, which is a previously unmeasured impact of the pandemic. Those who returned had > 1 year between procedures with progression of fibrotic features and need for esophageal dilation.
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Affiliation(s)
- Adolfo A Ocampo
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, CB#7080, Bioinformatics Building, 130 Mason Farm Rd., Chapel Hill, NC, 27599-7080, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, CB#7080, Bioinformatics Building, 130 Mason Farm Rd., Chapel Hill, NC, 27599-7080, USA.
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, USA.
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Alexander JA, Ravi K, Symrk TC, Wu TT, Lavey CJ, Geno D, Johnson AJ, Lennon RJ, Collins MH, Dellon ES, Katzka DA. Use of the Esophageal Sponge in Directing Food Reintroduction in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2023; 21:299-306.e3. [PMID: 35697266 DOI: 10.1016/j.cgh.2022.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/18/2022] [Accepted: 05/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND & AIMS Dietary therapy is successful in eosinophilic esophagitis (EoE) but requires multiple upper endoscopies. The aim of this study was to determine if food reintroduction in EoE can be directed by minimally-invasive esophageal sponge cytology. METHODS In this prospective non-blinded trial, 22 responders to 6-food elimination diets underwent sequential food reintroduction guided by esophageal sponge cytology. Foods were reintroduced followed by unsedated esophageal sponge cytology assessment. A food trigger was defined by sponge cytology peak eosinophil count of ≥15 eos/high-powered field (hpf). Symptoms (EoE symptom activity index [EEsAI]), endoscopic score (EoE endoscopic reference score [EREFS]), and biopsy histology (peak eosinophil count) were collected pre-dietary therapy and post-dietary therapy, and then 4 weeks post food reintroduction. RESULTS The EEsAI and EREFS were similar post-dietary therapy to post-food reintroduction: 12.0 (interquartile range [IQR], 0.0-27.0) vs 16.5 (IQR, 9.0-28.8) (P = .265) and 1.5 (IQR, 0.2-3.0) vs 1.0 (IQR, 0.0-2.0) (P = .185). However, the peak eosinophil count was increased post-food reintroduction compared with post-dietary therapy: 20.0 (IQR, 5.0-51.5) vs 2.0 (IQR, 1.0-4.0) (P < .001), suggesting a failure of identification of all food triggers. The peak eosinophil count was lower post-food reintroduction compared with pre-dietary therapy: 20.0 (IQR, 5.0-51.5) vs 52.0 (IQR, 30.8-76.2) (P = .008). At the post food reintroduction evaluation, sponge cytology and biopsy histology were in agreement in 59% (13/22) of cases using a cutoff of <15 eos/hpf and 68% (15/22) of cases using a cutoff of <6 eos/hpf. CONCLUSIONS In the first study to evaluate a non-endoscopic technique in the clinical management of EoE, the esophageal sponge was moderately successful at guiding food reintroduction in EoE dietary responders in the outpatient setting. CLINICALTRIALS gov, Number NCT02599558.
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Affiliation(s)
- Jeffrey A Alexander
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Karthik Ravi
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Thomas C Symrk
- Department of Pathology, Mayo Clinic, Rochester, Minnesota
| | - Tsung-The Wu
- Department of Pathology, Mayo Clinic, Rochester, Minnesota
| | - Crystal J Lavey
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Debra Geno
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Alyssa J Johnson
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ryan J Lennon
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Evan S Dellon
- Department of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina
| | - David A Katzka
- Department of Gastroenterology, Columbia University Medical Center, New York, New York
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Massimino L, Barchi A, Mandarino FV, Spanò S, Lamparelli LA, Vespa E, Passaretti S, Peyrin-Biroulet L, Savarino EV, Jairath V, Ungaro F, Danese S. A multi-omic analysis reveals the esophageal dysbiosis as the predominant trait of eosinophilic esophagitis. J Transl Med 2023; 21:46. [PMID: 36698146 PMCID: PMC9875471 DOI: 10.1186/s12967-023-03898-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/17/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic immune-mediated rare disease, characterized by esophageal dysfunctions. It is likely to be primarily activated by food antigens and is classified as a chronic disease for most patients. Therefore, a deeper understanding of the pathogenetic mechanisms underlying EoE is needed to implement and improve therapeutic lines of intervention and ameliorate overall patient wellness. METHODS RNA-seq data of 18 different studies on EoE, downloaded from NCBI GEO with faster-qdump ( https://github.com/ncbi/sra-tools ), were batch-corrected and analyzed for transcriptomics and metatranscriptomics profiling as well as biological process functional enrichment. The EoE TaMMA web app was designed with plotly and dash. Tabula Sapiens raw data were downloaded from the UCSC Cell Browser. Esophageal single-cell raw data analysis was performed within the Automated Single-cell Analysis Pipeline. Single-cell data-driven bulk RNA-seq data deconvolution was performed with MuSiC and CIBERSORTx. Multi-omics integration was performed with MOFA. RESULTS The EoE TaMMA framework pointed out disease-specific molecular signatures, confirming its reliability in reanalyzing transcriptomic data, and providing new EoE-specific molecular markers including CXCL14, distinguishing EoE from gastroesophageal reflux disorder. EoE TaMMA also revealed microbiota dysbiosis as a predominant characteristic of EoE pathogenesis. Finally, the multi-omics analysis highlighted the presence of defined classes of microbial entities in subsets of patients that may participate in inducing the antigen-mediated response typical of EoE pathogenesis. CONCLUSIONS Our study showed that the complex EoE molecular network may be unraveled through advanced bioinformatics, integrating different components of the disease process into an omics-based network approach. This may implement EoE management and treatment in the coming years.
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Affiliation(s)
- Luca Massimino
- grid.18887.3e0000000417581884Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy ,grid.18887.3e0000000417581884Division of Immunology, Transplantation and Infectious Disease, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Barchi
- grid.18887.3e0000000417581884Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Vito Mandarino
- grid.18887.3e0000000417581884Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Salvatore Spanò
- grid.18887.3e0000000417581884Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy ,grid.18887.3e0000000417581884Division of Immunology, Transplantation and Infectious Disease, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Edoardo Vespa
- grid.18887.3e0000000417581884Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Sandro Passaretti
- grid.18887.3e0000000417581884Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Laurent Peyrin-Biroulet
- grid.29172.3f0000 0001 2194 6418Inserm NGERE, University of Lorraine, Vandoeuvre-les-Nancy, France ,grid.410527.50000 0004 1765 1301Nancy University Hospital, Vandoeuvre-les-Nancy, France
| | - Edoardo Vincenzo Savarino
- grid.5608.b0000 0004 1757 3470Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy ,grid.5608.b0000 0004 1757 3470Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Vipul Jairath
- grid.39381.300000 0004 1936 8884Department of Medicine, Division of Gastroenterology, Western University, London, ON Canada
| | - Federica Ungaro
- grid.18887.3e0000000417581884Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy ,grid.18887.3e0000000417581884Division of Immunology, Transplantation and Infectious Disease, IRCCS Ospedale San Raffaele, Milan, Italy ,grid.15496.3f0000 0001 0439 0892Faculty of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
| | - Silvio Danese
- grid.18887.3e0000000417581884Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy ,grid.18887.3e0000000417581884Division of Immunology, Transplantation and Infectious Disease, IRCCS Ospedale San Raffaele, Milan, Italy ,grid.15496.3f0000 0001 0439 0892Faculty of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
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Nhu QM, Aceves SS. Current state of biologics in treating eosinophilic esophagitis. Ann Allergy Asthma Immunol 2023; 130:15-20. [PMID: 36243282 DOI: 10.1016/j.anai.2022.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Eosinophilic esophagitis (EoE) is a chronic, allergen-mediated, eosinophil-predominant, type 2 inflammatory disease that progresses to fibrostenosis of the esophagus if left untreated. This review focuses on biologics therapy in EoE. DATA SOURCES Manuscripts on EoE treatments are identified on PubMed. STUDY SELECTIONS Original research, randomized controlled trials, retrospective studies, meta-analyses, case series, and case reports of high relevance are selected and reviewed. RESULTS Biologics have been used as investigational therapies for EoE in clinical studies over the years, based on earlier work that identified key cytokines and mediators of eosinophilic inflammation and, more recently, type 2 inflammation that underlie EoE pathogenesis. Dupilumab, a monoclonal antibody that targets the interleukin (IL)-4Rα chain, thereby interfering with IL-4 and IL-13 binding with the receptor, was recently approved by the Food and Drug Administration for EoE. Dupilumab improved clinical symptoms, endoscopic scores, histologic inflammation, and esophageal distensibility. Several clinical trials that target key cytokines such as IL-5, IL-13, and thymic stromal lymphopoietin in EoE are still ongoing. CONCLUSION Topical corticosteroid, proton pump inhibitor therapy, elimination diet, and dilation are widely accepted treatment modalities for EoE. Dupilumab is the first Food and Drug Administration-approved therapy for EoE. Other studies evaluating biologics that target eosinophils, key cytokines, and inflammatory pathways in EoE are ongoing. Treatment algorithms are needed to position EoE therapies as they emerge.
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Affiliation(s)
- Quan M Nhu
- Division of Gastroenterology & Hepatology, Department of Medicine, Scripps Clinic, La Jolla, California; Department of Molecular Medicine, Scripps Research Institute, La Jolla, California
| | - Seema S Aceves
- Division of Allergy & Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, California; Rady Children's Hospital, San Diego, San Diego, California.
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Underwood B, Troutman TD, Schwartz JT. Breaking down the complex pathophysiology of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2023; 130:28-39. [PMID: 36351516 PMCID: PMC10165615 DOI: 10.1016/j.anai.2022.10.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/08/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated disease of the esophagus associated with antigen-driven type 2 inflammation and symptoms of esophageal dysfunction. Our understanding of EoE pathophysiology has evolved since its initial recognition more than 20 years ago and has translated into diagnostic and novel therapeutic approaches that are affecting patient care. The mechanisms underlying disease development and progression are influenced by diverse factors, such as genetics, age, allergic comorbidities, and allergen exposures. Central to EoE pathophysiology is a dysregulated feed-forward cycle that develops between the esophageal epithelium and the immune system. Allergen-induced, type 2-biased immune activation by the esophageal epithelium propagates a cycle of impaired mucosal barrier integrity and allergic inflammation, eventually leading to tissue remodeling and progressive organ dysfunction. Herein, we review the current understanding of fundamental pathophysiological mechanisms contributing to EoE pathogenesis.
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Affiliation(s)
- Brynne Underwood
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ty D Troutman
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Justin T Schwartz
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Dellon ES, Rothenberg ME, Collins MH, Hirano I, Chehade M, Bredenoord AJ, Lucendo AJ, Spergel JM, Aceves S, Sun X, Kosloski MP, Kamal MA, Hamilton JD, Beazley B, McCann E, Patel K, Mannent LP, Laws E, Akinlade B, Amin N, Lim WK, Wipperman MF, Ruddy M, Patel N, Weinreich DR, Yancopoulos GD, Shumel B, Maloney J, Giannelou A, Shabbir A. Dupilumab in Adults and Adolescents with Eosinophilic Esophagitis. N Engl J Med 2022; 387:2317-2330. [PMID: 36546624 DOI: 10.1056/nejmoa2205982] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Dupilumab, a fully human monoclonal antibody, blocks interleukin-4 and interleukin-13 signaling, which have key roles in eosinophilic esophagitis. METHODS We conducted a three-part, phase 3 trial in which patients 12 years of age or older underwent randomization in a 1:1 ratio to receive subcutaneous dupilumab at a weekly dose of 300 mg or placebo (Part A) or in a 1:1:1 ratio to receive 300 mg of dupilumab either weekly or every 2 weeks or weekly placebo (Part B) up to week 24. Eligible patients who completed Part A or Part B continued the trial in Part C, in which those who completed Part A received dupilumab at a weekly dose of 300 mg up to week 52 (the Part A-C group); Part C that included the eligible patients from Part B is ongoing. The two primary end points at week 24 were histologic remission (≤6 eosinophils per high-power field) and the change from baseline in the Dysphagia Symptom Questionnaire (DSQ) score (range, 0 to 84, with higher values indicating more frequent or more severe dysphagia). RESULTS In Part A, histologic remission occurred in 25 of 42 patients (60%) who received weekly dupilumab and in 2 of 39 patients (5%) who received placebo (difference, 55 percentage points; 95% confidence interval [CI], 40 to 71; P<0.001). In Part B, histologic remission occurred in 47 of 80 patients (59%) with weekly dupilumab, in 49 of 81 patients (60%) with dupilumab every 2 weeks, and in 5 of 79 patients (6%) with placebo (difference between weekly dupilumab and placebo, 54 percentage points; 95% CI, 41 to 66 [P<0.001]; difference between dupilumab every 2 weeks and placebo, 56 percentage points; 95% CI, 43 to 69 [not significant per hierarchical testing]). The mean (±SD) DSQ scores at baseline were 33.6±12.41 in Part A and 36.7±11.22 in Part B; the scores improved with weekly dupilumab as compared with placebo, with differences of -12.32 (95% CI, -19.11 to -5.54) in Part A and -9.92 (95% CI, -14.81 to -5.02) in Part B (both P<0.001) but not with dupilumab every 2 weeks (difference in Part B, -0.51; 95% CI, -5.42 to 4.41). Serious adverse events occurred in 9 patients during the Part A or B treatment period (in 7 who received weekly dupilumab, 1 who received dupilumab every 2 weeks, and 1 who received placebo) and in 1 patient in the Part A-C group during the Part C treatment period who received placebo in Part A and weekly dupilumab in Part C. CONCLUSIONS Among patients with eosinophilic esophagitis, subcutaneous dupilumab administered weekly improved histologic outcomes and alleviated symptoms of the disease. (Funded by Sanofi and Regeneron Pharmaceuticals; ClinicalTrials.gov number, NCT03633617.).
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Affiliation(s)
- Evan S Dellon
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Marc E Rothenberg
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Margaret H Collins
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Ikuo Hirano
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Mirna Chehade
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Albert J Bredenoord
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Alfredo J Lucendo
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Jonathan M Spergel
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Seema Aceves
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Xian Sun
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Matthew P Kosloski
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Mohamed A Kamal
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Jennifer D Hamilton
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Bethany Beazley
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Eilish McCann
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Kiran Patel
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Leda P Mannent
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Elizabeth Laws
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Bolanle Akinlade
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Nikhil Amin
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Wei Keat Lim
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Matthew F Wipperman
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Marcella Ruddy
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Naimish Patel
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - David R Weinreich
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - George D Yancopoulos
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Brad Shumel
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Jennifer Maloney
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Angeliki Giannelou
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
| | - Arsalan Shabbir
- From the Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill (E.S.D.); Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati (M.E.R., M.H.C.); Northwestern University Feinberg School of Medicine, Chicago (I.H.); Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York (M.C.), and Regeneron Pharmaceuticals, Tarrytown (X.S., M.P.K., M.A.K., J.D.H., B.B., E.M., B.A., N.A., W.K.L., M.F.W., M.R., D.R.W., G.D.Y., B.S., J.M., A.G., A.S.) - both in New York; Amsterdam University Medical Center, Amsterdam (A.J.B.); Hospital General de Tomelloso, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, and Instituto de Investigación Sanitaria de Castilla-La Mancha, Toledo - both in Spain (A.J.L.); Children's Hospital of Philadelphia, Philadelphia (J.M.S.); University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego - both in California (S.A.); Sanofi, Bridgewater, NJ (K.P., E.L.); Sanofi, Chilly-Mazarin, France (L.P.M.); and Sanofi, Cambridge, MA (N.P.)
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