1
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Berni Canani R, Caminati M, Carucci L, Eguiluz-Gracia I. Skin, gut, and lung barrier: Physiological interface and target of intervention for preventing and treating allergic diseases. Allergy 2024; 79:1485-1500. [PMID: 38439599 DOI: 10.1111/all.16092] [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] [Received: 09/05/2023] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 03/06/2024]
Abstract
The epithelial barriers of the skin, gut, and respiratory tract are critical interfaces between the environment and the host, and they orchestrate both homeostatic and pathogenic immune responses. The mechanisms underlying epithelial barrier dysfunction in allergic and inflammatory conditions, such as atopic dermatitis, food allergy, eosinophilic oesophagitis, allergic rhinitis, chronic rhinosinusitis, and asthma, are complex and influenced by the exposome, microbiome, individual genetics, and epigenetics. Here, we review the role of the epithelial barriers of the skin, digestive tract, and airways in maintaining homeostasis, how they influence the occurrence and progression of allergic and inflammatory conditions, how current treatments target the epithelium to improve symptoms of these disorders, and what the unmet needs are in the identification and treatment of epithelial disorders.
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Affiliation(s)
- Roberto Berni Canani
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Marco Caminati
- Allergy Unit and Asthma Centre, Verona Integrated University Hospital and Department of Medicine, University of Verona, Verona, Italy
| | - Laura Carucci
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Ibon Eguiluz-Gracia
- Allergy Unit, Hospital Regional Universitario de Malága, Malaga, Spain
- Allergy Group, Biomedical Research Institute of Malaga (IBIMA)-BIONAND Platform, RICORS Inflammatory Diseases, Malaga, Spain
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2
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Burk CM, Shreffler WG. Triggers for eosinophilic esophagitis (EoE): The intersection of food allergy and EoE. J Allergy Clin Immunol 2024; 153:1500-1509. [PMID: 38849185 DOI: 10.1016/j.jaci.2024.04.010] [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: 01/31/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 06/09/2024]
Abstract
Eosinophilic esophagitis and IgE-mediated food allergy are both food-triggered diseases that are increasing in prevalence. They share many clinical links, including significant comorbidity and similar food triggers, and as atopic diseases, they likely share upstream mechanisms related to barrier function and signals leading to TH2 skewing. In this review, we focus on links between eosinophilic esophagitis and IgE-mediated food allergy with an emphasis on what insights may be derived from overlapping food triggers and immune phenotypes. Through further investigation of these connections, we may be able to better understand not only IgE-mediated food allergy and eosinophilic esophagitis but also general atopic response to food proteins and evolution of allergic response to food.
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Affiliation(s)
- Caitlin M Burk
- Food Allergy Center, Division of Pediatric Allergy and Immunology, and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, Mass.
| | - Wayne G Shreffler
- Food Allergy Center, Division of Pediatric Allergy and Immunology, and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, Mass
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3
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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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Lucendo A, Groetch M, Gonsalves N. Dietary Management of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:223-244. [PMID: 38575220 DOI: 10.1016/j.iac.2023.12.009] [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
Eosinophilic esophagitis (EoE) is a chronic immune-mediated food allergy-driven disease characterized by eosinophilic inflammation of the esophagus leading to symptoms of esophageal dysfunction. Prior studies have supported the key role of food allergen exposure as the main driver behind the etiopathogenesis showing that removal of food antigens can result in disease remission in both children and adults. These landmark studies serve as the basis for the rising interest and evolution of dietary therapy in EoE. This article will focus on the rationale for dietary therapy in EoE and provide helpful tools for the implementation of dietary therapy in practice.
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Affiliation(s)
- Alfredo Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd); Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Ciudad Real 13700, Spain
| | - Marion Groetch
- Department of Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, 676 North St. Claire, Suite 1400, Chicago, IL 60611, USA.
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5
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Rodríguez-Alcolado L, Navarro P, Arias-González L, Grueso-Navarro E, Lucendo AJ, Laserna-Mendieta EJ. Proton-Pump Inhibitors in Eosinophilic Esophagitis: A Review Focused on the Role of Pharmacogenetics. Pharmaceutics 2024; 16:487. [PMID: 38675148 PMCID: PMC11054109 DOI: 10.3390/pharmaceutics16040487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Proton-pump inhibitors (PPIs) are the most administered first-line treatment for eosinophilic esophagitis (EoE). However, only around half of EoE patients respond histologically to a double dosage of PPI. In addition, 70% of responders maintain EoE in remission after tapering the PPI dose. In order to avoid endoscopy with biopsies-the only accurate method of assessing PPI response-efforts have been made to identify PPI responder patients. The clinical or endoscopic features and biomarkers evaluated so far, however, have not proven to be sufficient in predicting PPI response. Although new approaches based on omics technologies have uncovered promising biomarkers, the specialized and complex procedures required are difficult to implement in clinical settings. Alternatively, PPI pharmacogenetics based on identifying variations in CYP2C19 and STAT6 genes have shown promising results in EoE, and could easily be performed in most laboratories. Other genetic variations have also been associated with PPI response and may explain those cases not related to CYP2C19 or STAT6. Here, we provide an overview of PPI treatment in EoE and evidence of how genetic variations in CYP2C19 and other genes could affect PPI effectiveness, and also discuss studies evaluating the role of pharmacogenetics in predicting PPI response in patients with EoE.
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Affiliation(s)
- Leticia Rodríguez-Alcolado
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Department of Surgery, Medical and Social Sciences, Universidad de Alcalá, 28805 Alcalá de Henares, Spain
| | - Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Laura Arias-González
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Elena Grueso-Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
| | - Alfredo J. Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Emilio J. Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
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6
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Jacobse J, Brown R, Revetta F, Vaezi M, Buendia MA, Williams CS, Higginbotham T, Washington MK, Goettel J, Hiremath G, Choksi YA. A synthesis and subgroup analysis of the eosinophilic esophagitis tissue transcriptome. J Allergy Clin Immunol 2024; 153:759-771. [PMID: 37852329 PMCID: PMC10939980 DOI: 10.1016/j.jaci.2023.10.002] [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] [Received: 04/24/2023] [Revised: 09/08/2023] [Accepted: 10/03/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic immune mediated inflammatory disorder of the esophagus. It is still unknown why children and adults present differently, and there is little evidence about why it is more common in men than women. OBJECTIVE Our aim was to synthesize published and unpublished esophageal bulk RNA-sequencing (RNA-seq) data to gain novel insights into the pathobiology of EoE and examine the differences in EoE transcriptome by sex and age group. METHODS Esophageal bulk RNA-seq data from 5 published and 2 unpublished studies resulting in 137 subjects (EoE: N = 76; controls: N = 61) were analyzed. For overall analysis, combined RNA-seq data of patients with EoE were compared with those of controls and subgroup analysis was conducted in patients with EoE by age of the patient (children [<18 years] vs adults [≥18 years]) and sex (female vs male). Gene-set enrichment analysis, ingenuity pathway analysis (IPA), cell-type analysis, immunohistochemistry, and T-cell or B-cell receptor analysis were performed. RESULTS Overall analysis identified dysregulation of new genes in EoE compared with controls. IPA revealed that EoE is characterized by a mixed inflammatory response compared with controls. Cell-type analysis showed that cell composition varied with age: children had more mast cells, whereas adults had more macrophages. Finally, gene-set enrichment analysis and IPA revealed pathways that were differentially regulated in adults versus children and male versus female patients with EoE. CONCLUSIONS Using a unique approach to analyze bulk RNA-seq data, we found that EoE is characterized by a mixed inflammatory response, and the EoE transcriptome may be influenced by age and sex. These findings enhance insights into the molecular mechanisms of EoE.
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Affiliation(s)
- Justin Jacobse
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands; Division of Molecular Pathogenesis, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Veterans Affairs Tennessee Valley Health Care System, Nashville, Tenn
| | - Rachel Brown
- Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, Tenn; Program in Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Frank Revetta
- Division of Molecular Pathogenesis, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Michael Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthew A Buendia
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tenn
| | - Christopher S Williams
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Veterans Affairs Tennessee Valley Health Care System, Nashville, Tenn; Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, Tenn; Program in Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Tina Higginbotham
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - M Kay Washington
- Division of Molecular Pathogenesis, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Center for Mucosal Inflammation and Cancer, Vanderbilt University Medical Center, Nashville, Tenn
| | - Jeremy Goettel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Division of Molecular Pathogenesis, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Center for Mucosal Inflammation and Cancer, Vanderbilt University Medical Center, Nashville, Tenn; Vanderbilt Institute for Infection Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, Tenn
| | - Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tenn
| | - Yash A Choksi
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Veterans Affairs Tennessee Valley Health Care System, Nashville, Tenn; Program in Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tenn.
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7
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Vandenplas Y, Meyer RM, Huysentruyt K. Food allergy: Prevention and treatment of Cow's milk allergy. Clin Nutr ESPEN 2024; 59:9-20. [PMID: 38220412 DOI: 10.1016/j.clnesp.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 01/16/2024]
Affiliation(s)
- Yvan Vandenplas
- Paediatric Gastroenterology, KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Rosan M Meyer
- Imperial College, London, United Kingdom; Winchester University, Winchester, United Kingdom
| | - Koen Huysentruyt
- Paediatric Gastroenterology, KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Lal M, Burk CM, Gautam R, Mrozek Z, Trachsel T, Beers J, Carroll MC, Morgan DM, Muir AB, Shreffler WG, Ruffner MA. Interferon-γ signaling in eosinophilic esophagitis has implications for epithelial barrier function and programmed cell death. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.26.577407. [PMID: 38352458 PMCID: PMC10862711 DOI: 10.1101/2024.01.26.577407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Objective Eosinophilic esophagitis (EoE) is a chronic esophageal inflammatory disorder characterized by eosinophil-rich mucosal inflammation and tissue remodeling. Transcriptional profiling of esophageal biopsies has previously revealed upregulation of type I and II interferon (IFN) response genes. We aim to unravel interactions between immune and epithelial cells and examine functional significance in esophageal epithelial cells. Design We investigated epithelial gene expression from EoE patients using single-cell RNA sequencing and a confirmatory bulk RNA-sequencing experiment of isolated epithelial cells. The functional impact of interferon signaling on epithelial cells was investigated using in vitro organoid models. Results We observe upregulation of interferon response signature genes (ISGs) in the esophageal epithelium during active EoE compared to other cell types, single-cell data, and pathway analyses, identified upregulation in ISGs in epithelial cells isolated from EoE patients. Using an esophageal organoid and air-liquid interface models, we demonstrate that IFN-γ stimulation triggered disruption of esophageal epithelial differentiation, barrier integrity, and induced apoptosis via caspase upregulation. We show that an increase in cleaved caspase-3 is seen in EoE tissue and identify interferon gamma (IFNG) expression predominantly in a cluster of majority-CD8+ T cells with high expression of CD69 and FOS. Conclusion These findings offer insight into the interplay between immune and epithelial cells in EoE. Our data illustrate the relevance of several IFN-γ-mediated mechanisms on epithelial function in the esophagus, which have the potential to impact epithelial function during inflammatory conditions.
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Affiliation(s)
- Megha Lal
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Caitlin M. Burk
- Food Allergy Center and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Gautam
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zoe Mrozek
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tina Trachsel
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Allergy, University Children’s Hospital Zurich, Zurich, Switzerland
- Division of Allergy, University Children’s Hospital Basel, Basel, Switzerland
| | - Jarad Beers
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Margaret C. Carroll
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Duncan M. Morgan
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology (MIT); Department of Chemical Engineering, MIT, Cambridge, MA, USA
| | - Amanda B. Muir
- Divison of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania
| | - Wayne G. Shreffler
- Food Allergy Center and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Melanie A. Ruffner
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania
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9
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Arias-González L, Rodríguez-Alcolado L, Laserna-Mendieta EJ, Navarro P, Lucendo AJ, Grueso-Navarro E. Fibrous Remodeling in Eosinophilic Esophagitis: Clinical Facts and Pathophysiological Uncertainties. Int J Mol Sci 2024; 25:927. [PMID: 38256003 PMCID: PMC10815180 DOI: 10.3390/ijms25020927] [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: 12/17/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory disease with increasing global prevalence. An eosinophil-predominant inflammation that permeates the epithelium and deeper esophageal layers characterizes the disease. Several cytokines, mainly derived from inflammatory T-helper 2 (Th2) cells and epithelial cells, are involved in perpetuating inflammatory responses by increasing surface permeability and promoting tissue remodeling characterized by epithelial-mesenchymal transition (EMT) and collagen deposition. This leads to esophageal strictures and narrow caliber esophagi, which are proportional a patient's age and untreated disease length. Pathophysiological mechanisms leading to EoE have been described in recent years, and transforming growth factor beta (TGF)-beta have been involved in fibrotic phenomena in EoE. However, evidence on the dependence of these phenomena on TGF-beta is scarce and contradictory. This review provides state-of-the art knowledge on intimate mechanisms of esophageal fibrosis in EoE and its clinical consequences.
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Affiliation(s)
- Laura Arias-González
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700 Tomelloso, Spain; (L.A.-G.); (L.R.-A.); (E.J.L.-M.); (P.N.); (E.G.-N.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria Princesa, 28006 Madrid, Spain
| | - Leticia Rodríguez-Alcolado
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700 Tomelloso, Spain; (L.A.-G.); (L.R.-A.); (E.J.L.-M.); (P.N.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
| | - Emilio J. Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700 Tomelloso, Spain; (L.A.-G.); (L.R.-A.); (E.J.L.-M.); (P.N.); (E.G.-N.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria Princesa, 28006 Madrid, Spain
| | - Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700 Tomelloso, Spain; (L.A.-G.); (L.R.-A.); (E.J.L.-M.); (P.N.); (E.G.-N.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
| | - Alfredo J. Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700 Tomelloso, Spain; (L.A.-G.); (L.R.-A.); (E.J.L.-M.); (P.N.); (E.G.-N.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria Princesa, 28006 Madrid, Spain
| | - Elena Grueso-Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700 Tomelloso, Spain; (L.A.-G.); (L.R.-A.); (E.J.L.-M.); (P.N.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
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10
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Visser E, Ten Brinke A, Sizoo D, Pepels JJS, Ten Have L, van der Wiel E, van Zutphen T, Kerstjens HAM, de Jong K. Effect of dietary interventions on markers of type 2 inflammation in asthma: A systematic review. Respir Med 2024; 221:107504. [PMID: 38141862 DOI: 10.1016/j.rmed.2023.107504] [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] [Received: 06/19/2023] [Revised: 11/29/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Type 2 (T2) inflammation is a key mechanism in the pathophysiology of asthma. Diet may have immunomodulatory effects, and a role for diet in T2 inflammation has been suggested in the literature. Indeed, diet and food allergies play a role in children with atopic asthma, but less is known about diet in relation to adult asthma, which is often non-atopic. OBJECTIVE To review the effect of dietary interventions on markers of T2 inflammation in adults with asthma. METHODS The databases PubMed, Embase, Cochrane Library, and CINAHL were searched for eligible studies until December 2022. We included studies of all types of foods, nutrients, diets or supplements, either as an exposure or as an intervention, in adults and adolescents with asthma. Outcomes of interest included the T2 biomarkers FeNO, eosinophils, IL-4, IL-5, IL-13, eosinophil cationic protein and eosinophil peroxidase. The methodological quality of eligible studies was systematically evaluated, and the results were summarised according to dietary clusters. RESULTS The systematic search identified studies on the dietary clusters antioxidants (n = 14), fatty acids, (n = 14), Mediterranean-style diets (n = 5), phytotherapy (n = 7), prebiotics & probiotics (n = 8), vitamin D (n = 7), and other dietary factors (n = 5). Studies within the phytotherapy and omega-3 poly-unsaturated fatty acids (PUFA) clusters showed possible improvements in T2 inflammation. Furthermore, we found little evidence for an effect of antioxidants, prebiotics & probiotics, and Mediterranean-style diets on T2 inflammation. However, heterogeneity in study protocols, methodological shortcomings and limited power of almost all studies make it difficult to fully determine the impact of different dietary approaches on T2 inflammation in asthma. CONCLUSIONS Overall, the current evidence does not support a specific dietary intervention to improve T2 inflammation in asthma. Interventions involving phytotherapy and omega-3 PUFA currently have the best evidence and warrant further evaluation in well-designed and adequately powered studies, while taking into account T2-high phenotypes of asthma.
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Affiliation(s)
- Edith Visser
- Department of Epidemiology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands; Department of Sustainable Health, Faculty Campus Fryslân, University of Groningen, Leeuwarden, the Netherlands.
| | - Anneke Ten Brinke
- Department of Pulmonary Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.
| | - Dionne Sizoo
- Department of Sustainable Health, Faculty Campus Fryslân, University of Groningen, Leeuwarden, the Netherlands; Centre Obesity Northern Netherlands (CON), Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.
| | - Janneke J S Pepels
- Department of Epidemiology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.
| | - Lianne Ten Have
- Department of Epidemiology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.
| | - Erica van der Wiel
- Department of Pulmonary Medicine, Martini Hospital, Groningen, the Netherlands.
| | - Tim van Zutphen
- Department of Sustainable Health, Faculty Campus Fryslân, University of Groningen, Leeuwarden, the Netherlands.
| | - Huib A M Kerstjens
- Department of Pulmonary Medicine, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands; Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, the Netherlands.
| | - Kim de Jong
- Department of Epidemiology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands.
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11
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Chehade M, Wright BL, Atkins D, Aceves SS, Ackerman SJ, Assa'ad AH, Bauer M, Collins MH, Commins SP, Davis CM, Dellon ES, Doerfler B, Gleich GJ, Gupta SK, Hill DA, Jensen ET, Katzka D, Kliewer K, Kodroff E, Kottyan LC, Kyle S, Muir AB, Pesek RD, Peterson K, Shreffler WG, Spergel JM, Strobel MJ, Wechsler J, Zimmermann N, Furuta GT, Rothenberg ME. Breakthroughs in understanding and treating eosinophilic gastrointestinal diseases presented at the CEGIR/TIGERs Symposium at the 2022 American Academy of Allergy, Asthma & Immunology Meeting. J Allergy Clin Immunol 2023; 152:1382-1393. [PMID: 37660987 DOI: 10.1016/j.jaci.2023.08.021] [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] [Received: 06/30/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 09/05/2023]
Abstract
The Consortium of Eosinophilic Gastrointestinal Diseases and The International Gastrointestinal Eosinophil Researchers organized a day-long symposium at the 2022 Annual Meeting of the American Academy of Allergy, Asthma & Immunology. The symposium featured a review of recent discoveries in the basic biology and pathogenesis of eosinophilic gastrointestinal diseases (EGIDs) in addition to advances in our understanding of the clinical features of EGIDs. Diagnostic and management approaches were reviewed and debated, and clinical trials of emerging therapies were highlighted. Herein, we briefly summarize the breakthrough discoveries in EGIDs.
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Affiliation(s)
- Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz; Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Dan Atkins
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Seema S Aceves
- Rady Children's Hospital, San Diego, Calif; Division of Allergy, Immunology, University of California-San Diego, San Diego, Calif
| | - Steven J Ackerman
- Department of Biochemistry and Molecular Genetics, College of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Amal H Assa'ad
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Maureen Bauer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Margaret H Collins
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Scott P Commins
- Division of Allergy & Immunology, Center for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Carla M Davis
- Division of Immunology, Allergy, and Retrovirology, Baylor College of Medicine, Houston, Tex; Texas Children's Hospital Food Allergy Program, Texas Children's Hospital, Houston, Tex
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Bethan Doerfler
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Chicago, Ill
| | - Gerald J Gleich
- Department of Dermatology, School of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Sandeep K Gupta
- Children's of Alabama, University of Alabama at Birmingham, Birmingham, Ala
| | - David A Hill
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | | | - David Katzka
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY
| | - Kara Kliewer
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ellyn Kodroff
- Campaign Urging Research for Eosinophilic Disease, Lincolnshire, Ill
| | - Leah C Kottyan
- Cincinnati Children's Research Foundation, Division of Human Genetics, Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Shay Kyle
- Campaign Urging Research for Eosinophilic Disease, Lincolnshire, Ill
| | - Amanda B Muir
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock, Ark; Arkansas Children's Hospital, Little Rock, Ark
| | - Kathryn Peterson
- Division of Gastroenterology, University of Utah Health, Salt Lake City, Utah
| | - Wayne G Shreffler
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Massachusetts General Hospital, Boston, Mass; Food Allergy Center, Massachusetts General Hospital, Boston, Mass
| | - Jonathan M Spergel
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Mary Jo Strobel
- American Partnership for Eosinophilic Disorders, Atlanta, Ga
| | - Joshua Wechsler
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Nives Zimmermann
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Marc E Rothenberg
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
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12
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Shichkin VP, Kurchenko OV, Okhotnikova EN, Chopyak VV, Delfino DV. Enterosorbents in complex therapy of food allergies: a focus on digestive disorders and systemic toxicity in children. Front Immunol 2023; 14:1210481. [PMID: 37901242 PMCID: PMC10611465 DOI: 10.3389/fimmu.2023.1210481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023] Open
Abstract
The review analyzes mechanisms and concomitant factors in developing IgE-associated allergic diseases provoked by food allergens and discusses clinical symptoms and current approaches for the treatment of food allergies. The expediency of using enterosorbents in complex therapy of food allergies and skin and respiratory manifestations associated with gastroenterological disorders is substantiated. The review summarizes the experience of using enterosorbents in post-Soviet countries to detoxify the human body. In this regard, special attention is paid to the enterosorbent White Coal (Carbowhite) based on silicon dioxide produced by the Ukrainian company OmniFarma.
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Affiliation(s)
| | | | - Elena N. Okhotnikova
- Department of Pediatrics, Children’s Infectious Diseases, Immunology and Allergology, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | - Valentyna V. Chopyak
- Department of Clinical Immunology and Allergology, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Domenico V. Delfino
- Master in Musculoskeletal and Rheumatological Physiotherapy, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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13
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Parrish CP. A review of food allergy panels and their consequences. Ann Allergy Asthma Immunol 2023; 131:421-426. [PMID: 37098403 DOI: 10.1016/j.anai.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/28/2023] [Accepted: 04/10/2023] [Indexed: 04/27/2023]
Abstract
Serum immunoglobulin E (IgE) assays to food specific IgE (s-IgE) are useful tools for the confirmation of clinical suspicion of food allergy. However, the specificity of these assays is poor given that sensitization is much more common than clinical food allergy. Therefore, the use of broad panels to assess sensitization to multiple foods often leads to overdiagnosis and unnecessary food avoidance. Unintended consequences that may occur as a result include physical harm, psychological harm, financial cost, opportunity cost, and even worsening of existing health care disparities. Although current guidelines recommend against the use of s-IgE food panel testing, these tests are widely available and frequently used. To limit the negative impacts of s-IgE food panel testing, further work is needed to effectively spread the message that these food panels may cause unintended harm to patients and families.
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Affiliation(s)
- Christopher P Parrish
- Division of Allergy and Immunology, Departments of Pediatrics and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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14
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Kleuskens MTA, Bek MK, Al Halabi Y, Blokhuis BRJ, Diks MAP, Haasnoot ML, Garssen J, Bredenoord AJ, van Esch BCAM, Redegeld FA. Mast cells disrupt the function of the esophageal epithelial barrier. Mucosal Immunol 2023; 16:567-577. [PMID: 37302713 DOI: 10.1016/j.mucimm.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/24/2023] [Accepted: 06/05/2023] [Indexed: 06/13/2023]
Abstract
Mast cells (MCs) accumulate in the epithelium of patients with eosinophilic esophagitis (EoE), an inflammatory disorder characterized by extensive esophageal eosinophilic infiltration. Esophageal barrier dysfunction plays an important role in the pathophysiology of EoE. We hypothesized that MCs contribute to the observed impaired esophageal epithelial barrier. Herein, we demonstrate that coculture of differentiated esophageal epithelial cells with immunoglobulin E-activated MCs significanly decreased epithelial resistance by 30% and increased permeability by 22% compared with non-activated MCs. These changes were associated with decreased messenger RNA expression of barrier proteins filaggrin, desmoglein-1 and involucrin, and antiprotease serine peptidase inhibitor kazal type 7. Using targeted proteomics, we detected various cytokines in coculture supernatants, most notably granulocyte-macrophage colony-stimulating factor and oncostatin M (OSM). OSM expression was increased by 12-fold in active EoE and associated with MC marker genes. Furthermore, OSM receptor-expressing esophageal epithelial cells were found in the esophageal tissue of patients with EoE, suggesting that the epithelial cells may respond to OSM. Stimulation of esophageal epithelial cells with OSM resulted in a dose-dependent decrease in barrier function and expression of filaggrin and desmoglein-1 and an increase in protease calpain-14. Taken together, these data suggest a role for MCs in decreasing esophageal epithelial barrier function in EoE, which may in part be mediated by OSM.
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Affiliation(s)
- Mirelle T A Kleuskens
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Marie K Bek
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Youmna Al Halabi
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Bart R J Blokhuis
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Mara A P Diks
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Maria L Haasnoot
- Department of Gastroenterology & Hepatology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Johan Garssen
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands; Danone Nutricia Research, Utrecht, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Betty C A M van Esch
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands; Danone Nutricia Research, Utrecht, The Netherlands
| | - Frank A Redegeld
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands.
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15
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Makiya MA, Brown T, Holland N, Wetzler L, Ware JAM, Khoury P, Frischmeyer-Guerrerio PA, Klion AD, Kuang FL. Distinct CRTH2+CD161+ (peTh2) memory CD4+ T-cell cytokine profiles in food allergy and eosinophilic gastrointestinal disorders. Clin Exp Allergy 2023; 53:1031-1040. [PMID: 37487654 PMCID: PMC10592354 DOI: 10.1111/cea.14376] [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] [Received: 01/19/2023] [Revised: 06/20/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Although IgE-mediated food allergy (FA) and eosinophilic gastrointestinal disorders (EGID) are clinically distinct and treated differently, pathogenic effector Th2 (peTh2) cells are implicated in the pathogenesis of both FA and EGID. The aim of this study was to better characterize peTh2 cells in the context of FA and EGID and the overlap between these two conditions. METHODS Peripheral blood peTh2 cells (CD3+CD4+CD27-CD49d+CRTH2+CD161+) were profiled by intracellular cytokine flow cytometry in the following patient cohorts: patients with FA alone (n = 8), FA and food-triggered EGID (EGID+FA+FT, n = 7), food-triggered EGID alone (EGID+FT, n = 7), EGID without FA or specific food triggers (ONLY_EGID, n = 9), and healthy volunteers (HV, n = 7). Overnight peripheral blood mononuclear cell (PBMC) culture supernatants were assessed for cytokine production by multiplex analysis. RESULTS CRTH2+CD161+ (peTh2) memory CD4+ T cells were significantly increased in both patients with FA and those with ALL_EGID (inclusive of EGID+FA+FT, EGID+FT and ONLY_EGID) when compared to HV. However, ALL_EGID patients, particularly those with EGID+FA+FT, had significantly elevated IL-5+IL-13+ peTh2 cells, whereas FA patients had significantly elevated IFN-γ or IL-17A-expressing peTh2 cells. This finding was supported by increased spontaneous IL-5 and IL-13 production in overnight cultures of PBMC from EGID+FA+FT patients compared to spontaneous IL-10 and IFN-γ production by PBMC from FA patients. FA patients had increased IL-9, IL-10, IL-17A, and IFN-γ production in overnight cultures of stimulated PBMC. CONCLUSIONS EGID and IgE-mediated FA share a common cell subtype defined by specific surface markers and termed CRTH2+CD161+ (peTh2) memory CD4+ T cells. However, the cytokine profiles of these CRTH2+CD161+ (peTh2) memory CD4+ T cells are markedly different between the two disorders.
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Affiliation(s)
| | - Thomas Brown
- Clinical Parasitology Section, LPD, NIAID, NIH, Bethesda, MD
| | - Nicole Holland
- Clinical Parasitology Section, LPD, NIAID, NIH, Bethesda, MD
| | - Lauren Wetzler
- Clinical Parasitology Section, LPD, NIAID, NIH, Bethesda, MD
| | | | - Paneez Khoury
- Human Eosinophil Section, LPD, NIAID, NIH, Bethesda, MD
| | | | - Amy D. Klion
- Human Eosinophil Section, LPD, NIAID, NIH, Bethesda, MD
| | - Fei Li Kuang
- Human Eosinophil Section, LPD, NIAID, NIH, Bethesda, MD
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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16
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Zhang X, Zhang N, Wang Z. Eosinophilic esophagitis and esophageal microbiota. Front Cell Infect Microbiol 2023; 13:1206343. [PMID: 37600943 PMCID: PMC10434796 DOI: 10.3389/fcimb.2023.1206343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is an antigen-mediated chronic inflammatory disease of the esophagus, the prevalence of which has steadily increased in recent years. The pathogenesis of EoE is not yet well-defined; however, recent studies have demonstrated that the esophageal microbiota is an essential regulator of physiological and pathological processes of EoE. Currently, research on EoE and microbiota is an emerging field of study that is receiving increasing attention. Here, we review existing EoE-related esophageal microbiota studies to explore the potential mechanisms underlying esophageal microbiota-mediated EoE. The esophageal microbiome is altered in patients with EoE. Although α diversity is usually not significantly different, an increase in Haemophilus and a decrease in Firmicutes were observed in EoE patients. The role of microbiota in initiating and perpetuating inflammation is not fully understood. Current evidence suggests that the penetration of microbiota leads to the activation of epithelial cells as well as innate and adaptive immune cells, with the subsequent release of cytokines, leading to immune responses and inflammation. The involvement of toll-like receptors in EoE also supports the potential role of the microbiota in the progression of this disease. While EoE-induced inflammation can also lead to alterations in the local microbiome. Moreover, dietary modifications, proton pump inhibitors, and corticosteroids can modulate the esophageal microbiota; however, definitive conclusions about the alterations of microbes after treatment cannot be drawn. These findings provide promising avenues for future studies.
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Affiliation(s)
- Xiaohan Zhang
- Microbiota Division, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Medical School, Nankai University, Tianjin, China
| | - Nana Zhang
- Microbiota Division, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zikai Wang
- Microbiota Division, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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17
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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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18
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Molina-Infante J, Mata-Romero P, Martín-Holgado D. New approaches to diet therapy for eosinophilic esophagitis. Curr Opin Gastroenterol 2023; 39:315-319. [PMID: 37097832 DOI: 10.1097/mog.0000000000000940] [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: 04/26/2023]
Abstract
PURPOSE OF REVIEW An empiric step-up (2-4-6) elimination diet remains the most common dietary approach in clinical practice when treating eosinophilic esophagitis (EoE). However, research in this field has fallen behind pharmacological therapy. This review aims to summarize novel approaches to dietary therapy for EoE. RECENT FINDINGS A first prospective multicenter study in 41 pediatric patients (mean age 9 years) has evaluated the efficacy of a cow's milk elimination diet. This dietary approach led to histological remission in 51% of patients, albeit a caveat is that up to 80% of patients were receiving concomitant therapy with proton pump inhibitors. In a series of 18 adult patients with documented milk-induced EoE, ingestión of 400 ml of sterilized milk (boiled for up to 20 min) daily for 8 weeks did not induce histologic relapse in two-thirds of patients. SUMMARY Milk elimination diet is effective in one-half of pediatric EoE patients and should likely be the first choice in children with EoE (within a step-up dietary approach). Promising data on tolerance of sterilized milk in adults with milk-induced EoE (66%) merit further replication in children, which may radically improve quality of life for patients and their caregivers.
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Affiliation(s)
- Javier Molina-Infante
- Department of Gastroenterology, Hospital Universitario de Cáceres, Cáceres
- Centro de Investigacion Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Pilar Mata-Romero
- Department of Gastroenterology, Hospital Universitario de Cáceres, Cáceres
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19
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Chen K, Hao Y, Guzmán M, Li G, Cerutti A. Antibody-mediated regulation of basophils: emerging views and clinical implications. Trends Immunol 2023; 44:408-423. [PMID: 37147229 PMCID: PMC10219851 DOI: 10.1016/j.it.2023.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 05/07/2023]
Abstract
An increasing number of human diseases, including allergies, infections, inflammation, and cancer, involve roles for basophils. Traditionally viewed as the rarest leukocytes that are present only in the circulation, basophils have recently emerged as important players in systemic as well as tissue-specific immune responses. Their functions are regulated by immunoglobulins (Igs), and this enables basophils to integrate diverse adaptive and innate immunity signals. IgE is well known to regulate basophil responses in the context of type 2 immunity and allergic inflammation; however, growing evidence shows that IgG, IgA, and IgD also shape specific aspects of basophil functions relevant to many human diseases. We discuss recent mechanistic advances underpinning antibody-mediated basophil responses and propose strategies for the treatment of basophil-associated disorders.
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Affiliation(s)
- Kang Chen
- Departments of Obstetrics and Gynecology, Oncology, Biochemistry, and Microbiology and Immunology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI 48201, USA; Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China.
| | - Yujing Hao
- Departments of Obstetrics and Gynecology, Oncology, Biochemistry, and Microbiology and Immunology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI 48201, USA; Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Mauricio Guzmán
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona Biomedical Research Park, Barcelona 08003, Spain
| | - Genxia Li
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Andrea Cerutti
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona Biomedical Research Park, Barcelona 08003, Spain; Marc and Jennifer Lipschultz Precision Immunology Institute and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Catalan Institute for Research and Advanced Studies (ICREA), Barcelona Biomedical Research Park, Barcelona 08003, Spain.
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20
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Masuda MY, LeSuer WE, Horsley-Silva JL, Putikova A, Buras MR, Gibson JB, Pyon GC, Simmons TD, Doyle AD, Wright BL. Food-Specific IgG4 Is Elevated Throughout the Upper Gastrointestinal Tract in Eosinophilic Esophagitis. Dig Dis Sci 2023; 68:2406-2413. [PMID: 36973521 PMCID: PMC10198037 DOI: 10.1007/s10620-023-07924-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/12/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Food-specific immunoglobulin G4 (FS-IgG4) is associated with eosinophilic esophagitis (EoE); however, it is not clear whether production is limited to the esophagus. AIMS To assess FS-IgG4 levels in the upper gastrointestinal tract and plasma and compare these with endoscopic disease severity, tissue eosinophil counts, and patient-reported symptoms. METHODS We examined prospectively banked plasma, throat swabs, and upper gastrointestinal biopsies (esophagus, gastric antrum, and duodenum) from control (n = 15), active EoE (n = 24), and inactive EoE (n = 8) subjects undergoing upper endoscopy. Patient-reported symptoms were assessed using the EoE symptom activity index (EEsAI). Endoscopic findings were evaluated using the EoE endoscopic reference score (EREFS). Peak eosinophils per high-power field (eos/hpf) were assessed from esophageal biopsies. Biopsy homogenates and throat swabs were normalized for protein content and assessed for FS-IgG4 to milk, wheat, and egg. RESULTS Median FS-IgG4 for milk and wheat was significantly increased in the plasma, throat swabs, esophagus, stomach, and duodenum of active EoE subjects compared to controls. No significant differences for milk- or wheat-IgG4 were observed between active and inactive EoE subjects. Among the gastrointestinal sites sampled, FS-IgG4 levels were highest in the esophagus. Esophageal FS-IgG4 for all foods correlated significantly across all sites sampled (r ≥ 0.59, p < 0.05). Among subjects with EoE, esophageal FS-IgG4 correlated significantly with peak eos/hpf (milk and wheat) and total EREFS (milk). EEsAI scores and esophageal FS-IgG4 levels did not correlate. CONCLUSIONS Milk and wheat FS-IgG4 levels are elevated in plasma and throughout the upper gastrointestinal tract in EoE subjects and correlate with endoscopic findings and esophageal eosinophilia.
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Affiliation(s)
- Mia Y Masuda
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
- Department of Immunology, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - William E LeSuer
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Jennifer L Horsley-Silva
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Arina Putikova
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Matthew R Buras
- Division of Biomedical Statistics and Biomedical Informatics, Department of Health Sciences Research, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Jessica B Gibson
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Grace C Pyon
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Temeka D Simmons
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Alfred D Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
- Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, USA.
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21
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Guarnieri KM, Saba NK, Schwartz JT, Devonshire AL, Bufford J, Casale TB, Rothenberg ME, Andorf S. Food Allergy Characteristics Associated With Coexisting Eosinophilic Esophagitis in FARE Registry Participants. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1509-1521.e6. [PMID: 36801492 PMCID: PMC10164686 DOI: 10.1016/j.jaip.2023.02.008] [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: 07/25/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) can coexist in individuals with food allergy. OBJECTIVE To evaluate the characteristics of food-allergic patients with and without coexisting EoE using a large food allergy patient registry. METHODS Data were derived from 2 Food Allergy Research & Education, Inc, Patient Registry surveys. A series of multivariable regression models were used to evaluate associations between demographic, comorbidity, and food allergy characteristics and the likelihood of reporting EoE. RESULTS Five percent (n = 309) of registry participants (n = 6074; ages <1 year->80 years, mean, 20.20 ± 15.37 years) reported having EoE. The odds of having EoE were significantly greater in male participants (adjusted odds ratio [aOR], 1.3; 95% CI, 1.04-1.72) and those with comorbid asthma (aOR, 2.0; 95% CI, 1.55-2.49), allergic rhinitis (aOR, 1.8; 95% CI, 1.37-2.22), oral allergy syndrome (aOR, 2.8; 95% CI, 2.09-3.70), food protein-induced enterocolitis syndrome (aOR, 2.5; 95% CI, 1.34-4.84), and hyper-IgE syndrome (aOR, 7.6; 95% CI, 2.93-19.92), though not atopic dermatitis (aOR, 1.3; 95% CI, 0.99-1.59), when adjusting for demographics (sex, age, race, ethnicity, and geographic location). Those with a greater number of food allergies (aOR, 1.3; 95% CI, 1.23-1.32), more frequent food-related allergic reactions (aOR, 1.2; 95% CI, 1.11-1.24), previous anaphylaxis (aOR, 1.5; 95% CI, 1.15-1.83), and health care utilization for food-related allergic reactions (aOR, 1.3; 95% CI, 1.01-1.67)-specifically intensive care unit admission (aOR, 1.2; 95% CI, 1.07-1.33)-were more likely to have EoE after controlling for demographics. However, no significant difference in ever using epinephrine for food-related allergic reactions was detected. CONCLUSIONS These self-reported data showed that coexisting EoE is associated with an increased number of food allergies, food-related allergic reactions per year, and measures of reaction severity, calling attention to the likely increased health care needs of food-allergic patients with EoE.
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Affiliation(s)
- Katharine M Guarnieri
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nicholas K Saba
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Justin T Schwartz
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashley L Devonshire
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Thomas B Casale
- Food Allergy Research & Education, McLean, Va; Division of Allergy and Immunology, University of South Florida, Tampa, Fla
| | - Marc E Rothenberg
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sandra Andorf
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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22
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Grueso-Navarro E, Navarro P, Laserna-Mendieta EJ, Lucendo AJ, Arias-González L. Blood-Based Biomarkers for Eosinophilic Esophagitis and Concomitant Atopic Diseases: A Look into the Potential of Extracellular Vesicles. Int J Mol Sci 2023; 24:ijms24043669. [PMID: 36835081 PMCID: PMC9967575 DOI: 10.3390/ijms24043669] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/17/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, Th2-inflammatory disease of the esophagus that can severely affect food intake. Currently, diagnosis and assessing response to treatment of EoE is highly invasive and requires endoscopy with esophageal biopsies. Finding non-invasive and accurate biomarkers is important for improving patient well-being. Unfortunately, EoE is usually accompanied by other atopies, which make it difficult to identify specific biomarkers. Providing an update of circulating EoE biomarkers and concomitant atopies is therefore timely. This review summarizes the current knowledge in EoE blood biomarkers and two of its most common comorbidities, bronchial asthma (BA) and atopic dermatitis (AD), focusing on dysregulated proteins, metabolites, and RNAs. It also revises the current knowledge on extracellular vesicles (EVs) as non-invasive biomarkers for BA and AD, and concludes with the potential use of EVs as biomarkers in EoE.
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Affiliation(s)
- Elena Grueso-Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, 13700 Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45004 Toledo, Spain
- Correspondence: (E.G.-N.); (A.J.L.)
| | - Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, 13700 Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45004 Toledo, Spain
| | - Emilio J. Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, 13700 Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45004 Toledo, Spain
- Laboratory Medicine Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006 Madrid, Spain
| | - Alfredo J. Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, 13700 Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45004 Toledo, Spain
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28006 Madrid, Spain
- Correspondence: (E.G.-N.); (A.J.L.)
| | - Laura Arias-González
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, 13700 Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45004 Toledo, Spain
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28006 Madrid, Spain
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23
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Description of allergic phenotype in patients with eosinophilic oesophagitis: management protocol proposal. Sci Rep 2023; 13:2226. [PMID: 36755125 PMCID: PMC9906574 DOI: 10.1038/s41598-023-29602-z] [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: 04/16/2022] [Accepted: 02/07/2023] [Indexed: 02/10/2023] Open
Abstract
There is a profile of patient with eosinophilic oesophagitis and atopic background, marked by the existence of IgE-mediated sensitizations. Our aim is to report the observed sensitivities to environmental and food allergens and panallergens in patients with eosinophilic oesophagitis with atopic background as well as characterizing other markers or analytical parameters. We suspect that the prevalence of sensitization to panallergens will be high and this will probably be relevant in terms of the onset and clinical course of the disease. We collated clinical and analytical data from 160 adult patients with a reported diagnosis of eosinophilic oesophagitis. These patients were studied between 1 January 2012 and 31 December 2020. During an initial visit skin tests were performed with full batteries of routine aero-allergens and foodstuffs. Patients were subsequently referred for blood test and determination of specific IgE, blood count and total IgE (in all cases), as well as eosinophilic cation protein and IMMUNOISAC in the centres in which this was available. We were able to detect a broad spectrum of sensitizations to environmental, foodstuffs and panallergens. The most common allergic disease was rhinoconjuntivitis. The sensitizations observed to foodstuffs were atypical for the adult population and were not responsible for manifestations compatible with immediate allergy. An important percentage of patients presented seasonal worsening of choking symptoms. We should be able to identify patients with eosinophilic oesophagitis and atopic background. Identifying this phenomenon would enable giving dietary and environmental recommendations as well as more specific and effective treatments to our patients.
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24
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Mechanisms and clinical management of eosinophilic oesophagitis: an overview. Nat Rev Gastroenterol Hepatol 2023; 20:101-119. [PMID: 36253463 DOI: 10.1038/s41575-022-00691-x] [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] [Accepted: 09/14/2022] [Indexed: 02/03/2023]
Abstract
Since the first description of eosinophilic oesophagitis (EoE) less than three decades ago, we have observed a striking increase in the number of patients diagnosed with EoE and the understanding of its clinical and immunopathogenic background. Nonetheless, a plethora of open questions await elucidation. In this Review, we discuss the current state of knowledge regarding the underlying mechanisms, particularly environmental factors and their interaction with genetic susceptibility. Subsequently, we discuss how to translate these factors into the diagnostic and therapeutic management of this chronic, immune-mediated disorder. Finally, we dissect the still long list of unmet needs, such as reasons for and handling refractory EoE and atypical clinical presentations. These open questions can guide us through future research steps and potentially foster reconsideration of the diagnostic guidelines of EoE.
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25
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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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26
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Maskey A, Srivastava K, Soffer G, Dunkin D, Yuan Q, Li XM. Induction of Severe Eosinophilic Esophagitis and Multi-Organ Inflammation by Airborne Allergens is Associated with IL-4/IL-13 and CCL11 but Not IgE in Genetic Susceptible Mice. J Inflamm Res 2022; 15:5527-5540. [PMID: 36176352 PMCID: PMC9514888 DOI: 10.2147/jir.s372449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
Background Eosinophilic Esophagitis (EoE) is an increasingly common chronic inflammatory disease. The pathological mechanisms underlying EoE are largely unknown. Objective We sought to understand the mechanisms underlying aeroallergen-induced EoE in Sharpin gene deficient (Sharpin-/-) mice that is prone to inflammatory response. Methods Sharpin-/-mice were exposed with Aspergillus fumigatus and ovalbumin intranasally every alternate day for 4 weeks. Wild type (WT) naïve mice, WT exposed, and un-exposed Sharpin-/- mice were controls. Histopathological analysis was performed by H&E, trichrome and major basic protein staining. Total and specific IgE, IgG, and IgA levels were measured by ELISA and Th2 cytokine and CCL11 chemokine gene expression were determined. Results Airborne allergen exposed Sharpin-/- mice showed severe eosinophilic inflammation in the esophagus (p < 0.001), and markedly increased epithelial thickening (p < 0.0001) compared to WT normal controls, whereas airborne allergen exposed WT mice and unexposed Sharpin-/- mice only showed mild eosinophilic inflammation in the esophagus. These exposed Sharpin-/- mice also showed over 7-fold increase in blood eosinophils (p < 0.0001), 60-fold increase in eosinophils in bronchoalveolar lavage fluid (p < 0.0001) and 4-fold increase in eosinophils in the skin (p < 0.0001) compared to normal controls. Surprisingly, exposed Sharpin-/- mice did not show elevation of serum total or antigen-specific IgE levels but reduced total IgA and IgG levels than normal controls There was a marked increase in IL-4, IL-13 and CCL11 gene expression in esophageal tissue (p < 0.001) in exposed Sharpin-/- mice compared to WT normal mice. Conclusion Th2 cytokines and chemokines, but not IgE may play an important pathologic role in aeroallergen-induced EoE. This study may provide insight into new therapeutics for EoE.
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Affiliation(s)
- Anish Maskey
- Department of Pathology, Microbiology & Immunology, New York Medical College, Valhalla, NY, USA
| | - Kamal Srivastava
- Department of Pathology, Microbiology & Immunology, New York Medical College, Valhalla, NY, USA.,General Nutraceutical Technology, LLC, Elmsford, NY, USA
| | - Gary Soffer
- Department of Allergy and Immunology, Yale University, New Haven, CT, USA
| | - David Dunkin
- Division of Pediatric Gastroenterology and Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Qian Yuan
- Pediatric Gastroenterology and Nutrition, Mass General Hospital for Children, Boston, MA, USA
| | - Xiu-Min Li
- Department of Pathology, Microbiology & Immunology, New York Medical College, Valhalla, NY, USA.,Department of Otolaryngology, New York Medical College, Valhalla, NY, USA
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27
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Khokhar D, Marella S, Idelman G, Chang JW, Chehade M, Hogan SP. Eosinophilic esophagitis: Immune mechanisms and therapeutic targets. Clin Exp Allergy 2022; 52:1142-1156. [PMID: 35778876 PMCID: PMC9547832 DOI: 10.1111/cea.14196] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/08/2022] [Accepted: 06/20/2022] [Indexed: 01/26/2023]
Abstract
Eosinophilic esophagitis (EoE) is an emerging chronic inflammatory disease of the oesophagus and is clinically characterized by upper gastrointestinal (GI) symptoms including dysphagia and esophageal food impaction. Histopathologic manifestations, which include intraepithelial eosinophilic inflammation and alterations of the esophageal squamous epithelium, such as basal zone hyperplasia (BZH) and dilated intercellular spaces (DIS), are thought to contribute to esophageal dysfunction and disease symptoms. Corroborative clinical and discovery science-based studies have established that EoE is characterized by an underlying allergic inflammatory response, in part, related to the IL-13/CCL26/eosinophil axis driving dysregulation of several key epithelial barrier and proliferative regulatory genes including kallikrein (KLK) serine proteases, calpain 14 (CAPN14) and anoctamin 1 (ANO1). The contribution of these inflammatory and proliferative processes to the clinical and histological manifestations of disease are not fully elucidated. Herein, we discuss the immune molecules and cells that are thought to underlie the clinical and pathologic manifestations of EoE and the emerging therapeutics targeting these processes for the treatment of EoE.
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Affiliation(s)
- Dilawar Khokhar
- Division of Allergy and ImmunologyUniversity of MichiganAnn ArborMichiganUSA
- Mary H Weiser Food Allergy CenterUniversity of MichiganAnn ArborMichiganUSA
| | - Sahiti Marella
- Mary H Weiser Food Allergy CenterUniversity of MichiganAnn ArborMichiganUSA
- Department of PathologyUniversity of MichiganAnn ArborMichiganUSA
| | - Gila Idelman
- Mary H Weiser Food Allergy CenterUniversity of MichiganAnn ArborMichiganUSA
| | - Joy W. Chang
- Division of Gastroenterology, Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic DisordersIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Simon P. Hogan
- Mary H Weiser Food Allergy CenterUniversity of MichiganAnn ArborMichiganUSA
- Department of PathologyUniversity of MichiganAnn ArborMichiganUSA
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28
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González-Cervera J, Arias Á, Navarro P, Juárez-Tosina R, Cobo-Palacios M, Olalla JM, Angueira-Lapeña T, Lucendo AJ. Tolerance to sterilised cow's milk in patients with eosinophilic oesophagitis triggered by milk. Aliment Pharmacol Ther 2022; 56:957-967. [PMID: 35916162 DOI: 10.1111/apt.17171] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/09/2022] [Accepted: 07/20/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Cow's milk protein is the main food trigger for eosinophilic oesophagitis (EoE) in children and adults and should be continuously avoided once identified as such. AIMS To evaluate tolerance of sterilised cow's milk (boiled instead of UHT processing) with regard to maintenance of EoE remission, health-related quality of life (HRQoL), nutritional intake and allergic sensitisation in patients of all ages with milk-triggered EoE METHODS: We prospectively recruited patients in whom cow's milk was demonstrated to trigger EoE after an empirical food elimination diet-based study. They were given 200 ml of sterilised cow's milk twice daily for 8 weeks. Endoscopic assessment, peak eosinophil counts, oesophageal-related symptoms, HRQoL, blood eosinophils, eosinophil cationic protein (ECP), skin prick test and serum total and specific immunoglobulin E (IgE) to major milk proteins were monitored before and after sterilised milk intake. RESULTS Eighteen patients (13 male) in EoE remission underwent a sterilised milk challenge. Twelve maintained EoE remission (<15 eos/hpf) while EoE recurred in the remainder. Endoscopic appearances deteriorated in non-tolerant patients. HRQoL scored well at baseline and was maintained among patients tolerant to sterilised milk, but deteriorated in reactive ones. No significant changes in blood eosinophil count, ECP, tryptase or total and milk-specific IgE serum levels were observed from baseline. However, cow's milk-specific IgE increased slightly in non-tolerant patients. Clinical and histological remission were maintained in patients who regularly consumed sterilised milk for 1 year. CONCLUSION Sterilised milk did not trigger EoE in two-thirds of patients with documented milk-induced EoE, in either the short or long term.
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Affiliation(s)
- Jesús González-Cervera
- Department of Allergy, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
| | - Ángel Arias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain.,Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Spain.,Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Pilar Navarro
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain.,Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Rocío Juárez-Tosina
- Department of Pathology, Hospital General Mancha Centro, Alcázar de San Juan, Spain
| | - María Cobo-Palacios
- Nutrition and Dietetics Unit, Hospital General de Tomelloso, Tomelloso, Spain
| | - José M Olalla
- Department of Pathology, Hospital General Mancha Centro, Alcázar de San Juan, Spain
| | | | - Alfredo J Lucendo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain.,Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain.,Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
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29
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Straumann A, Greuter T. Novel targets in EoE: one step forward? Gut 2022; 72:811-812. [PMID: 35977813 DOI: 10.1136/gutjnl-2022-327770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/31/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Greuter
- Department of Gastroenterology and Hepatology, Lausanne University Hospital, Lausanne, Switzerland
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30
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Aloi M, D'Arcangelo G, Rossetti D, Bucherini S, Felici E, Romano C, Martinelli M, Dipasquale V, Lionetti P, Oliva S. Occurrence and Clinical Impact of Eosinophilic Esophagitis in a Large Cohort of Children With Inflammatory Bowel Disease. Inflamm Bowel Dis 2022:6658537. [PMID: 35942651 DOI: 10.1093/ibd/izac172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Scarce data have investigated the association between pediatric inflammatory bowel disease (IBD) and eosinophilic esophagitis (EoE). We, therefore, aimed to describe the epidemiology and the possible peculiar phenotype and natural history of such an association. METHODS Case-control study is based on the Italian Society for Pediatric Gastroenterology (SIGENP) national registry. All children with a combined diagnosis of IBD and EoE were included. The overall prevalence and incidence in 2 periods, 2009 to 2015, and 2016 to 2021, were calculated. Cases were matched with IBD only and EoE only patients in a 1:3:3 ratio. Phenotype and outcomes (courses of steroids, risk of complications, surgery, treatment escalation, and hospitalization) were compared between groups. RESULTS Eleven patients (age 11.2 ± 2.8 years, Males 91%) with EoE-IBD out of 3090 patients with IBD were identified, resulting in an overall prevalence of 0.35% and an incidence of 0.18% for 2009 to 2015 and 0.45% for 2016 to 2021. Treatment escalation rates for IBD were significantly higher in patients with IBD compared with EoE-IBD at 12- and 24-month follow-up (0% vs 30%, P = .04; and 9% vs 45.5%, P = .03, respectively). Furthermore, patients with IBD were at a significantly higher risk of hospitalization than both EoE-IBD and EoE patients (log rank P < .001). We found no significant differences in major outcomes related to the EoE course in EoE-IBD patients compared with EoE ones. CONCLUSIONS The incidence and prevalence of EoE in children with IBD are low, although the incidence seems to be rising in recent years. Having EoE appears to be associated with a milder IBD disease course, whereas having IBD does not seem to affect the natural history of EoE. More data are needed to better define the phenotype of such association.
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Affiliation(s)
- Marina Aloi
- Sapienza University of Rome - Umberto I Hospital, Rome, Italy
| | | | - Danilo Rossetti
- Sapienza University of Rome - Umberto I Hospital, Rome, Italy
| | | | - Enrico Felici
- Sapienza University of Rome - Umberto I Hospital, Rome, Italy
| | - Claudio Romano
- Sapienza University of Rome - Umberto I Hospital, Rome, Italy
| | | | | | - Paolo Lionetti
- Sapienza University of Rome - Umberto I Hospital, Rome, Italy
| | - Salvatore Oliva
- Sapienza University of Rome - Umberto I Hospital, Rome, Italy
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31
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Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R, Morris D, Epstein J, Novelli MR, Hunter H, Cordell A, Hall S, Hayat JO, Kapur K, Moore AR, Read C, Sami SS, Turner PJ, Trudgill NJ. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022; 71:1459-1487. [PMID: 35606089 PMCID: PMC9279848 DOI: 10.1136/gutjnl-2022-327326] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE. METHODS The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance. RESULTS Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research. CONCLUSIONS These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.
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Affiliation(s)
- Anjan Dhar
- Gastroenterology, Darlington Memorial Hospital, Darlington, UK .,Teesside University, Middlesbrough, UK
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea University, Swansea, UK,Department of Gastroenterology, University Hospital Llandough, Llandough, UK
| | | | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
| | - Jason M Dunn
- Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
| | - Rami Sweis
- Research Department of Tissue and Energy, Division of Surgery & Interventional Science, University College London, London, UK
| | - Danielle Morris
- Department of Gastroenterology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Hannah Hunter
- Department of Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Amanda Cordell
- Trustee & Chair, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sharon Hall
- Department of Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Jamal O Hayat
- Gastroenterology, St George's Healthcare NHS Trust, London, UK
| | - Kapil Kapur
- Gastroenterology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Andrew Robert Moore
- Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Carol Read
- Medical advisor/Patient advocate, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sarmed S Sami
- Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul J Turner
- National Heart and Lung Institute Section of Allergy and Clinical Immunology, London, UK,Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
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32
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Lucendo AJ, Molina-Infante J. Current treatment options and long-term outcomes in patients with eosinophilic esophagitis. Expert Rev Clin Immunol 2022; 18:859-872. [PMID: 35770955 DOI: 10.1080/1744666x.2022.2096591] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Dietary and pharmacological (proton pump inhibitors, swallowed topical corticosteroids) therapies are effective for induction of clinical and histological remission of eosinophilic esophagitis. However, data evaluating their long-term efficacy and safety is limited. AREAS COVERED Since eosinophilic esophagitis is chronic, clinical, endoscopic, and histological features usually recur when successful treatments are stopped. In untreated patients, persistent esophageal eosinophilic inflammation may progress to fibrostenosis over time, giving place to strictures and narrow-caliber esophagi. This article comprehensively reviews available data on long-term maintenance of eosinophilic esophagitis with pharmacological and dietary treatment. It also discusses limitations re: available literature and outlines data gaps on adherence to therapy and monitoring disease activity in the long-term. EXPERT OPINION Evidence indicates that long-term maintenance therapy may decrease the risk of esophageal stricture, food bolus impaction, and need for dilation in patients with eosinophilic esophagitis. Further knowledge on eosinophilic esophagitis phenotypes is needed to ascertain who will benefit best from sustained therapy. Unanswered questions include an adequate definition for sustained remission, best strategies for maintenance drugs and diets, enhancement of treatment adherence, and proper monitoring for long-term surveillance.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Javier Molina-Infante
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de Caceres, Caceres, Spain
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33
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Kaymak T, Kaya B, Wuggenig P, Nuciforo S, Göldi A, Oswald F, Roux J, Noti M, Melhem H, Hruz P, Niess JH. IL-20 subfamily cytokines impair the oesophageal epithelial barrier by diminishing filaggrin in eosinophilic oesophagitis. Gut 2022; 72:821-833. [PMID: 35613844 PMCID: PMC10086458 DOI: 10.1136/gutjnl-2022-327166] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/02/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Disruption of the epithelial barrier plays an essential role in developing eosinophilic oesophagitis (EoE), a disease defined by type 2 helper T cell (Th2)-mediated food-associated and aeroallergen-associated chronic inflammation. Although an increased expression of interleukin (IL)-20 subfamily members, IL-19, IL-20 and IL-24, in Th2-mediated diseases has been reported, their function in EoE remains unknown. DESIGN Combining transcriptomic, proteomic and functional analyses, we studied the importance of the IL-20 subfamily for EoE using patient-derived oesophageal three-dimensional models and an EoE mouse model. RESULTS Patients with active EoE have increased expression of IL-20 subfamily cytokines in the oesophagus and serum. In patient-derived oesophageal organoids stimulated with IL-20 cytokines, RNA sequencing and mass spectrometry revealed a downregulation of genes and proteins forming the cornified envelope, including filaggrins. On the contrary, abrogation of IL-20 subfamily signalling in Il20R2 -/- animals resulted in attenuated experimental EoE reflected by reduced eosinophil infiltration, lower Th2 cytokine expression and preserved expression of filaggrins in the oesophagus. Mechanistically, these observations were mediated by the mitogen-activated protein kinase (MAPK); extracellular-signal regulated kinases (ERK)1/2) pathway. Its blockade prevented epithelial barrier impairment in patient-derived air-liquid interface cultures stimulated with IL-20 cytokines and attenuated experimental EoE in mice. CONCLUSION Our findings reveal a previously unknown regulatory role of the IL-20 subfamily for oesophageal barrier function in the context of EoE. We propose that aberrant IL-20 subfamily signalling disturbs the oesophageal epithelial barrier integrity and promotes EoE development. Our study suggests that specific targeting of the IL-20 subfamily signalling pathway may present a novel strategy for the treatment of EoE.
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Affiliation(s)
- Tanay Kaymak
- Department of Biomedicine, Gastroenterology, University of Basel, Basel, Switzerland
| | - Berna Kaya
- Department of Biomedicine, Gastroenterology, University of Basel, Basel, Switzerland
| | - Philipp Wuggenig
- Department of Biomedicine, Gastroenterology, University of Basel, Basel, Switzerland
| | - Sandro Nuciforo
- Department of Biomedicine, Hepatology, University of Basel, Basel, Switzerland
| | - Andreas Göldi
- Department of Gastroenterology, Clarunis - University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | | | - Franz Oswald
- Department of Internal Medicine I, University Hospital Ulm, Ulm, Germany
| | - Julien Roux
- Department of Biomedicine, Gastroenterology, University of Basel, Basel, Switzerland.,Swiss Institute of Bioinformatics, Basel, Switzerland
| | - Mario Noti
- Institute of Pathology, University of Bern, Bern, Switzerland, Current address: Nestlé SA, Nestlé Research, Nestlé Institute of Health Sciences, Department of Gastrointestinal Health Immunology, Vers-Chez-les-Blancs, Lausanne, Switzerland
| | - Hassan Melhem
- Department of Biomedicine, Gastroenterology, University of Basel, Basel, Switzerland
| | - Petr Hruz
- Department of Gastroenterology, Clarunis - University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Jan Hendrik Niess
- Department of Biomedicine, Gastroenterology, University of Basel, Basel, Switzerland .,Department of Gastroenterology, Clarunis - University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland
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34
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Navarro P, Laserna-Mendieta EJ, Casabona S, Savarino E, Pérez-Fernández MT, Ghisa M, Pérez-Martínez I, Guagnozzi D, Perelló A, Guardiola-Arévalo A, Racca F, Betoré E, Blas-Jhon L, Krarup AL, Martín-Domínguez V, Maniero D, Suárez A, Llerena-Castro R, de la Peña-Negro L, Navacerrada AG, Pellegatta G, Alcedo J, de Hurtado Mendoza-Guena L, Feo-Ortega S, Barrio J, Gutiérrez-Junquera C, Fernández-Fernández S, De la Riva S, E Navés J, Carrión S, Ciriza de Los Ríos C, García-Morales N, Rodríguez-Oballe JA, Dainese R, Rodríguez-Sánchez A, Masiques-Mas ML, Palomeque MT, Santander C, Tamarit-Sebastián S, Arias Á, Lucendo AJ. Accurate and timely diagnosis of Eosinophilic Esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry. United European Gastroenterol J 2022; 10:507-517. [PMID: 35578565 PMCID: PMC9189464 DOI: 10.1002/ueg2.12240] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/24/2022] [Indexed: 12/29/2022] Open
Abstract
Background Poor adherence to clinical practice guidelines for eosinophilic esophagitis (EoE) has been described and the diagnostic delay of the disease continues to be unacceptable in many settings. Objective To analyze the impact of improved knowledge provided by the successive international clinical practice guidelines on reducing diagnostic delay and improving the diagnostic process for European patients with EoE. Methods Cross‐sectional analysis of the EoE CONNECT registry based on clinical practice. Time periods defined by the publication dates of four major sets of guidelines over 10 years were considered. Patients were grouped per time period according to date of symptom onset. Results Data from 1,132 patients was analyzed and median (IQR) diagnostic delay in the whole series was 2.1 (0.7‐6.2) years. This gradually decreased over time with subsequent release of new guidelines (p < 0.001), from 12.7 years up to 2007 to 0.7 years after 2017. The proportion of patients with stricturing of mixed phenotypes at the point of EoE diagnosis also decreased over time (41.3% vs. 16%; p < 0.001), as did EREFS scores. The fibrotic sub‐score decreased from a median (IQR) of 2 (1‐2) to 0 (0‐1) when patients whose symptoms started up to 2007 and after 2017 were compared (p < 0.001). In parallel, symptoms measured with the Dysphagia Symptoms Score reduced significantly when patients with symptoms starting before 2007 and after 2012 were compared. A reduction in the number of endoscopies patients underwent before the one that achieved an EoE diagnosis, and the use of allergy testing as part of the diagnostic workout of EoE, also reduced significantly over time (p = 0.010 and p < 0.001, respectively). Conclusion The diagnostic work‐up of EoE patients improved substantially over time at the European sites contributing to EoE CONNECT, with a dramatic reduction in diagnostic delay.
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Affiliation(s)
- Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain
| | - Sergio Casabona
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - María Teresa Pérez-Fernández
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Viladecans, Viladecans, Spain
| | | | - Francesca Racca
- Personalized Medicine, Asthma and Allergy. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Elena Betoré
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Leonardo Blas-Jhon
- Department of Gastroenterology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Anne Lund Krarup
- Department of Medicine and Department of Clinical Medicine. The North Danish Regional Hospital, Hjoerring and Aalborg University, Aalborg, Denmark
| | - Verónica Martín-Domínguez
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Adolfo Suárez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ronald Llerena-Castro
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Gaia Pellegatta
- Endoscopy Unit. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Javier Alcedo
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Sara Feo-Ortega
- Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Pediatric Gastroenterology Unit. Hospital General de Tomelloso, Tomelloso, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carolina Gutiérrez-Junquera
- Department of Pediatric Gastroenterology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Susana De la Riva
- Department of Gastroenterology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan E Navés
- Department of Gastroenterology, Parc de Salut Mar, Barcelona, Spain
| | - Silvia Carrión
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Department of Gastroenterology, Hospital de Mataró, Mataró, Spain
| | - Constanza Ciriza de Los Ríos
- Department of Gastroenterology. Hospital Clínico Universitario San Carlos, Instituto de Investigacion Sanitaria San Carlos (IdISSC), Madrid, Spain.,Universidad Complutense, Madrid, Spain
| | | | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology, Hospital Universitario Arnau de Vilanova & Hospital Universitario Santa María, Lérida, Spain
| | - Raffaela Dainese
- Department of Gastroenterology, Centre Hospitalier d'Antibes Juan-les-Pins, Antibes, France
| | | | | | | | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Sonsoles Tamarit-Sebastián
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Research Unit. Hospital General Mancha-Centro, Alcázar de San Juan, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
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Tedner SG, Asarnoj A, Thulin H, Westman M, Konradsen JR, Nilsson C. Food allergy and hypersensitivity reactions in children and adults-A review. J Intern Med 2022; 291:283-302. [PMID: 34875122 DOI: 10.1111/joim.13422] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Adverse reactions after food intake are commonly reported and a cause of concern and anxiety that can lead to a very strict diet. The severity of the reaction can vary depending on the type of food and mechanism, and it is not always easy to disentangle different hypersensitivity diagnoses, which sometimes can exist simultaneously. After a carefully taken medical history, hypersensitivity to food can often be ruled out or suspected. The most common type of allergic reaction is immunoglobulin E (IgE)-mediated food allergy (prevalence 5-10%). Symptoms vary from mild itching, stomach pain, and rash to severe anaphylaxis. The definition of IgE-mediated food allergy is allergic symptoms combined with specific IgE-antibodies, and therefore only IgE-antibodies to suspected allergens should be analyzed. Nowadays, methods of molecular allergology can help with the diagnostic process. The most common allergens are milk and egg in infants, peanut and tree nuts in children, and fish and shellfish in adults. In young children, milk/egg allergy has a good chance to remit, making it important to follow up and reintroduce the food when possible. Other diseases triggered by food are non-IgE-mediated food allergy, for example, eosinophilic esophagitis, celiac disease, food protein-induced enterocolitis syndrome, and hypersensitivity to milk and biogenic amines. Some of the food hypersensitivities dominate in childhood, others are more common in adults. Interesting studies are ongoing regarding the possibilities of treating food hypersensitivity, such as through oral immunotherapy. The purpose of this review was to provide an overview of the most common types of food hypersensitivity reactions.
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Affiliation(s)
- Sandra G Tedner
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Asarnoj
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Thulin
- Allergy and Lung Department, Sachs' Children and Youth Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Marit Westman
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Asthma and Allergy Clinic S:t Göran, Stockholm, Sweden
| | - Jon R Konradsen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Nilsson
- Allergy and Lung Department, Sachs' Children and Youth Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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36
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Greuter T, Straumann A, Fernandez‐Marrero Y, Germic N, Hosseini A, Yousefi S, Simon D, Collins MH, Bussmann C, Chehade M, Dellon ES, Furuta GT, Gonsalves N, Hirano I, Moawad FJ, Biedermann L, Safroneeva E, Schoepfer AM, Simon H. Characterization of eosinophilic esophagitis variants by clinical, histological, and molecular analyses: A cross-sectional multi-center study. Allergy 2022; 77:2520-2533. [PMID: 35094416 PMCID: PMC9545458 DOI: 10.1111/all.15233] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/29/2021] [Accepted: 12/31/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Physicians are increasingly confronted with patients presenting with symptoms of esophageal dysfunction resembling eosinophilic esophagitis (EoE), but absence of significant esophageal eosinophilia. The purpose of this study was to characterize and classify this group of EoE variants. DESIGN Patients from six EoE-centers with symptoms of esophageal dysfunction, but peak eosinophil counts of <60/mm2 (<15/hpf) in esophageal biopsies and absence of gastro-esophageal reflux disease (GERD) were included. Clinical, endoscopic, (immuno)-histological, and molecular features were determined and compared with EoE, GERD, and healthy controls. RESULTS We included 69 patients with EoE variants. Endoscopic abnormalities were found in 53.6%. We identified three histological subtypes: EoE-like esophagitis (36/69, 52.2%), lymphocytic esophagitis (14/69, 20.3%), and non-specific esophagitis (19/69, 27.5%). Immunohistochemistry revealed-in contrast to EoE-no significant increase in inflammatory cell infiltrates compared with GERD and healthy controls, except for lymphocytes in lymphocytic esophagitis. EoE-typical Th2-response was absent in all EoE variants. However, considerable structural changes were detected based on histology and protein expression. Using next generation mRNA sequencing, we found the three EoE variants to have distinct molecular fingerprints partially sharing pronounced traits of EoE. Hierarchical sample clustering of RNA sequencing data confirmed the presence of an EoE-like (characterized by eotaxin-3 expression), non-specific, and lymphocytic variant cluster (characterized by CD3 cells and TSLP expression). CONCLUSION All EoE variants are clinically and histologically active conditions despite the absence of esophageal eosinophilia. EoE variants appear to be part of a disease spectrum, where classical EoE represents the most common and apparent phenotype.
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Affiliation(s)
- Thomas Greuter
- Department of Gastroenterology and Hepatology University Hospital Zurich Zurich Switzerland
- Division of Gastroenterology and Hepatology University Hospital Lausanne – Centre Hopitalier Universitaire Vaudois (CHUV) Lausanne Switzerland
| | - Alex Straumann
- Department of Gastroenterology and Hepatology University Hospital Zurich Zurich Switzerland
| | | | - Nina Germic
- Institute of Pharmacology University of Bern Bern Switzerland
| | - Aref Hosseini
- Institute of Pharmacology University of Bern Bern Switzerland
| | - Shida Yousefi
- Institute of Pharmacology University of Bern Bern Switzerland
| | - Dagmar Simon
- Department of Dermatology, Inselspital Bern University Hospital University of Bern Bern Switzerland
| | - Margaret H. Collins
- Division of Pathology Cincinnati Children`s Hospital Medical Center Cincinnati Ohio USA
| | | | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders Icahn School of Medicine at Mount Sinai New York New York USA
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology UNC Hospital Chapel Hill North Carolina USA
| | - Glenn T. Furuta
- Department of Pediatrics Gastrointestinal Eosinophilic Diseases Program Digestive Health Institute Children’s Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology Northwestern University Chicago Illinois USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology Northwestern University Chicago Illinois USA
| | - Fouad J. Moawad
- Division of Gastroenterology Scripps Clinic La Jolla California USA
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology University Hospital Zurich Zurich Switzerland
| | | | - Alain M. Schoepfer
- Division of Gastroenterology and Hepatology University Hospital Lausanne – Centre Hopitalier Universitaire Vaudois (CHUV) Lausanne Switzerland
| | - Hans‐Uwe Simon
- Institute of Pharmacology University of Bern Bern Switzerland
- Institute of Biochemistry Brandenburg Medical School Neuruppin Germany
- Department of Clinical Immunology and Allergology Sechenov University Moscow Russia
- Laboratory of Molecular Immunology Institute of Fundamental Medicine and Biology Kazan Federal University Kazan Russia
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Feo-Ortega S, Lucendo AJ. Evidence-based treatments for eosinophilic esophagitis: insights for the clinician. Therap Adv Gastroenterol 2022; 15:17562848211068665. [PMID: 35069803 PMCID: PMC8777364 DOI: 10.1177/17562848211068665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/03/2021] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. Left untreated, EoE progresses to fibrous remodeling and stricture formation that impairs quality of life. Therefore, EoE requires either repeated treatments or maintenance therapy. Current guidelines recommend swallowed topical corticosteroids (STCs), proton-pump inhibitors (PPIs), or dietary intervention as initial options to induce and maintain long-term disease remission. Impractical exclusive elemental diets and suboptimal allergy testing-directed food avoidance paved the way for empirical elimination diets. These are moderately effective and highly reproducible in inducing EoE remission and allow for identification of specific food triggers. Step-up strategies, including two- and four-food rather than six-food elimination diets, should be considered as initial approaches for dietary treatment in patients of all ages, as they reduce the need for endoscopic procedures, shorten diagnostic processing time, and avoid unnecessary restrictions. Formulations of STC originally designed for asthma therapy are suboptimal for EoE treatment, with new effervescent orodispersible tablets and viscose formulations designed to coat the esophageal mucosa providing increased effectiveness at reduced doses. The anti-inflammatory effects of PPI in EoE are independent from gastric acid secretion inhibition; despite evidence from observational research, PPIs are the most commonly prescribed first-line therapy for EoE due to their accessibility, low cost, and safety profile. Double doses of PPI only induce remission in half of EoE patients, irrespective of the drug used or patients' age. Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving EoE remission. Most responders effectively maintain long-term remission with standard PPI doses. Finally, endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. This article provides a state-of-the-art review and updated discussion of current therapies and newly developed options for EoE.
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Affiliation(s)
- Sara Feo-Ortega
- Pediatric Gastroenterology Unit, Hospital
General de Tomelloso, Tomelloso, Spain, and Instituto de Investigación
Sanitaria de Castilla-La Mancha (IDISCAM)
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Yousef E, Korotkaya Y, Simpson AB. Eosinophilic esophagitis in children: Updates and practical aspects of management for allergists in a non-tertiary care private practice setup. Allergy Asthma Proc 2022; 43:5-11. [PMID: 34983704 DOI: 10.2500/aap.2022.43.210084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Eosinophilic esophagitis (EoE) is a chronic immune and/or antigen-mediated disease characterized by eosinophilic infiltration of mucosa (≥15 eosinophils per high power field) without any secondary etiology. Non-immunoglobulin E mediated mechanisms predominate in EoE. Objective: This review concentrated on a stepwise approach for the allergist working in non-tertiary care private practice. Methods: A medical literature search that focused on several areas of the latest developments in the diagnosis and management of EoE was conducted. Results: There has been a steady increase in the prevalence and incidence of EoE. Clinical symptoms can vary from dysphagia to failure to thrive, depending on the age at presentation; some children develop adaptive behaviors to compensate for dysphagia, such as food preferences and slow eating. The diagnosis is based on a high index of clinical suspicion and is confirmed with endoscopy with biopsies after ruling out other causes of esophageal eosinophilia. Treatment options may include dietary therapy, pharmacologic therapies, or combination therapy. Therapeutic options may also include endoscopic dilation for stricturing disease. Conclusion: Providers should be aware of recent recommendation changes in the diagnostic workup, the role of skin-prick testing, and role of the proton-pump inhibitor as first-line therapy for EoE. Also, clinicians should be aware of the emerging role of empiric dietary therapy as a preferable therapeutic option when compared with the testing-directed diet and the elemental diet. Furthermore, topical glucocorticoid therapies are available, and new developing therapies are being investigated. Reevaluation of esophageal mucosa with biopsies is required approximately 2 months after therapy for a response and after a change in therapies to confirm continued resolution.
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Affiliation(s)
- Ejaz Yousef
- From the Divisions of Allergy/Immunology and Pediatric Gastroentrology, Nemours Children Specialty Care, Jacksonville, Florida; and
| | - Yelena Korotkaya
- From the Divisions of Allergy/Immunology and Pediatric Gastroentrology, Nemours Children Specialty Care, Jacksonville, Florida; and
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Cortes LM, Brodsky D, Chen C, Pridgen T, Odle J, Snider DB, Cruse G, Putikova A, Masuda MY, Doyle AD, Wright BL, Dawson HD, Blikslager A, Dellon ES, Laster SM, Käser T. Immunologic and pathologic characterization of a novel swine biomedical research model for eosinophilic esophagitis. FRONTIERS IN ALLERGY 2022; 3:1029184. [PMID: 36452260 PMCID: PMC9701751 DOI: 10.3389/falgy.2022.1029184] [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: 08/26/2022] [Accepted: 10/18/2022] [Indexed: 11/15/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergy-mediated condition with an increasing incidence in both children and adults. Despite EoE's strong impact on human health and welfare, there is a large unmet need for treatments with only one recently FDA-approved medication for EoE. The goal of this study was to establish swine as a relevant large animal model for translational biomedical research in EoE with the potential to facilitate development of therapeutics. We recently showed that after intraperitoneal sensitization and oral challenge with the food allergen hen egg white protein (HEWP), swine develop esophageal eosinophilia-a hallmark of human EoE. Herein, we used a similar sensitization and challenge treatment and evaluated immunological and pathological markers associated with human EoE. Our data demonstrate that the incorporated sensitization and challenge treatment induces (i) a systemic T-helper 2 and IgE response, (ii) a local expression of eotaxin-1 and other allergy-related immune markers, (iii) esophageal eosinophilia (>15 eosinophils/0.24 mm2), and (iv) esophageal endoscopic findings including linear furrows and white exudates. Thereby, we demonstrate that our sensitization and oral challenge protocol not only induces the underlying immune markers but also the micro- and macro-pathological hallmarks of human EoE. This swine model for EoE represents a novel relevant large animal model that can drive translational biomedical research to develop urgently needed treatment strategies for EoE.
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Affiliation(s)
- Lizette M Cortes
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.,Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
| | - David Brodsky
- Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.,Department of Biological Sciences, North Carolina State University, Raleigh, NC, United States
| | - Celine Chen
- USDA, ARS, Diet, Genomics and Immunology Laboratory, Beltsville, MD, United States
| | - Tiffany Pridgen
- Department of Clinical Sciences, North Carolina State University, Raleigh, NC, United States
| | - Jack Odle
- Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.,Laboratory of Developmental Nutrition, Department of Animal Science, North Carolina State University, Raleigh, NC, United States
| | - Douglas B Snider
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, United States
| | - Glenn Cruse
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, United States
| | - Arina Putikova
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Mia Y Masuda
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Department of Immunology, Mayo Clinic, Rochester, MN, United States.,Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Alfred D Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Harry D Dawson
- USDA, ARS, Diet, Genomics and Immunology Laboratory, Beltsville, MD, United States
| | - Anthony Blikslager
- Department of Clinical Sciences, North Carolina State University, Raleigh, NC, United States
| | - Evan S Dellon
- Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.,Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Scott M Laster
- Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.,Department of Biological Sciences, North Carolina State University, Raleigh, NC, United States
| | - Tobias Käser
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States.,Center for Food Allergy Modeling in Pigs (CFAMP), Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
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Watkinson RL, Looi K, Laing IA, Cianferoni A, Kicic A. Viral Induced Effects on a Vulnerable Epithelium; Lessons Learned From Paediatric Asthma and Eosinophilic Oesophagitis. Front Immunol 2021; 12:773600. [PMID: 34912343 PMCID: PMC8666438 DOI: 10.3389/fimmu.2021.773600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/05/2021] [Indexed: 01/07/2023] Open
Abstract
The epithelium is integral to the protection of many different biological systems and for the maintenance of biochemical homeostasis. Emerging evidence suggests that particular children have epithelial vulnerabilities leading to dysregulated barrier function and integrity, that resultantly contributes to disease pathogenesis. These epithelial vulnerabilities likely develop in utero or in early life due to various genetic, epigenetic and environmental factors. Although various epithelia are uniquely structured with specific function, prevalent allergic-type epithelial diseases in children potentially have common or parallel disease processes. These include inflammation and immune response dysregulation stemming from atypical epithelial barrier function and integrity. Two diseases where aetiology and pathogenesis are potentially linked to epithelial vulnerabilities include Paediatric Asthma and Eosinophilic Oesophagitis (EoE). For example, rhinovirus C (RV-C) is a known risk factor for paediatric asthma development and is known to disrupt respiratory epithelial barrier function causing acute inflammation. In addition, EoE, a prevalent atopic condition of the oesophageal epithelium, is characterised by similar innate immune and epithelial responses to viral injury. This review examines the current literature and identifies the gaps in the field defining viral-induced effects on a vulnerable respiratory epithelium and resulting chronic inflammation, drawing from knowledge generated in acute wheezing illness, paediatric asthma and EoE. Besides highlighting the importance of epithelial structure and barrier function in allergic disease pathogenesis regardless of specific epithelial sub-types, this review focuses on the importance of examining other parallel allergic-type disease processes that may uncover commonalities driving disease pathogenesis. This in turn may be beneficial in the development of common therapeutics for current clinical management and disease prevention in the future.
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Affiliation(s)
- Rebecca L Watkinson
- Division of Paediatrics, Medical School, The University of Western Australia, Nedlands, WA, Australia.,Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Perth, WA, Australia
| | - Kevin Looi
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Perth, WA, Australia.,School of Public Health, Curtin University, Bentley, WA, Australia
| | - Ingrid A Laing
- Division of Paediatrics, Medical School, The University of Western Australia, Nedlands, WA, Australia.,Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Perth, WA, Australia
| | - Antonella Cianferoni
- Pediatrics Department, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Anthony Kicic
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Perth, WA, Australia.,School of Public Health, Curtin University, Bentley, WA, Australia.,Centre for Cell Therapy and Regenerative Medicine, School of Medicine, The University of Western Australia, Nedlands, WA, Australia
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41
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Zhernov YV, Vysochanskaya SO, Sukhov VA, Zaostrovtseva OK, Gorshenin DS, Sidorova EA, Mitrokhin OV. Molecular Mechanisms of Eosinophilic Esophagitis. Int J Mol Sci 2021; 22:ijms222413183. [PMID: 34947981 PMCID: PMC8703627 DOI: 10.3390/ijms222413183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/04/2021] [Accepted: 12/05/2021] [Indexed: 12/19/2022] Open
Abstract
Food hypersensitivity is a group of diseases arising from a specific immune response that reproduces on exposure to a given food. The current understanding of molecular mechanisms and immunopathology of non-IgE-mediated/mixed food hypersensitivity, e.g., eosinophilic esophagitis, contains many gaps in knowledge. This review aims to provide a modern classification and identify the primary diseases of non-IgE-mediated/mixed food hypersensitivity reactions, delineate the distinctive molecular features, and discuss recent findings in the immunopathology of eosinophilic esophagitis that may become a basis to develop valid biomarkers and novel therapies for this disease. Eosinophilic esophagitis is a recently recognized allergic-mediated disease with eosinophil-predominant esophagus inflammation. Its pathogenesis is a complicated network of interactions and signaling between epithelial, mesenchymal, and immune cells on molecular and intercellular levels. Alterations produced by overactivation of some cytokine signaling pathways, e.g., IL-13 or thymic stromal lymphopoietin (TSLP), were evolved and observed in this review from the viewpoints of molecular, genetic, epigenetic, and transcriptomic changes. Despite substantial experimental data, the reliable and representative mechanism of eosinophilic esophagitis pathogenesis has yet to show itself. So, the place of esophagitis between mixed and non-IgE-mediated allergic disorders and between eosinophilic gastrointestinal disorders currently seems vague and unclear.
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Affiliation(s)
- Yury V. Zhernov
- Department of General Hygiene, F. Erismann Institute of Public Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia; (S.O.V.); (V.A.S.); (O.K.Z.); (D.S.G.); (E.A.S.); (O.V.M.)
- Department of Chemistry, Lomonosov Moscow State University, 119991 Moscow, Russia
- Correspondence: ; Tel.: +7-(915)-1552000
| | - Sonya O. Vysochanskaya
- Department of General Hygiene, F. Erismann Institute of Public Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia; (S.O.V.); (V.A.S.); (O.K.Z.); (D.S.G.); (E.A.S.); (O.V.M.)
| | - Vitaly A. Sukhov
- Department of General Hygiene, F. Erismann Institute of Public Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia; (S.O.V.); (V.A.S.); (O.K.Z.); (D.S.G.); (E.A.S.); (O.V.M.)
| | - Olga K. Zaostrovtseva
- Department of General Hygiene, F. Erismann Institute of Public Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia; (S.O.V.); (V.A.S.); (O.K.Z.); (D.S.G.); (E.A.S.); (O.V.M.)
| | - Denis S. Gorshenin
- Department of General Hygiene, F. Erismann Institute of Public Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia; (S.O.V.); (V.A.S.); (O.K.Z.); (D.S.G.); (E.A.S.); (O.V.M.)
| | - Ekaterina A. Sidorova
- Department of General Hygiene, F. Erismann Institute of Public Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia; (S.O.V.); (V.A.S.); (O.K.Z.); (D.S.G.); (E.A.S.); (O.V.M.)
| | - Oleg V. Mitrokhin
- Department of General Hygiene, F. Erismann Institute of Public Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia; (S.O.V.); (V.A.S.); (O.K.Z.); (D.S.G.); (E.A.S.); (O.V.M.)
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Irani MZ, Jones MP, Halland M, Herrick L, Choung RS, Loftus YAS, Walker MM, Murray JA, Talley NJ. Prevalence, symptoms and risk factor profile of rumination syndrome and functional dyspepsia: a population-based study. Aliment Pharmacol Ther 2021; 54:1416-1431. [PMID: 34626489 PMCID: PMC10835603 DOI: 10.1111/apt.16630] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/26/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Rumination syndrome is a functional gastroduodenal disorder characterised by effortless regurgitation of recently ingested food. Emerging evidence reports duodenal eosinophilic inflammation in a subset, suggesting a shared pathophysiology with functional dyspepsia (FD). AIM To assess the clinical features of rumination syndrome and FD in a community-based study. METHODS We mailed a survey assessing gastrointestinal symptoms, diet and psychological symptoms to 9835 residents of Olmsted County, MN, USA in 2017-2018; diagnostic codes were obtained from linked clinical records. The two disorders were assessed as mutually exclusive in 'pure' forms with a separate overlap group, all compared to a control group not meeting criteria for either. Prevalence of associations, and univariate and independent associations with predictors were assessed by logistic regression. RESULTS Prevalence of rumination syndrome and FD were 5.8% and 7.1%, respectively; the overlap was 3.83-times more likely than expected by chance. Independent predictors for rumination (odds ratio (OR), 95% confidence interval (CI)) were female gender (1.79, 1.21-2.63), smoking (1.89, 1.28-2.78), gluten-free diet (1.58, 1.14-2.19), allergic rhinitis (1.45, 1.01-2.08) and depression (1.10, 1.05-1.16). FD was independently associated with female gender, depression, non-coeliac wheat sensitivity, migraine, irritable bowel syndrome and somatic symptoms. A similar reported efficacy (≥54%) of low fat or dairy-free diets was found with both disorders (P = 0.53 and P = 1.00, respectively). The strongest independent associations with overlapping FD and rumination syndrome were a history of rheumatoid arthritis (3.93, 1.28-12.06) and asthma (3.02, 1.44-6.34). CONCLUSION Rumination syndrome overlaps with FD with a shared risk factor profile, suggesting a common pathophysiology.
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Affiliation(s)
- Mudar Zand Irani
- Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health
- Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Michael P. Jones
- NHMRC Centre of Research Excellence in Digestive Health
- School of Psychological Sciences, Macquarie University, North Ryde, Australia
| | - Magnus Halland
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Linda Herrick
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rok Seon Choung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Marjorie M. Walker
- Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health
| | - Joseph A. Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Nicholas J. Talley
- Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
- NHMRC Centre of Research Excellence in Digestive Health
- Hunter Medical Research Institute, New Lambton Heights, Australia
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Dilollo J, Rodríguez‐López EM, Wilkey L, Martin EK, Spergel JM, Hill DA. Peripheral markers of allergen-specific immune activation predict clinical allergy in eosinophilic esophagitis. Allergy 2021; 76:3470-3478. [PMID: 33840099 DOI: 10.1111/all.14854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/23/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a T-cell-mediated disease that is caused by specific foods and results in esophageal dysfunction. Existing allergy testing modalities are not helpful when attempting to identify EoE-causal foods necessitating empiric food elimination and recurrent endoscopy. The goal of this study was to identify and compare allergen-specific immune features that can be assayed in a minimally invasive manner to predict clinical food allergy in EoE. METHODS We obtained blood samples from control subjects (n = 17), subjects with clinical EoE milk allergy (n = 17), and subjects with immunoglobulin E-mediated milk allergy (n = 9). We measured total and milk-specific plasma immunoglobulin G (IgG)4 levels and peripheral memory CD4+ T helper (TH ) cell proliferation and cytokine production after stimulation with endotoxin-depleted milk proteins. Sensitivity and specificity for predicting clinical EoE milk allergy were calculated and compared between approaches. RESULTS Total and milk-specific IgG4 levels were not significantly different between control subjects and subjects with clinical EoE milk allergy. Stimulation with milk proteins caused TH lymphocytes from subjects with clinical EoE milk allergy to proliferate more (%P1 of 38.3 ± 4.6 vs. 12.7 ± 2.8, p < 0.0001), and produce more type 2 cytokines (%IL-4+ of 33.7 ± 2.8 vs. 6.9 ± 1.6, p < 0.0001) than cells from control subjects. Milk-dependent memory TH -cell proliferation (sensitivity and specificity of 88% and 82%, respectively) and interleukin 4 (IL-4) production (sensitivity and specificity of 100%) most strongly predicted clinical EoE milk allergy. CONCLUSIONS Peripheral markers of allergen-specific immune activation may be useful in identifying EoE-causal foods. Assaying milk-dependent IL-4 production by circulating memory TH lymphocytes most accurately predicts clinical EoE milk allergy.
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Affiliation(s)
- Julianna Dilollo
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
| | - Eric M. Rodríguez‐López
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
- Institute for Immunology and Department of Pediatrics Perelman School of Medicine Philadelphia PA USA
| | - Leah Wilkey
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
| | - Elizabeth K. Martin
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
| | - Jonathan M. Spergel
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
- Institute for Immunology and Department of Pediatrics Perelman School of Medicine Philadelphia PA USA
| | - David A. Hill
- Division of Allergy and Immunology Center for Pediatric Eosinophilic Disorders Children's Hospital of Philadelphia Philadelphia PA USA
- Institute for Immunology and Department of Pediatrics Perelman School of Medicine Philadelphia PA USA
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Vandenplas Y, Brough HA, Fiocchi A, Miqdady M, Munasir Z, Salvatore S, Thapar N, Venter C, Vieira MC, Meyer R. Current Guidelines and Future Strategies for the Management of Cow's Milk Allergy. J Asthma Allergy 2021; 14:1243-1256. [PMID: 34712052 PMCID: PMC8548055 DOI: 10.2147/jaa.s276992] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/08/2021] [Indexed: 12/13/2022] Open
Abstract
Abstract Exclusive breast feeding is recommended in all guidelines as the first choice feeding. Cow milk allergy (CMA) can be diagnosed by a diagnostic elimination diet for 2 to 4 weeks with a hypo-allergenic formula, followed by a challenge test with intact cow milk protein. The most often used hypo-allergenic formula for the diagnostic elimination diet and the therapeutic diet is a CM based extensive hydrolysate. CM-based partial hydrolysates cannot be recommended in the management of CMA because of insufficient efficacy and possible reactions, but about half of the infants with CMA may tolerate a partial hydrolysate. The pros and cons of other dietary options are discussed in this paper. The use of an amino acid-based formula and/or rice based hydrolysate formula during the diagnostic elimination and therapeutic diet is debated. When available, there is sufficient evidence to consider rice hydrolysates as an adequate alternative to CM-based hydrolysates, since some infants will still react to the CM hydrolysate. The pros and cons of dietary options such as soy formula, buckwheat, almond, pea or other plant based dietary products are discussed. Although the majority of the plant-based beverages are nutritionally inadequate, some are nutritionally adapted for toddlers. However, accessibility and content vary by country and, thus far there is insufficient evidence on the efficacy and tolerance of these plant-based drinks (except for soy formula and rice hydrolysates) to provide an opinion on them. Conclusion A diagnostic elimination diet, followed by a challenge remains the diagnostic standard. The use of an awareness tool may result in a decrease of delayed diagnosis. Breastmilk remains the ideal source of nutrition and when not available a CM extensively hydrolyzed formula, rice hydrolysate or amino acid formula should be recommended. More evidence is needed regarding plant-based drinks.
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Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Helen A Brough
- Department Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK.,Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, UK
| | - Alessandro Fiocchi
- Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, Rome, Italy
| | - Mohamad Miqdady
- Department of Pediatrics, Sheikh Khalifa Medical City, College of Medicine & Health Sciences, Khalifa University, Khalifa, United Arab Emirates
| | - Zakiudin Munasir
- Department of Child Health, Ciptomangunkusumo Hospital-Medical Faculty Universitas Indonesia, Jakarta, Indonesia
| | - Silvia Salvatore
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, Varese, Italy
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Carina Venter
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Mario C Vieira
- Center for Pediatric Gastroenterology -Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Rosan Meyer
- Department of Paediatrics, Imperial College, London, UK.,Department Nutrition and Dietetics, University of Winchester, Winchester, UK
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Cianferoni A, Jensen E, Davis CM. The Role of the Environment in Eosinophilic Esophagitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3268-3274. [PMID: 34507708 DOI: 10.1016/j.jaip.2021.07.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 12/17/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease clinicopathologically characterized by esophageal dysfunction. EoE is characterized by eosinophilic histologic inflammation indistinguishable from other atopic diseases such as asthma, eczema, or allergic rhinitis, which often co-occur in patients with EoE. This suggest a possible shared pathophysiology and triggers in the development of EoE with other atopic conditions. Although the evidence of EoE being linked to exposure to allergenic foods is strong, the connection between EoE and aeroallergens is less understood. In this review, we will discuss clinical, epidemiological, and animal studies that investigate how environmental allergens influence the clinical manifestations of EoE and its seasonality. It is also known that the developing immune system is significantly shaped by early-life exposures, pollution, climate change, and those factors that are known to influence development of asthma. We therefore also describe the evidence for and the gaps in our knowledge of the role of early-life exposures, pollution, and climate change in the development of EoE.
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Affiliation(s)
- Antonella Cianferoni
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Elizabeth Jensen
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | - Carla M Davis
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
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Meyer R, De Koker C, Dziubak R, Godwin H, Reeve K, Chebar-Lozinsky A, Foong RX, Skrapac AK, Ellmer M, Shah N. The Challenge of Home Allergen Re-introductions Using the Ladder Approach in Children With Non-IgE Mediated Gastrointestinal Food Allergy. FRONTIERS IN ALLERGY 2021; 2:721686. [PMID: 35386976 PMCID: PMC8974734 DOI: 10.3389/falgy.2021.721686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Oral food challenges remain the most reliable method for allergy confirmation. Although consensus guidelines have been published to unify Immunoglobulin E (IgE)-mediated challenges, this does not exist for non-IgE mediated gastrointestinal allergies outside of Food Protein Induced Enterocolitis Syndrome. We therefore set out to establish the use of home introduction protocols (HIP) for confirmation of food allergy for milk, soya, egg and wheat using a ladder approach in children with non-IgE mediated allergy. Materials and Methods: Patients with suspected non-IgE mediated gastrointestinal allergies (0–16 years) were recruited following symptom improvement on an elimination diet. All children had skin prick or specific IgE tests to rule out IgE-mediated allergies prior to suggestion the HIP. Number of trials and outcome was documented. HIPs were developed using a published ladder approach for cow's milk as baseline and final dose was calculated based on guidelines for food protein induced enterocolitis syndrome and portions for age from the National Diet and Nutrition Survey. First foods were baked/highly processed and every 4th day patients moved to a more unprocessed/unheated food. Results: From 131 recruited patients, 117 (89.3%) followed the HIP for food allergens. No adverse events were documented. In more than 50% of cases one attempt at the HIP was sufficient to establish allergy status, but many required 2–5 attempts before the outcome was clear. About half of the children were fully tolerant to foods they initially eliminated: 36, 26 and 30% were partially tolerant to milk, soya, and egg and only 15% achieved partial tolerance to wheat. Wheat was the allergen introduced earliest, followed by soya, cow's milk and egg. Conclusions: This study indicates that home HIPs are safe in non-IgE mediated gastrointestinal food allergy and that the ladder approach may be useful in re-introducing allergens in children at home with non-IgE mediated gastrointestinal allergies. From this study we can also conclude that tolerance to processed/baked allergens was observed in many children. Further studies should be performed on the HIP and ideally reintroduction should occur pre-defined time intervals.
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Affiliation(s)
- Rosan Meyer
- Department of Paediatric, Imperial College, London, United Kingdom
- *Correspondence: Rosan Meyer
| | - Claire De Koker
- Brackengate Intermediate Care Facility, Cape Town, South Africa
| | - Robert Dziubak
- Department of Gastroenterology, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Heather Godwin
- Frimley Health NHS Foundation Trust, Camberley, United Kingdom
| | - Kate Reeve
- Royal Hospital for Sick Children and Young People, Edinburgh, United Kingdom
| | | | - Ru-Xin Foong
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ana-Kristina Skrapac
- Department Nutrition and Dietetics, Chelsea and Westminster Hospital NHS Foundation Trust, Department of Nutrition and Dietetics, London, United Kingdom
| | - Marlene Ellmer
- Department of Gastroenterology, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Neil Shah
- Department of Gastroenterology, University College London, UK and Reckitt, Slough, United Kingdom
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Khan S, Guo X, Liu T, Iqbal M, Jiang K, Zhu L, Chen X, Wang BM. An Update on Eosinophilic Esophagitis: Etiological Factors, Coexisting Diseases, and Complications. Digestion 2021; 102:342-356. [PMID: 32570246 DOI: 10.1159/000508191] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 04/26/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is an immune-mediated clinicopathological condition characterized by esophageal infiltration with eosinophils resulting in chronic inflammation and stricture. SUMMARY The recent increase in the incidence of EoE and the characteristic presentation of symptoms with difficulty swallowing and food bolus impaction has raised key concerns of clinicians as well as researchers. EoE often presents with dysphagia, food impaction, nausea, regurgitation or vomiting, and decreased appetite. It is more common in males, affecting both adults and children. The causative manner of this condition is complex and multifactorial. Throughout recent years, researchers have made a significant contribution to understanding the pathogenesis of EoE, genetic background, natural history, work on allergy, and standardization in the evaluation of disease activity. There is relatively high prevalence of EoE among the population, emphasizing the importance of this disease. Key messages: Esophageal involvement with eosinophils may be manifested as isolated or with coexisting conditions and should be taken into consideration in the differential diagnosis. This study aimed to provide gastroenterologists with novel insights into the evaluation of esophageal involvement with eosinophils and to pay special attention to the etiological factors, coexisting clinical diseases, and complications.
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Affiliation(s)
- Samiullah Khan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaopei Guo
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Tianyu Liu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Muhammad Iqbal
- Department of Otorhinolaryngology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Kui Jiang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Lanping Zhu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xin Chen
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Bang-Mao Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China,
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Di Chio T, Sokollik C, Peroni DG, Hart L, Simonetti G, Righini-Grunder F, Borrelli O. Nutritional Aspects of Pediatric Gastrointestinal Diseases. Nutrients 2021; 13:nu13062109. [PMID: 34205445 PMCID: PMC8235230 DOI: 10.3390/nu13062109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 12/16/2022] Open
Abstract
In the last decade, the role of nutritional management in pediatric gastrointestinal diseases has gained increasing popularity. Disease-specific diets have been introduced as conventional treatments by international guidelines. Patients tend to more willingly accept food-based therapies than drugs because of their relatively “harmless” nature. Apart from a diet’s therapeutic role, nutritional support is crucial in maintaining growth and improving clinical outcomes in pediatric patients. Despite the absence of classical “side effects”, however, it should be emphasized that any dietary modification might have negative consequences on children’s growth and development. Hence, expert supervision is always advised, in order to support adequate nutritional requirements. Unfortunately, the media provide an inaccurate perception of the role of diet for gastrointestinal diseases, leading to misconceptions by patients or their caregivers that tends to overestimate the beneficial role of diets and underestimate the potential adverse effects. Moreover, not only patients, but also healthcare professionals, have a number of misconceptions about the nutritional benefits of diet modification on gastrointestinal diseases. The aim of this review is to highlight the role of diet in pediatric gastrointestinal diseases, to detect misconceptions and to give a practical guide for physicians on the basis of current scientific evidence.
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Affiliation(s)
- Teresa Di Chio
- Pediatric Institute of Southern Switzerland, Ospedale Regionale di Bellinzona e Valli, Via Ospedale 12, 6500 Bellinzona, Switzerland;
- Correspondence: (T.D.C.); (C.S.); (F.R.-G.); (O.B.)
| | - Christiane Sokollik
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital, Inselspital, University of Bern, 3010 Bern, Switzerland
- Correspondence: (T.D.C.); (C.S.); (F.R.-G.); (O.B.)
| | - Diego G. Peroni
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, 56126 Pisa, Italy;
| | - Lara Hart
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, McMaster University, Hamilton, ON L8N 3Z5, Canada;
| | - Giacomo Simonetti
- Pediatric Institute of Southern Switzerland, Ospedale Regionale di Bellinzona e Valli, Via Ospedale 12, 6500 Bellinzona, Switzerland;
- Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Franziska Righini-Grunder
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucerne Children’s Hospital, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland
- Correspondence: (T.D.C.); (C.S.); (F.R.-G.); (O.B.)
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Pediatric Gastroenterology, University College London (UCL) Institute of Child Health and Great Ormond Street, London WC1N 3JH, UK
- Correspondence: (T.D.C.); (C.S.); (F.R.-G.); (O.B.)
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Philpott H, Lee SZ, Arrington A, McGee SJ, Dellon ES. Impact of food challenge on local oesophageal immunophenotype in eosinophilic oesophagitis. Clin Exp Allergy 2021; 50:463-470. [PMID: 32012383 DOI: 10.1111/cea.13578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/24/2019] [Accepted: 12/02/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is caused by the ingestion of food antigens. Dietary avoidance can result in clinical and histological remission, while food reintroduction can cause recurrence. It is uncertain if food antigen processing and immune activation occurs locally, in the oesophagus. Therefore, we performed a comparative study of the density of cell surface proteins (known to be involved with antigen presentation) on oesophageal tissue prior to, and following food antigen induced disease recurrence. A secondary aim was to consider novel biomarkers. METHOD Adult patients with a diagnosis of EoE, who had achieved histological remission with an elimination diet (<15 eosinophils per high power field at oesophageal biopsy), and who underwent food challenge with proven recurrence were included. Immunohistochemistry/immunofluorescence for CD1a, CD3, CD28, CD40, CD69, CD80, CD138, CXCR3 and HLA-DR was performed. Staining intensity of each biomarker (pixels/mm2 ) was quantified by semi-automated analysis (Studio-FL software). RESULTS Fourteen cases of EoE (pre and post food challenge), 6 GORD and 5 healthy controls were included. HLA-DR, CD3, CD28, CD40 and CD 138 significantly increased with food reintroduction (P = <0.05). CD1a, CD 69, CD 80 and CXCR3 did not measurably change. CONCLUSION The presence of cell surface proteins typically associated with antigen presentation (following food antigen induced recurrence) suggests immune activation occurs in the oesophagus, and the relative lack of langerhans cells (CD1a) may indicate this cell type is unimportant. The cell surface protein CD 138 increases with disease recurrence, is not elevated in GORD or healthy controls, and has promise as a biomarker.
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Affiliation(s)
- Hamish Philpott
- Department of Gastroenterology NALHN, Adelaide, University of Adelaide, Adelaide, SA, Australia
| | - Shawn Zhenhui Lee
- Department of Gastroenterology NALHN, Adelaide, University of Adelaide, Adelaide, SA, Australia
| | - Ashley Arrington
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sarah J McGee
- 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
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Biedermann L, Straumann A, Greuter T, Schreiner P. Eosinophilic esophagitis-established facts and new horizons. Semin Immunopathol 2021; 43:319-335. [PMID: 34097125 PMCID: PMC8241662 DOI: 10.1007/s00281-021-00855-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/23/2021] [Indexed: 12/13/2022]
Abstract
Despite dramatic advances in our understanding of the pathogenesis and course of disease in the relatively short timeframe since the discovery and first description of eosinophilic esophagitis (EoE) less than three decades ago, many open questions remain to be elucidated. For instance, we will need to better characterize atypical clinical presentations of EoE and other forms of esophageal inflammatory conditions with often similar clinical presentations, nut fulfilling current diagnostic criteria for EoE and to determine their significance and interrelationship with genuine EoE. In addition, the interrelationship of EoE with other immune-mediated diseases remains to be clarified. Hopefully, a closer look at the role of environmental factors and their interaction with genetic susceptibility often in context of atopic predisposition may enable identifying the candidate substances/agents/allergens and potentially earlier (childhood) events to trigger the condition. It appears plausible to assume that in the end—comparable to current concepts in other immune-mediated chronic diseases, such as for instance inflammatory bowel disease or asthma bronchiale—we will not be rewarded with the identification of a “one-and-only” underlying pathogenetic trigger factor, with causal responsibility for the disease in each and every EoE patient. Rather, the relative contribution and importance of intrinsic susceptibility, i.e., patient-driven factors (genetics, aberrant immune response) and external trigger factors, such as food (or aero-) allergens as well as early childhood events (e.g., infection and exposure to antibiotics and other drugs) may substantially differ among given individuals with EoE. Accordingly, selection and treatment duration of medical therapy, success rates and extent of required restriction in dietary treatment, and the need for mechanical treatment to address strictures and stenosis require an individualized approach, tailored to each patient. With the advances of emerging treatment options, the importance of such an individualized and patient-centered assessment will increase even further.
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Affiliation(s)
- Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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