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Shaker A. Esophageal remodeling in eosinophilic esophagitis. Curr Opin Gastroenterol 2024; 40:291-298. [PMID: 38661722 PMCID: PMC11156539 DOI: 10.1097/mog.0000000000001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW Eosinophilic esophagitis (EoE) is a Th2 immune/antigen-mediated disorder characterized by esophageal dysfunction and eosinophilic inflammation. Worsening dysphagia and food impactions are significant complications associated with esophageal remodeling and fibrostenotic disease. This review highlights the most recent research findings pertaining to mechanisms of sub-epithelial fibrosis in EoE, current diagnostic tools, and therapeutic approaches. RECENT FINDINGS Recent studies leveraging publicly available single cell sequencing databases and comparative proteomics have furthered our understanding of the mechanisms mediating fibrosis. Fibroblast crosstalk with the extracellular matrix and with epithelial, endothelial, and T cells have been implicated, with the likely existence of multiple fibroblast sub-types. Accurate diagnosis of remodeling with biopsies remains a challenge due to inadequate depth of sampling. Web-based tools incorporating epithelial findings show promise in predicting subepithelial fibrosis. Impedance planimetry with esophageal distensibility measurements are increasingly utilized tools to assess fibrostenotic severity. Immunostaining and luminal captured proteins associated with remodeling show promise as potential molecular markers of fibrosis. Anti-inflammatory therapy may improve esophageal fibrosis and distensibility, although specific fibrosis-targeted therapy is lacking. SUMMARY Recent studies highlight novel mechanisms of fibrosis in EoE. Improved understanding of these mechanisms may lead to novel diagnostic strategies and therapies, and thereby inform treatment decisions.
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Affiliation(s)
- Anisa Shaker
- University of Southern California, Keck School of Medicine of USC, Department of Medicine, Division of Gastrointestinal and Liver Diseases, Swallowing and Esophageal Disorders Center, Los Angeles, California, USA
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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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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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Nelson MR, Zhang X, Podgaetz E, Wang X, Zhang Q, Pan Z, Spechler SJ, Souza RF. Th2 cytokine signaling through IL-4Rα increases eotaxin-3 secretion and tension in human esophageal smooth muscle. Am J Physiol Gastrointest Liver Physiol 2024; 326:G38-G52. [PMID: 37933466 DOI: 10.1152/ajpgi.00155.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023]
Abstract
In esophageal epithelial cells in eosinophilic esophagitis (EoE), Th2 cytokines (IL-4, IL-13) signal through IL-4Rα, activating JAK to increase eotaxin-3 secretion, which draws eosinophils into the mucosa. We explored whether Th2 cytokines also might stimulate eotaxin-3 secretion and increase tension in esophageal smooth muscle (ESM), which might impair esophageal distensibility, and whether those events could be blocked by proton pump inhibitors (PPIs) or agents that disrupt IL-4Rα signaling. We established human ESM cell cultures from organ donors, characterizing Th2 cytokine receptor and P-type ATPase expression by qPCR. We measured Th2 cytokine-stimulated eotaxin-3 secretion by enzyme-linked immunosorbent assay (ELISA) and ESM cell tension by gel contraction assay, before and after treatment with omeprazole, ruxolitinib (JAK inhibitor), or IL-4Rα blocking antibody. CPI-17 (inhibitor of a muscle-relaxing enzyme) effects were studied with CPI-17 knockdown by siRNA or CPI-17 phospho(T38A)-mutant overexpression. ESM cells expressed IL-4Rα and IL-13Rα1 but only minimal H+-K+-ATPase mRNA. Th2 cytokines increased ESM eotaxin-3 secretion and tension, effects blocked by ruxolitinib and IL-4Rα blocking antibody but not consistently blocked by omeprazole. IL-13 increased ESM tension by increasing CPI-17 expression and phosphorylation, effects blocked by CPI-17 knockdown. Blocking IL-4Rα decreased IL-13-stimulated eotaxin-3 secretion, CPI-17 expression, and tension in ESM. Th2 cytokines increase ESM eotaxin-3 secretion and tension via IL-4Rα signaling that activates CPI-17. Omeprazole does not reliably inhibit this process, but IL-4Rα blocking antibody does. This suggests that ESM eosinophilia and impaired esophageal distensibility might persist despite elimination of mucosal eosinophils by PPIs, and IL-4Rα blocking agents might be especially useful in this circumstance.NEW & NOTEWORTHY We have found that Th2 cytokines increase eotaxin-3 secretion and tension in esophageal smooth muscle (ESM) cells via IL-4Rα signaling. Unlike esophageal epithelial cells, ESM cells do not express H+-K+-ATPase, and omeprazole does not inhibit their cytokine-stimulated eotaxin-3 secretion or tension. An IL-4Rα blocking antibody reduces both eotaxin-3 secretion and tension induced by Th2 cytokines in ESM cells, suggesting that an agent such as dupilumab might be preferred for patients with EoE with esophageal muscle involvement.
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Affiliation(s)
- Melissa R Nelson
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas, United States
| | - Xi Zhang
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas, United States
| | - Eitan Podgaetz
- Center for Thoracic Surgery, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas, United States
| | - Xuan Wang
- Biostatistics Core, Baylor Scott and White Research Institute, Dallas, Texas, United States
| | - Qiuyang Zhang
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas, United States
| | - Zui Pan
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, United States
| | - Stuart Jon Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas, United States
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas, United States
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Aceves SS, Dellon ES, Greenhawt M, Hirano I, Liacouras CA, Spergel JM. Clinical guidance for the use of dupilumab in eosinophilic esophagitis: A yardstick. Ann Allergy Asthma Immunol 2023; 130:371-378. [PMID: 36521784 DOI: 10.1016/j.anai.2022.12.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
The Joint Task Force for the American Academy of Allergy Asthma Immunology and American College of Allergy Asthma Immunology and the American Gastroenterology Association recently published guidelines for the management of eosinophilic esophagitis (EoE). Because the guideline was published, dupilumab became the first and only medication to gain regulatory approval for the treatment of EoE. This expert opinion document provides a framework for how the clinician can consider using dupilumab in the treatment strategy for patients with EoE.
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Affiliation(s)
- Seema S Aceves
- Division of Allergy Immunology, Departments of Pediatrics and Medicine, University of California and Rady Children's Hospital, San Diego, California
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Thaker AI, Smith J, Pathak M, Park JY. Challenges in Inter-rater Agreement on Lamina Propria Fibrosis in Esophageal Biopsies. Pediatr Dev Pathol 2023; 26:106-114. [PMID: 36755427 DOI: 10.1177/10935266221147084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Mucosal biopsies in eosinophilic esophagitis (EoE) can exhibit lamina propria (LP) fibrosis, which may portend stenotic complications; however, the histologic diagnosis of LP fibrosis is subjective. We sought to assess and improve the consistency of LP fibrosis diagnosis among our pathologist group. METHODS At a large pediatric hospital, 25 esophageal biopsy slides from 19 patients (16 with EoE) exhibiting a wide spectrum of LP area, artifacts, and fibrosis severity were scanned into whole-slide images. Staff pediatric pathologists (n = 8) separate from the authors classified each biopsy by LP adequacy and fibrosis severity 1 month before and after completion of an educational tutorial. Consensus was defined as >70% agreement. RESULTS At baseline, 16/25 (64%) cases reached consensus for no fibrosis (n = 3), fibrosis (n = 7), or inadequate LP (n = 6); agreement was fair (α = 0.34). Post-tutorial, 13/25 (52%) cases reached consensus for no fibrosis (n = 2), fibrosis (n = 7), or inadequate LP (n = 4); agreement was again fair (α = 0.33). There was moderate agreement in grading of fibrosis severity (α = 0.54). CONCLUSION We document only fair-to-moderate agreement in the diagnosis of esophageal LP fibrosis and adequacy in a large pediatric pathologist group despite targeted education, highlighting a challenge in incorporating this feature into EoE research and clinical decision-making.
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Affiliation(s)
- Ameet I Thaker
- Division of Pediatric Pathology, UT Southwestern/Children's Health, Dallas, TX, USA
| | - Jacob Smith
- Division of Pediatric Pathology, UT Austin/Dell Children's Medical Center, Austin, TX, USA
| | - Mona Pathak
- Department of Population and Data Sciences, UT Southwestern, Dallas, TX, USA
| | - Jason Y Park
- Division of Pediatric Pathology, UT Southwestern/Children's Health, Dallas, TX, USA
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Klochkova A, Fuller AD, Miller R, Karami AL, Panchani SR, Natarajan S, Mu A, Jackson JL, Klein-Szanto AJ, Muir AB, Whelan KA. A role for age-associated alterations in esophageal epithelium in eosinophilic esophagitis-associated fibrosis. FRONTIERS IN ALLERGY 2022; 3:983412. [PMID: 36591561 PMCID: PMC9798296 DOI: 10.3389/falgy.2022.983412] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
Subepithelial fibrosis occurs in a subset of eosinophilic esophagitis (EoE) patients and is associated with esophageal stricture. While mechanisms driving EoE fibrosis remain incompletely understood, findings from experimental systems support roles for epithelial-fibroblast crosstalk in this type of tissue remodeling. The current paradigm presents EoE as a progressive fibrostenotic disease in which aged patients develop fibrosis as a function of disease chronicity. In the current study we provide evidence that altered epithelial biology in the aging esophagus may also contribute to EoE-associated fibrosis. We find that induction of EoE inflammation in young and aged mice using the MC903/Ovalbumin protocol for the same time period results in increased lamina propria thickness uniquely in aged animals. Additionally, epithelial cells from aged mice less efficiently limit fibroblast contractility in collagen plug contraction assays compared to those from their young counterparts. Finally, to identify potential mechanisms through which aged esophageal epithelial cells may stimulate fibrotic remodeling, we perform cytokine array experiments in young and aged mice. These studies are significant as identification of age-associated factors that contribute to fibrotic remodeling may aid in the design of strategies toward early detection, prevention, and therapy of fibrostenotic EoE.
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Affiliation(s)
- Alena Klochkova
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Annie D. Fuller
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Riley Miller
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Adam L. Karami
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Surali R. Panchani
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Shruthi Natarajan
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Anbin Mu
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | - Jazmyne L. Jackson
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
| | | | - Amanda B. Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Kelly A. Whelan
- Fels Cancer Institute for Personalized Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
- Department of Cancer and Cellular Biology, Temple University Lewis Katz School of Medicine, Philadelphia, PA, United States
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8
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Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R, Morris D, Epstein J, Novelli MR, Hunter H, Cordell A, Hall S, Hayat JO, Kapur K, Moore AR, Read C, Sami SS, Turner PJ, Trudgill NJ. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022; 71:1459-1487. [PMID: 35606089 PMCID: PMC9279848 DOI: 10.1136/gutjnl-2022-327326] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE. METHODS The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance. RESULTS Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research. CONCLUSIONS These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.
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Affiliation(s)
- Anjan Dhar
- Gastroenterology, Darlington Memorial Hospital, Darlington, UK .,Teesside University, Middlesbrough, UK
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea University, Swansea, UK,Department of Gastroenterology, University Hospital Llandough, Llandough, UK
| | | | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
| | - Jason M Dunn
- Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
| | - Rami Sweis
- Research Department of Tissue and Energy, Division of Surgery & Interventional Science, University College London, London, UK
| | - Danielle Morris
- Department of Gastroenterology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Hannah Hunter
- Department of Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Amanda Cordell
- Trustee & Chair, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sharon Hall
- Department of Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Jamal O Hayat
- Gastroenterology, St George's Healthcare NHS Trust, London, UK
| | - Kapil Kapur
- Gastroenterology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Andrew Robert Moore
- Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Carol Read
- Medical advisor/Patient advocate, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sarmed S Sami
- Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul J Turner
- National Heart and Lung Institute Section of Allergy and Clinical Immunology, London, UK,Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
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9
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Chehade M, Falk GW, Aceves S, Lee JK, Mehta V, Leung J, Shumel B, Jacob-Nara JA, Deniz Y, Rowe PJ, Cunoosamy D, Khodzhayev A. Examining the Role of Type 2 Inflammation in Eosinophilic Esophagitis. GASTRO HEP ADVANCES 2022; 1:720-732. [PMID: 39131849 PMCID: PMC11307682 DOI: 10.1016/j.gastha.2022.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/06/2022] [Indexed: 08/13/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic type 2 inflammatory disease characterized by an eosinophilic inflammatory infiltrate in the esophagus, leading to remodeling, stricture formation, and fibrosis. Triggered by food and aeroallergens, type 2 cytokines interleukin (IL)-4, IL-13, IL-5 produced by CD4+ T helper 2 cells (Th2), eosinophils, mast cells, basophils, and type 2 innate lymphoid cells alter the esophageal epithelial barrier and increase inflammatory cell tissue infiltration. Clustering analysis based on the expression of type 2 inflammatory genes demonstrated the diversity of EoE endotypes. Despite the availability of treatment options for patients with EoE, which include dietary restriction, proton pump inhibitors, swallowed topical steroids, and esophageal dilation, there are still no Food and Drug Administration-approved medications for this disease; as such, there are clear unmet medical needs for these patients. A number of novel biologic therapies currently in clinical trials represent a promising avenue for targeted therapeutic approaches in EoE. This review summarizes our current knowledge on the role of type 2 inflammatory cells and mediators in EoE disease pathogenesis, as well as the future treatment landscape targeting underlying inflammation in EoE.
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Affiliation(s)
- Mirna Chehade
- Deparment of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gary W. Falk
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Seema Aceves
- Deparment of Pediatrics and Medicine, University of California, San Diego, California
| | - Jason K. Lee
- Deparment of Clinical Immunology and Allergy and Internal Medicine, Toronto Allergy and Asthma Clinic, Toronto, Ontario, Canada
| | - Vinay Mehta
- Allergy, Asthma & Immunology Associates, P.C., Lincoln, Nebraska
| | - John Leung
- Boston Specialists, Boston, Massachusetts
| | - Brad Shumel
- Regeneron Pharmaceuticals, Inc, Tarrytown, New York
| | | | - Yamo Deniz
- Regeneron Pharmaceuticals, Inc, Tarrytown, New York
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10
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Williamson P, Proudfoot J, Gharibans A, Dohil L, Newbury R, Barsamian J, Hassan M, Rawson R, Katzka D, Kurten R, Dohil R, Mousa H, Aceves S. Plasminogen Activator Inhibitor-1 as a Marker of Esophageal Functional Changes in Pediatric Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2022; 20:57-64.e3. [PMID: 33007513 PMCID: PMC8007666 DOI: 10.1016/j.cgh.2020.09.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal remodeling in eosinophilic esophagitis (EoE) can lead to esophageal rigidity with eventual luminal compromise and stenoses. Gauging esophageal functional alterations in EoE is challenging. An epithelial marker of functional remodeling would impact EoE management. METHODS Esophageal biopsy specimens from children with and without EoE and primary human esophageal epithelial cells were used for PAI-1 immunohistochemistry, and cell proliferation experiments. PAI-1 immunostaining and basal cell hyperplasia were assessed in the context of concurrently obtained esophageal compliance measures on endoscopic functional lumen imaging probe (EndoFLIP). RESULTS EndoFLIPs were performed in 45 children (32 with and 13 without EoE). Epithelial PAI-1 was increased in patients with active EoE versus inactive or control patients (P < .01). Esophageal compliance was lower in EoE patients versus controls, particularly in the proximal esophagus (P < .001). Proximal compliance was the strongest predictor of EoE (AUROC 0.88, 95% CI 0.77, 0.98) with esophageal compliance of less than 2.6%mL/mmHg demonstrating 82% sensitivity and 84% specificity for EoE. PAI-1 inhibition significantly diminished esophageal epithelial cell proliferation, suggesting PAI-1 could trigger basal cell hyperplasia. A composite mid-esophageal BZH + PAI-1 score was the strongest predictor of altered compliance (P = .02, AUROC 0.89 (95% CI 0.80, 0.99). CONCLUSIONS PAI-1 is significantly elevated in pediatric EoE and distinguishes altered compliance in children. PAI-1 may be a novel disease marker and therapeutic target.
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Affiliation(s)
- Prerana Williamson
- Department of Pediatrics, University of California, San Diego, CA,Division of Pediatric Gastroenterology,Rady Children’s Hospital, San Diego, CA
| | - James Proudfoot
- Altman Clinical and Translational Research Institute, University of California, San Diego, CA
| | - Armen Gharibans
- Rady Children’s Hospital, San Diego, CA,Department of Surgery, University of Auckland, New Zealand,Auckland Bioengineering Institute, University of Auckland, New Zealand
| | - Lucas Dohil
- Department of Pediatrics, University of California, San Diego, CA,Division of Allergy and Immunology
| | - Robert Newbury
- Rady Children’s Hospital, San Diego, CA,Department of Pathology, University of California San Diego, CA
| | | | - Maheen Hassan
- Department of Pediatrics, University of California, San Diego, CA,Division of Pediatric Gastroenterology,Rady Children’s Hospital, San Diego, CA
| | - Renee Rawson
- Department of Pediatrics, University of California, San Diego, CA,Division of Allergy and Immunology
| | - David Katzka
- Department of Internal Medicine, Mayo Clinic, Rochester, MN,Division of Gastroenterology and Hepatology
| | - Richard Kurten
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AK
| | - Ranjan Dohil
- Department of Pediatrics, University of California, San Diego, CA,Division of Pediatric Gastroenterology,Rady Children’s Hospital, San Diego, CA
| | - Hayat Mousa
- Department of Pediatrics, University of California, San Diego, CA,Division of Pediatric Gastroenterology,Rady Children’s Hospital, San Diego, CA
| | - Seema Aceves
- Rady Children's Hospital, San Diego, California; Division of Allergy and Immunology, University of California San Diego, San Diego, California; Department of Medicine, University of California San Diego, San Diego, California.
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11
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Young E, Philpott H. Pathophysiology of Dysphagia in Eosinophilic Esophagitis: Causes, Consequences, and Management. Dig Dis Sci 2022; 67:1101-1115. [PMID: 35230577 PMCID: PMC8976791 DOI: 10.1007/s10620-022-07419-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/20/2022] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is a leading cause of food bolus impaction in children and adults. The mechanism of dysphagia in EoE, particularly non-obstructive dysphagia, remains incompletely understood. While fibrostenotic processes appear to be critical in the development of dysphagia, somatosensory dysfunction and dysmotility also contribute. This review considers potential mechanisms of dysphagia and evaluates the utility of current and future treatment strategies in this context.
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Affiliation(s)
- Edward Young
- grid.460761.20000 0001 0323 4206Department of Gastroenterology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5031 Australia ,grid.1010.00000 0004 1936 7304Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA Australia
| | - Hamish Philpott
- grid.460761.20000 0001 0323 4206Department of Gastroenterology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5031 Australia ,grid.1010.00000 0004 1936 7304Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA Australia
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12
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Lim AH, Wong S, Nguyen NQ. Eosinophilic Esophagitis and IgG4: Is There a Relationship? Dig Dis Sci 2021; 66:4099-4108. [PMID: 33534011 DOI: 10.1007/s10620-020-06788-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/14/2020] [Indexed: 02/06/2023]
Abstract
Our knowledge of the pathophysiology of eosinophilic esophagitis is constantly evolving. There is significant association between eosinophilic esophagitis and atopy; however, multiple studies have refuted the role of IgE in its pathogenesis. Instead, new data have demonstrated an elevated IgG4 level in patients with eosinophilic esophagitis. We review the current understanding of eosinophilic esophagitis pathogenesis and highlight the increasing evidence for the role of IgG4.
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Affiliation(s)
- Amanda H Lim
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, 5000, Adelaide, SA, Australia
| | - Stephanie Wong
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, 5000, Adelaide, SA, Australia
| | - Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, 5000, Adelaide, SA, Australia. .,Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.
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13
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Navarro P, Laserna-Mendieta EJ, Guagnozzi D, Casabona S, Perelló A, Savarino E, de la Riva S, Olalla JM, Ghisa M, Serrano-Moya N, Alcolea-Valero C, Ortega-Rabbione G, Majano P, Santander C, Arias Á, Lucendo AJ. Proton pump inhibitor therapy reverses endoscopic features of fibrosis in eosinophilic esophagitis. Dig Liver Dis 2021; 53:1479-1485. [PMID: 34120859 DOI: 10.1016/j.dld.2021.05.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/15/2021] [Accepted: 05/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-standing inflammation leads to esophageal remodeling with stricture formation in patients with eosinophilic esophagitis (EoE). The ability of proton pump inhibitors (PPI) to reverse endoscopic features of fibrosis is still unknown. OBJECTIVE To investigate the effect of a short course of PPI treatment in reducing endoscopic findings indicative of esophageal fibrosis in EoE patients. METHODS Cross-sectional analysis of the EoE CONNECT registry. Patients who received PPI to induce EoE remission were evaluated. Endoscopic features were graded using the EoE Endoscopic Reference Score (EREFS), with rings and strictures indicating fibrosis. Results were compared to those from patients treated with swallowed topic corticosteroids (STC). RESULTS Clinico-histological remission was achieved in 83/166 adult patients treated with PPI (50%) and in 65/79 (82%) treated with STC; among responders, 60 (36%) and 57 (72%) patients respectively achieved deep histological remission (<5 eosinophils/hpf). At baseline, mean±SD EREFS was lower in patients treated with PPI compared to those who received STC (p < 0.001). Short term treatment significantly reduced EREFS scores in patients treated either with PPI or STC as well as rings and strictures. Among patients treated with PPI, deep histological remission (<5 eosinophils/hpf) provided further reduction in total EREFS score. CONCLUSION Effective PPI therapy for EoE significantly reduced endoscopic esophageal fibrosis in the short term.
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Affiliation(s)
- Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Clinical Laboratory, Hospital Universitario de La Princesa, Madrid, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Sergio Casabona
- Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Viladecans, Barcelona, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Università di Padova, Padova, Italy
| | | | - José María Olalla
- Department of Gastroenterology Clinica Universidad de Navarra, Pamplona, Spain
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, Università di Padova, Padova, Italy
| | | | | | - Guillermo Ortega-Rabbione
- Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Data Analysis Unit, Health Research Institute Hospital Universitario de la Princesa, Madrid, Spain
| | - Pedro Majano
- Research Unit, Hospital Universitario La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Cecilio Santander
- Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ángel Arias
- Research Unit, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad. Real, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
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14
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Oliva S, Dellon ES. Reversal of fibrosis in eosinophilic esophagitis: Another feather in the PPI cap? Dig Liver Dis 2021; 53:1476-1478. [PMID: 34531128 DOI: 10.1016/j.dld.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/26/2021] [Accepted: 08/10/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy.
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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15
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Hiremath G, Choksi YA, Acra S, Correa H, Dellon ES. Factors Associated With Adequate Lamina Propria Sampling and Presence of Lamina Propria Fibrosis in Children with Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2021; 19:1814-1823.e1. [PMID: 32707338 PMCID: PMC8033509 DOI: 10.1016/j.cgh.2020.07.035] [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: 12/13/2019] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal biopsies in children with eosinophilic esophagitis (EoE) are often inadequate for assessment of lamina propria and lamina propria fibrosis (LPF). For children with EoE, little is known about the factors associated with adequate lamina propria (aLP) sampling or the relationship among epithelial features in esophageal biopsies with and without LPF. We aimed to evaluate aLP in esophageal biopsies from children with and without EoE, identify factors associated with aLP and LPF, and examine the relationship among epithelial features in biopsies with and without LPF in children with EoE. METHODS In a retrospective study, we analyzed clinical, endoscopic, and histologic data from 217 children (124 with EoE and 94 without EoE [controls]) using descriptive statistics, logistic regression, Spearman's correlation, and receiver operating characteristic curve analysis. Active and inactive EoE were defined per the 2011 consensus guidelines. RESULTS aLP was observed in biopsies from higher proportion of children with EoE (69%) than controls (31%) (P = .0001). Active EoE was independently associated with aLP (adjusted odds ratio [aOR], 4.23; 95% CI, 1.00-18.13; P = .05). Patient sex (aOR for boys, 8.37; 95% CI, 1.23-56.74; P = .03) and peak eosinophil count (aOR, 1.02; 95% CI, 1.01-1.04; P = .01) were independently associated with LPF. Epithelial features were strongly interrelated in biopsies with LPF, and the presence of specific epithelial features was associated with LPF. CONCLUSIONS aLP was observed in a higher proportion of esophageal biopsies from children with EoE than controls. EoE status, patient sex, and peak eosinophil count were associated with aLP sampling and LPF. Given the intricate relationship between epithelial features and LPF, computational models can be developed to identify children with esophageal biopsies without aLP who are at risk for LPF.
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Affiliation(s)
- Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Yash A. Choksi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA,Veterans Affairs Tennessee Valley Health Care System, Nashville, Tennessee, USA
| | - Sari Acra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hernan Correa
- Division of Pediatric Pathology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill North Carolina, USA
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16
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The role of the allergist in the management of eosinophilic esophagitis. Curr Opin Gastroenterol 2021; 37:390-396. [PMID: 34059605 PMCID: PMC8527848 DOI: 10.1097/mog.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide the current understanding of the role of allergens/antigens, the use of allergy testing, and to elucidate the role of the allergist in the management of eosinophilic esophagitis (EoE). RECENT FINDINGS EoE is a T2 immune disorder that is part of the atopic march. EoE patients commonly have multiple concurrent allergic disorders. Recent studies demonstrate that, like other allergic diseases, epithelial barrier dysfunction plays a key role in EoE pathogenesis. Aero- and food allergens have been identified as EoE triggers. EoE management includes the assessment and avoidance of its instigating antigens. Due to the integrated T2 immune response in an allergic individual, proper EoE care should include the control of underlying atopic disorders. EoE is a complex disease that is optimally managed by a multidisciplinary approach. SUMMARY This review provides an update on the role of the allergist in the clinical management of EoE.
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17
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Gargano D, Appanna R, Santonicola A, De Bartolomeis F, Stellato C, Cianferoni A, Casolaro V, Iovino P. Food Allergy and Intolerance: A Narrative Review on Nutritional Concerns. Nutrients 2021; 13:1638. [PMID: 34068047 PMCID: PMC8152468 DOI: 10.3390/nu13051638] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 02/07/2023] Open
Abstract
Adverse food reactions include immune-mediated food allergies and non-immune-mediated intolerances. However, this distinction and the involvement of different pathogenetic mechanisms are often confused. Furthermore, there is a discrepancy between the perceived vs. actual prevalence of immune-mediated food allergies and non-immune reactions to food that are extremely common. The risk of an inappropriate approach to their correct identification can lead to inappropriate diets with severe nutritional deficiencies. This narrative review provides an outline of the pathophysiologic and clinical features of immune and non-immune adverse reactions to food-along with general diagnostic and therapeutic strategies. Special emphasis is placed on specific nutritional concerns for each of these conditions from the combined point of view of gastroenterology and immunology, in an attempt to offer a useful tool to practicing physicians in discriminating these diverging disease entities and planning their correct management. We conclude that a correct diagnostic approach and dietary control of both immune- and non-immune-mediated food-induced diseases might minimize the nutritional gaps in these patients, thus helping to improve their quality of life and reduce the economic costs of their management.
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Affiliation(s)
- Domenico Gargano
- Allergy and Clinical Immunology Unit, San Giuseppe Moscati Hospital, 83100 Avellino, Italy; (D.G.); (F.D.B.)
| | - Ramapraba Appanna
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
| | - Antonella Santonicola
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
| | - Fabio De Bartolomeis
- Allergy and Clinical Immunology Unit, San Giuseppe Moscati Hospital, 83100 Avellino, Italy; (D.G.); (F.D.B.)
| | - Cristiana Stellato
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
| | - Antonella Cianferoni
- Division of Allergy and Immunology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Vincenzo Casolaro
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
| | - Paola Iovino
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
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18
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Antifibrotic Effects of the Thiazolidinediones in Eosinophilic Esophagitis Pathologic Remodeling: A Preclinical Evaluation. Clin Transl Gastroenterol 2021; 11:e00164. [PMID: 32352681 PMCID: PMC7263661 DOI: 10.14309/ctg.0000000000000164] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a T-helper 2 (Th2), eosinophilic disease associated with pathologic tissue remodeling that leads to end-organ dysfunction. During early-stage disease, inflammation and subepithelial fibrosis are coupled and reversible, but in late-stage or therapy-resistant disease, there can be uncoupling of these features with progressive esophageal rigidity and strictures contributing to clinical dysphagia and food impactions. No current pharmacotherapeutic interventions directly target esophageal fibrosis. Based on the ability of the thiazolidinediones (TZD) to regulate intestinal and hepatic fibrosis, we tested the antifibrotic effects of the TZDs, rosiglitazone and pioglitazone, in preclinical studies using primary human esophageal fibroblasts.
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19
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Lieberman JA. Minimally symptomatic patients with eosinophilic esophagitis should still be actively treated-CON. Ann Allergy Asthma Immunol 2020; 122:574-575. [PMID: 31171239 DOI: 10.1016/j.anai.2018.11.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 11/08/2018] [Accepted: 11/19/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Jay Adam Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, LeBonheur Children's Hospital, Memphis, Tennessee.
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20
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Chehade M, Nowak-Wegrzyn A. The asymptomatic patient with eosinophilic esophagitis: To treat or not to treat? Ann Allergy Asthma Immunol 2019; 122:550-551. [PMID: 31171235 DOI: 10.1016/j.anai.2019.03.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/20/2019] [Indexed: 01/07/2023]
Affiliation(s)
- Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Anna Nowak-Wegrzyn
- Jaffe Food Allergy Institute, Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
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21
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Abstract
Eosinophilic esophagitis (EoE) is an immune-mediated disease triggered by food antigens for which dietary elimination treatment can induce and sustain histologic remission. Our review aims to describe the state of the art regarding dietary treatment of EoE, highlighting a number of areas of controversy related to dietary therapy in EoE, including novel modalities for determining food triggers, making the empiric dietary elimination process more efficient, issues of cross-contamination and "dosing" of how much food to avoid or add back, costs and effects on quality of life, long-term efficacy, and the risk of developing immediate IgE-type reactions after initial dietary elimination. Elemental formulas, empiric elimination diets, and targeted allergy test-directed elimination diets are well-described treatments for EoE. Although elemental diets are most efficacious, their clinical use is limited by cost and the palatability of an exclusively liquid diet. While empiric elimination is less effective than elemental formula-based diets, they are more easily implemented and often sustainable. Since the comparative effectiveness of elimination diets with proton-pump inhibitors and swallowed topical steroids remains unknown, there are multiple areas to address with future research.
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22
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Esophageal Compliance Quantifies Epithelial Remodeling in Pediatric Patients With Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2019; 68:559-565. [PMID: 30418408 PMCID: PMC6453699 DOI: 10.1097/mpg.0000000000002202] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The management of eosinophilic esophagitis (EoE) relies on the severity of esophageal eosinophilia, yet there is poor evidence of its prediction of esophageal fibrotic remodeling and subsequent complications such as dysphagia, food impactions, or strictures. Functional luminal imaging planimetry (FLIP) has had limited use in pediatric patients to evaluate esophageal tissue mechanics. We aimed to standardize the FLIP technique and to measure esophageal compliance in children with EoE in comparison to controls. METHODS Subjects were enrolled into a prospective observational study and had FLIP performed at the time of endoscopy. We calculated esophageal distensibility and compliance for the total and segmental esophagus independently (ie, proximal, middle, and distal esophageal segments). We evaluated esophageal biopsies for eosinophilia and epithelial remodeling, calculated endoscopy scores, and documented patient symptoms. RESULTS We enrolled 11 EoE and 12 controls subjects, aged 5 to 18 years old. While EoE subjects had lower esophageal compliance (P = 0.004) than controls, the difference in distensibility did not reach significance (P = 0.151). Epithelial remodeling severity was more strongly correlated with compliance than with distensibility. Epithelial remodeling scores ≥2 had a significant association with lower compliance both segmentally and in the entire esophagus (P = 0.029), but not with distensibility. Compliance measures were more sensitive in detecting subjects with remodeling score ≥2 than distensibility (79% vs 64%). CONCLUSIONS Compliance is a more sensitive measure of esophageal epithelial remodeling in children compared to distensibility, and a more appropriate measure of esophageal tissue mechanics. Standardized placement of the FLIP catheter is important to accurately assess esophageal compliance.
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Nhu QM, Moawad FJ. New Developments in the Diagnosis and Treatment of Eosinophilic Esophagitis. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:48-62. [PMID: 30707411 PMCID: PMC6519728 DOI: 10.1007/s11938-019-00216-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Eosinophilic esophagitis (EoE) is a chronic, allergen-driven, immune-mediated disease of the esophagus that progresses to esophageal fibrostenosis if left untreated. The aim of this review is to provide a concise update on recent clinically relevant advances in the development of diagnostic and therapeutic approaches for EoE. RECENT FINDINGS Current diagnostic and disease monitoring protocols for EoE rely on repetitive endoscopic evaluations and esophageal tissue acquisition for histopathologic analysis. Recent advancements in EoE diagnosis include endoscopic functional lumen imaging probe (FLIP), transnasal endoscopy (TNE), and the emergence of non-invasive diagnostic tools including cytosponge, esophageal string test, and mucosal impedance probe. Biomarkers for EoE have not yet proven their clinical utility. No Food and Drug Administration (FDA)-approved drugs currently exist for the treatment of EoE. Topical corticosteroid, proton-pump inhibitors (PPI), elimination diet, and dilation are the current treatment modalities for confirmed EoE. Promising results from clinical trials are emerging for biologic agents that target the interleukin (IL)-13 and the IL-4/IL-13 receptor, specifically, RPC4046 and dupilumab, respectively. New diagnostic algorithms, non-invasive diagnostic strategies, and treatment modalities for EoE are emerging. Patients with EoE continue to require a multimodal and multi-disciplinary management approach.
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Affiliation(s)
- Quan M Nhu
- Division of Gastroenterology & Hepatology, Scripps Clinic, 10666 N. Torrey Pines Road, Suite 203N, La Jolla, CA, 92037, USA.
- Scripps Research Translational Institute, The Scripps Research Institute, La Jolla, CA, USA.
| | - Fouad J Moawad
- Division of Gastroenterology & Hepatology, Scripps Clinic, 10666 N. Torrey Pines Road, Suite 203N, La Jolla, CA, 92037, USA.
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Oliva S, Rossetti D, Papoff P, Tiberti A, Mallardo S, Volpe D, Ruggiero C, Russo G, Vezzoli D, Isoldi S, Cucchiara S. A 12-Week Maintenance Therapy with a New Prepared Viscous Budesonide in Pediatric Eosinophilic Esophagitis. Dig Dis Sci 2019; 64:1571-1578. [PMID: 30659470 PMCID: PMC6522447 DOI: 10.1007/s10620-018-5449-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 12/29/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND A new prepared oral viscous budesonide (PVB) has been effective in inducing clinical and histological remission in pediatric eosinophilic esophagitis (EoE). AIMS To evaluate the efficacy of a 12-week maintenance therapy on clinical, endoscopic, and histological remission using half of the dose used in the induction therapy. METHODS We prospectively enrolled pediatric patients with active EoE. After 12 weeks of induction therapy with PVB (< 150 cm: 2 mg/day; ≥ 150 cm: 4 mg/day) patients received a maintenance dose of half of the dose used in the induction therapy (1 mg or 2 mg) for another 12 weeks. A 12-week follow-up was then performed in all patients after the end of therapy. Endoscopy was performed at weeks 0, 12, 24, and 36. Symptoms, endoscopy, and histology scores were also calculated. Serum cortisol was evaluated during the treatment period. RESULTS We enrolled 20 children (15 males; median age 10 years; range 4-17). After the 12-week induction therapy 18 patients (90%) were in remission, with a significant decrease in the median peak of eosinophil count/HPF as well as a marked reduction in clinical, endoscopic, and histological scores (p < 0.01). At the end of the maintenance therapy (week 24), 17 patients (85%) were still in remission, while there were only 9 at week 36 (45%). No significant changes in cortisol levels were observed during the study period. CONCLUSIONS The 12-week maintenance treatment with the half the dose of PVB was effective in sustaining remission at week 24; however, no reduction in the rate of relapse after suspension of treatment occurred.
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Affiliation(s)
- Salvatore Oliva
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Danilo Rossetti
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Paola Papoff
- Department of Paediatrics, PICU, Sapienza University of Rome, 00161 Rome, Italy
| | - Antonio Tiberti
- Department of Radiological Sciences, Oncology, and Anatomical Pathology, Sapienza – University of Rome, Rome, Italy
| | - Saverio Mallardo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Danila Volpe
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Cosimo Ruggiero
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Giusy Russo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Debora Vezzoli
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Sara Isoldi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Salvatore Cucchiara
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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Ruffner MA, Kennedy K, Cianferoni A. Pathophysiology of eosinophilic esophagitis: recent advances and their clinical implications. Expert Rev Clin Immunol 2018; 15:83-95. [PMID: 30394139 DOI: 10.1080/1744666x.2019.1544893] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Diagnostic and therapeutic strategies in eosinophilic esophagitis (EoE) are evolving. New knowledge regarding the pathophysiology of EoE has been the foundation for updated diagnostic recommendations and new therapeutic trials. Areas covered: We performed structured literature searches in Medline and PubMed, Cochrane meta-analyses, and abstracts of international congresses to review therapeutic approaches for EoE in July 2018. Additional articles were obtained by perusing the references of articles identified in the original PubMed search. Articles were excluded if they did not focus on the mechanism of disease, diagnosis, or treatment of humans with EoE. Expert commentary: Recent advances in the understanding of mechanisms underlying the pathology of EoE have resulted in significant change in the diagnostic algorithm for EoE, and are identifying promising potential targets for personalized medicine. There is a clinical need for improved targeted therapy for EoE, and better understanding the underlying pathophysiology of EoE will help to determine therapeutic targets. In this review, we highlight key mechanisms in the pathophysiology of EoE and how they are being utilized to change therapy in EoE.
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Affiliation(s)
- Melanie A Ruffner
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Department of Pediatrics , University of Pennsylvania Perlman School of Medicine , Philadelphia , PA , USA
| | - Katie Kennedy
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Antonella Cianferoni
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Department of Pediatrics , University of Pennsylvania Perlman School of Medicine , Philadelphia , PA , USA
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Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus associated with an atopic predisposition which appears to be increasing in prevalence over the last few decades. Symptoms stem from fibrosis, swelling, and smooth muscle dysfunction. In the past two decades, the etiology of EoE has been and is continuing to be revealed. This review provides an overview of the effects of genetics, environment, and immune function including discussions that touch on microbiome, the role of diet, food allergy, and aeroallergy. The review further concentrates on the pathophysiology of the disease with particular focus on the important concepts of the molecular etiology of EoE including barrier dysfunction and allergic hypersensitivity.
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Affiliation(s)
- Benjamin P Davis
- Department of Internal Medicine, Division of Immunology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52246, USA.
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Steinbach EC, Hernandez M, Dellon ES. Eosinophilic Esophagitis and the Eosinophilic Gastrointestinal Diseases: Approach to Diagnosis and Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:1483-1495. [PMID: 30201096 PMCID: PMC6134874 DOI: 10.1016/j.jaip.2018.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/06/2018] [Accepted: 06/21/2018] [Indexed: 12/12/2022]
Abstract
The eosinophilic gastrointestinal diseases (EGIDs) represent disorders of the gastrointestinal (GI) tract that result from the local infiltration and aberrant activity of eosinophils and other immune cells. Eosinophilic esophagitis (EoE) is the most well-characterized EGID and is defined by the presence of intraepithelial eosinophils in the esophagus (≥15 eosinophils per high-powered field) and clinical symptoms associated with esophageal dysfunction. The other EGIDs are rare and lack strong data regarding pathogenesis and management. The incidence and prevalence of EoE are increasing, and EoE is now a major cause of upper GI morbidity. Management is multidisciplinary, with collaboration between gastroenterologists, allergists, pathologists, and dieticians, and is aimed at amelioration of symptoms and prevention of long-term complications such as esophageal stricture. Treatment options for EoE include proton pump inhibitors, swallowed topical corticosteroids, and elimination diets. Esophageal dilation is used when esophageal strictures or fibrostenotic changes are present. Additional therapies targeting eosinophils and other mediators of Th2 inflammation are under development and are promising. Treatment options for other EGIDs typically involve corticosteroids or dietary elimination.
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Affiliation(s)
- Erin C Steinbach
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Michelle Hernandez
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC.
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Spergel JM, Aceves SS, Kliewer K, Gonsalves N, Chehade M, Wechsler JB, Groetch M, Friedlander J, Dellon ES, Book W, Hirano I, Muir AB, Cianferoni A, Spencer L, Liacouras CA, Cheng E, Kottyan L, Wen T, Platts-Mills T, Rothenberg ME. New developments in patients with eosinophilic gastrointestinal diseases presented at the CEGIR/TIGERS Symposium at the 2018 American Academy of Allergy, Asthma & Immunology Meeting. J Allergy Clin Immunol 2018; 142:48-53. [PMID: 29803797 PMCID: PMC6129859 DOI: 10.1016/j.jaci.2018.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/17/2018] [Accepted: 05/18/2018] [Indexed: 12/28/2022]
Abstract
The Consortium of Eosinophilic Gastrointestinal Diseases and the International Gastrointestinal Eosinophil Researchers organized a day-long symposium at the recent 2018 Annual Meeting of the American Academy of Allergy, Asthma & Immunology, which was coupled for the first time with the World Allergy Organization meeting to create an international platform. The symposium featured experts in many facets of eosinophilic gastrointestinal diseases, including allergy, immunology, gastroenterology, pathology, and nutrition, and was a well-attended event. The basic science, genetics, cellular immunology, and clinical features of the diseases, with a focus on epithelial, eosinophil, and mast cell responses, as well as current and emerging treatment options, were reviewed. Here we briefly review some of the highlights of the material presented at the meeting.
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Affiliation(s)
- Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Seema S Aceves
- Division of Allergy, Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, Rady Children's Hospital, San Diego, La Jolla, Calif
| | - Kara Kliewer
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, Ill
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua B Wechsler
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Marion Groetch
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua Friedlander
- Digestive Health Institute, Children's Hospital Colorado, and the Aerodigestive Program, University of Colorado School of Medicine, Aurora, Colo
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Wendy Book
- American Partnership for Eosinophilic Disorders, Atlanta, Ga
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, Ill
| | - Amanda B Muir
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Antonella Cianferoni
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | | | - Chris A Liacouras
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Edaire Cheng
- Departments of Pediatrics and Internal Medicine, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Leah Kottyan
- Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Ting Wen
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Thomas Platts-Mills
- Division of Asthma, Allergy, and Immunology, University of Virginia, Charlottesville, Va
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio.
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Spergel J, Aceves SS. Allergic components of eosinophilic esophagitis. J Allergy Clin Immunol 2018; 142:1-8. [PMID: 29980277 PMCID: PMC6083871 DOI: 10.1016/j.jaci.2018.05.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/11/2018] [Accepted: 05/11/2018] [Indexed: 01/21/2023]
Abstract
Eosinophilic esophagitis (EoE) is a disorder of increasing prevalence worldwide, causing clinical symptoms of vomiting, failure to thrive, and dysphagia and complications of esophageal remodeling with strictures and food impactions. Molecular profiling demonstrates EoE to be an eosinophil-predominant disorder with a TH2 cytokine profile reminiscent of other allergic diseases, such as asthma, allergic rhinitis, and atopic dermatitis. Environmental antigens in the form of foods and aeroallergens induce eosinophil, basophil, mast cell, and T-cell infiltration. Pathogenesis depends on local epithelial immune activation with production of thymic stromal lymphopoietin and eotaxin-3. Complications mirror asthmatic airway pathogenesis, with increases in subepithelial collagen deposition, angiogenesis, and smooth muscle hypertrophy. The removal of instigating antigens, especially foods, causes disease resolution in more than 50% of adults and children. The prevalence of concurrent atopic disorders in patients with EoE and the need to control antigen-specific TH2 inflammation underscore the importance of testing for allergens and treating the entire atopic subject to control the potential interplay between organ-specific allergic responses.
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Affiliation(s)
- Jonathan Spergel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, and the Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Seema S Aceves
- Departments of Pediatrics and Medicine, Division of Allergy Immunology, University of California, San Diego, Rady Children's Hospital San Diego, La Jolla, Calif.
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The natural course of eosinophilic esophagitis and long-term consequences of undiagnosed disease in a large cohort. Am J Gastroenterol 2018; 113:836-844. [PMID: 29700481 DOI: 10.1038/s41395-018-0052-5] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 02/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic esophageal inflammation that may lead to stricture formation. This narrowing can cause major complications including food impactions. Despite increasing interest in EoE accurate data on its natural course is scarce. Therefore, we aimed to investigate the natural course of EoE and to evaluate the association between undiagnosed disease and the occurrence of complications over two decades in a large cohort. METHODS We retrospectively analyzed charts of patients diagnosed with EoE between 1996 and 2015, collected from 15 hospitals throughout the Netherlands. Histologic, clinical, and endoscopic characteristics were identified and stratified by age and diagnostic delay. RESULTS We included 721 patients (524 males, 117 children (≤18 years)). Dysphagia and food impactions were more common in adults whereas children more often presented with vomiting and abdominal pain (all p < 0.001). The prevalence of fibrotic endoscopic features was higher in adults (76%) than in children (39%) (p < 0.001). As time with undiagnosed disease progressed the percentage of patients with strictures and food impactions increased from 19% and 24% (diagnostic delay ≤ 2 years) to 52% and 57% (diagnostic delay ≥ 21 years) (p < 0.001), respectively. In a multivariate logistic regression model, diagnostic delay (odds ratio (OR) = 1.09; 95% confidence interval (CI) = 1.05-1.13) and male gender (OR = 2.69, 95% CI = 1.61-4.50) were the major risk factors for stricture presence. CONCLUSION During the natural course of EoE, progression from an inflammatory to a fibrostenotic phenotype occurs. With each additional year of undiagnosed EoE the risk of stricture presence increases with 9%.
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Nhu QM, Aceves SS. Medical and dietary management of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2018; 121:156-161. [PMID: 29753831 DOI: 10.1016/j.anai.2018.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Eosinophilic esophagitis (EoE) is a disease of chronic, allergen-driven, T-helper 2 (Th2) immune-mediated inflammation that progresses to fibrostenosis of the esophagus if left untreated. There are currently no Food and Drug Administration (FDA)-approved drugs for the treatment of EoE. This review focuses on the medical and dietary management of EoE. DATA SOURCES Manuscripts on EoE treatments were identified on PubMed. STUDY SELECTIONS Original research, randomized control trials, retrospective studies, meta-analyses, case series, and on occasions, case reports of high relevance, were selected and reviewed. RESULTS Current treatment strategies available to EoE patients center on monotherapy or combination therapy with dietary modification to exclude antigenic stimulation and topical corticosteroids to control Th2-mediated tissue inflammation and pathologic remodeling. Dilation as a rescue therapy for the narrowed, fibrostenotic, symptomatic esophagus can potentially be avoided with optimal medical and elimination diet therapies. The molecular mechanisms underlying EoE pathogenesis are being unraveled, from which targeted therapies can be developed and evaluated in preclinical and clinical studies. Current clinical research efforts focus on optimization of topical corticosteroid delivery, dosing, frequency, and duration of treatment, either alone or in combination with tailored elimination diet. Preliminary clinical trials with biologics targeting interleukin (IL)-5 and IL-13/IL-4 have been completed. CONCLUSION Topical corticosteroid, elimination diet, and dilation are the current treatment modalities for confirmed EoE. The use of proton-pump inhibitors (PPI) is being suggested as a potential regimen to treat EoE, based on evolving understanding of PPI-responsive esophageal eosinophilia (PPI-REE). The complexity of EoE treatment regimens and frequent follow-ups require a multimodal, multi-disciplinary management approach to optimize patient care.
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Affiliation(s)
- Quan M Nhu
- Scripps Translational Science Institute, The Scripps Research Institute, La Jolla, California; Division of Gastroenterology & Hepatology, Department of Medicine, Scripps Clinic-Scripps Green Hospital, La Jolla, California; Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Seema S Aceves
- Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California; Rady Children's Hospital, San Diego, San Diego, California.
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Wang J, Park JY, Huang R, Souza RF, Spechler SJ, Cheng E. Obtaining adequate lamina propria for subepithelial fibrosis evaluation in pediatric eosinophilic esophagitis. Gastrointest Endosc 2018; 87:1207-1214.e3. [PMID: 29309779 PMCID: PMC5899929 DOI: 10.1016/j.gie.2017.12.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 12/05/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Subepithelial fibrosis in eosinophilic esophagitis (EoE) can be detected only in esophageal biopsy specimens with adequate amounts of lamina propria (LP). We investigated how often pediatric esophageal biopsy specimens contain adequate LP, and whether esophageal eosinophilia influences the acquisition rates. METHODS We evaluated 284 esophageal biopsy specimens from 39 patients with EoE, and 87 biopsy specimens from 32 patients without esophageal eosinophilia or other esophageal abnormalities for the presence of adequate LP and fibrosis. RESULTS On a per biopsy specimen basis, there was no significant difference in the rate of procuring adequate amounts of LP between patients with EoE and patients without esophageal eosinophilia (43% vs 31%, P = .14). Eighty-five percent of patients with EoE had fibrosis. Fibrosis in patients with EoE was patchy and more likely to be detected in the middle or distal esophagus (odds ratio, 19.93; 95% confidence interval, 4.12-91.52). Among patients with fibrosis, the probability of its detection reached >95% with 7 middle-distal esophageal biopsy specimens. Most children with newly diagnosed EoE already had subepithelial fibrosis despite exhibiting only inflammatory endoscopic features. CONCLUSIONS Most individual esophageal biopsy specimens in children are inadequate for assessing subepithelial fibrosis, and the rates of procuring adequate LP per biopsy specimen are similar in patients with and without EoE. To reliably detect fibrosis in patients with EoE, at least 7 biopsy specimens should be taken from the middle-distal esophagus. The finding of fibrosis in children with newly diagnosed EoE and only inflammatory endoscopic features suggests that fibrosis can occur early in this disease.
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Affiliation(s)
- Jason Wang
- Department of Pathology, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jason Y Park
- Department of Pathology, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Rong Huang
- Department of Research Administration, Children's Medical Center, Dallas, Texas, USA
| | - Rhonda F Souza
- Center for Esophageal Diseases, Baylor University Medical Center, Dallas, Texas, USA; Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Center for Esophageal Diseases, Baylor University Medical Center, Dallas, Texas, USA; Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Edaire Cheng
- Department of Pediatrics, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Esofagitis eosinofílica: diagnóstico y tratamiento actual basado en la evidencia. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:281-291. [DOI: 10.1016/j.gastrohep.2017.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 12/01/2017] [Accepted: 12/15/2017] [Indexed: 12/19/2022]
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Armbruster-Lee J, Cavender CP, Lieberman JA, Samarasinghe AE. Understanding fibrosis in eosinophilic esophagitis: Are we there yet? J Leukoc Biol 2018; 104:31-40. [DOI: 10.1002/jlb.5mr1017-395r] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Jennifer Armbruster-Lee
- Department of Pediatrics; Division of Gastroenterology, University of Tennessee Health Science Center; Memphis Tennessee USA
| | - Cary P. Cavender
- Department of Pediatrics; Division of Gastroenterology, University of Tennessee Health Science Center; Memphis Tennessee USA
| | - Jay A. Lieberman
- Department of Pediatrics; Division of Allergy/Immunology, University of Tennessee Health Science Center; Memphis Tennessee USA
| | - Amali E. Samarasinghe
- Department of Pediatrics; Division of Pulmonology; University of Tennessee Health Science Center; Memphis Tennessee USA
- Children's Foundation Research Institute; Memphis Tennessee USA
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O'Shea KM, Aceves SS, Dellon ES, Gupta SK, Spergel JM, Furuta GT, Rothenberg ME. Pathophysiology of Eosinophilic Esophagitis. Gastroenterology 2018; 154:333-345. [PMID: 28757265 PMCID: PMC5787048 DOI: 10.1053/j.gastro.2017.06.065] [Citation(s) in RCA: 292] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/09/2017] [Accepted: 06/09/2017] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis is an emerging disease that is distinguished from gastroesophageal reflux disease by the expression of a unique esophageal transcriptome and the interplay of early life environmental factors with distinct genetic susceptibility elements at 5q22 (TSLP) and 2p23 (CAPN14). Rare genetic syndromes have uncovered the contribution of barrier disruption, mediated in part by defective desmosomes and dysregulated transforming growth factor beta production and signaling, to eosinophilic esophagitis pathophysiology. Experimental modeling has defined a cooperative role of activated eosinophils, mast cells, and the cytokines IL-5 and IL-13, mediated by allergic sensitization to multiple foods. Understanding these processes is opening the way to better treatment based on disrupting allergic inflammatory and type 2 cytokine-mediated responses, including anti-cytokine therapeutics and dietary therapy.
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Affiliation(s)
- Kelly M O'Shea
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Seema S Aceves
- Division of Allergy Immunology, Center for Immunity, Infection and Inflammation, University of California San Diego and Rady Children's Hospital San Diego, California
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine at Peoria and Children's Hospital of Illinois, Peoria, Illinois
| | - Jonathan M Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Glenn T Furuta
- Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Carlson DA, Hirano I, Zalewski A, Gonsalves N, Lin Z, Pandolfino JE. Improvement in Esophageal Distensibility in Response to Medical and Diet Therapy in Eosinophilic Esophagitis. Clin Transl Gastroenterol 2017; 8:e119. [PMID: 28981080 PMCID: PMC5666118 DOI: 10.1038/ctg.2017.47] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/11/2017] [Indexed: 12/13/2022] Open
Abstract
Objectives: We aimed to evaluate the effect of medical and diet therapies on esophageal distensibility assessed using the functional lumen imaging probe (FLIP) and the association of changes in esophageal distensibility with clinical outcomes in eosinophilic esophagitis (EoE). Methods: Patients with EoE were evaluated with FLIP during endoscopy at baseline and following therapy without interval dilatation. Evaluation also included a validated patient-reported outcome (PRO; a positive PRO was considered at a 30% score improvement), mucosal biopsies, and scoring of endoscopic features of EoE. FLIP data were analyzed to calculate the distensibility plateau (DP). Results: In all, 18 patients (ages 19–54 years; 4 female) treated with topical steroid (8), elimination diet (6), and/or proton-pump inhibitor (4 only treated with proton-pump inhibitor) were included. Follow-up testing occurred at a mean (range) of 14.6 (8–28) weeks. Improvement was observed in DP (13.9 (12.2–19.2) to 16.8 mm (15.8–19.2), P=0.007) and peak eosinophil count (45 (29–65) to 23 per high-power field (h.p.f.) (5–53), P=0.042). Nine patients had a positive symptomatic outcome. Six of 8 (75%) patients with a DP increase ≥2 mm had a positive PRO (P=0.077), while 2 of 7 (29%) patients that achieved an eosinophil count <15/h.p.f. had a positive PRO (P=0.167). Conclusions: Improvement in esophageal body distensibility can be achieved with medical and diet therapies without dilation in EoE. Improved DP appeared to be better indicator of symptomatic improvement than eosinophil count, supporting FLIP as a valuable outcome measure in EoE.
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Affiliation(s)
- Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ikuo Hirano
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Angelika Zalewski
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nirmala Gonsalves
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zhiyue Lin
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Six-Food Elimination Diet and Topical Steroids are Effective for Eosinophilic Esophagitis: A Meta-Regression. Dig Dis Sci 2017; 62:2408-2420. [PMID: 28608048 PMCID: PMC5709168 DOI: 10.1007/s10620-017-4642-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/02/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Topical corticosteroids or six-food elimination diet is recommended as initial therapy for eosinophilic esophagitis (EoE). AIMS We aimed to summarize published manuscripts that report outcomes of these therapies for EoE. METHODS We performed a systematic review in MEDLINE, Web of Science, and Embase of published manuscripts describing topical fluticasone, topical budesonide, and six-food elimination diet as therapies for EoE. We conducted meta-analysis of symptom improvement and the change in peak mucosal eosinophil count, with heterogeneity between studies examined with meta-regression analysis. RESULTS Systematic review yielded 51 articles that met inclusion criteria. Summary histologic response rates were 68.3% [95% prediction limits (PL) 16.2-96.0%] for fluticasone, 76.8% (95% PL 36.1-95.1%) for budesonide, and 69.0% (95% PL 31.9-91.4%) for six-food elimination diet. Corresponding decreases in eosinophil counts were 37.8 (95% PL 19.0-56.7), 62.5 (95% PL 125.6 to -0.67, and 44.6 (95% PL 26.5-62.7), respectively. Symptom response rates were 82.3% (95% PL 68.1-91.1%), 87.9% (95% PL 42.7-98.6%), and 87.3% (95% PL 64.5-96.3%), respectively. Meta-regression analyses decreased the initially large estimate of residual heterogeneity and suggested differences in histologic response rate associated with study populations' baseline eosinophil count and age. CONCLUSIONS The literature describing topical corticosteroids and six-food elimination diet consists of small studies with diverse methods and population characteristics. Meta-analysis with meta-regression shows initial histologic and symptomatic response rates on the same order of magnitude for topical corticosteroids and six-food elimination diet, but heterogeneity of study designs prevents direct comparison of modalities.
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Abstract
Over the past decades eosinophilic esophagitis (EoE) has been increasingly diagnosed, and significant progress has been made in our understanding of its pathophysiology. As EoE cannot be cured yet, treatment goals are suppression of disease activity and symptoms as well as the prevention of progression to a more severe disease phenotype. Disease-modifying treatment options can be divided into dietary therapy and immunosuppressive medications, of which topical steroids have been most investigated, yet are still prescribed off-label. In this review, we will summarize recent advances in our understanding of EoE and discuss the mechanisms of action of current treatment options, with emphasis on the role of the esophageal epithelial barrier and the effects of proton-pump inhibitors in the management of patients with EoE.
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Nhu QM, Aceves SS. Tissue Remodeling in Chronic Eosinophilic Esophageal Inflammation: Parallels in Asthma and Therapeutic Perspectives. Front Med (Lausanne) 2017; 4:128. [PMID: 28831387 PMCID: PMC5549614 DOI: 10.3389/fmed.2017.00128] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/21/2017] [Indexed: 12/20/2022] Open
Abstract
Chronic eosinophilic inflammation is associated with tissue remodeling and fibrosis in a number of chronic T-helper 2 (Th2)-mediated diseases including eosinophilic esophagitis (EoE) and asthma. Chronic inflammation results in dysregulated tissue healing, leading to fibrosis and end organ dysfunction, manifesting clinically as irreversible airway obstruction in asthma and as esophageal rigidity, strictures, narrowing, dysmotility, dysphagia, and food impactions in EoE. Current therapies for EoE and asthma center on reducing inflammation-driven tissue remodeling and fibrosis with corticosteroids, coupled with symptomatic control and allergen avoidance. Additional control of Th2 inflammation can be achieved in select asthma patients with biologic therapies such as anti-IL-5 and anti-IL-13 antibodies, which have also been trialed in EoE. Recent molecular analysis suggests an emerging role for structural cell dysfunction, either inherited or acquired, in the pathogenesis and progression of EoE and asthma tissue remodeling. In addition, new data suggest that inflammation-independent end organ rigidity can alter structural cell function. Herein, we review emerging data and concepts for the pathogenesis of tissue remodeling and fibrosis primarily in EoE and relevant pathogenetic parallels in asthma, focusing additionally on emerging disease-specific therapies and the ability of these therapies to reduce tissue remodeling in subsets of patients.
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Affiliation(s)
- Quan M Nhu
- Scripps Translational Science Institute, The Scripps Research Institute, La Jolla, CA, United States.,Division of Gastroenterology and Hepatology, Department of Medicine, Scripps Clinic - Scripps Green Hospital, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Medicine, Scripps Clinic-Scripps Green Hospital, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Seema S Aceves
- Division of Allergy and Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, United States.,Rady Children's Hospital - San Diego, San Diego, CA, United States
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Molina-Infante J, Schoepfer AM, Lucendo AJ, Dellon ES. Eosinophilic esophagitis: What can we learn from Crohn's disease? United European Gastroenterol J 2016; 5:762-772. [PMID: 29026590 DOI: 10.1177/2050640616672953] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/14/2016] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an emerging esophageal inflammatory disorder affecting children and young adults. As a relatively new disease, EoE is still burdened by frequent diagnostic and therapeutic pitfalls in clinical practice. This manuscript posits a number of similarities with Crohn's disease, which may help optimize EoE patient management. Commonalities include epidemiologic trends (Westernized diseases, rising incidence, early-life risk factors), diagnostic considerations (symptoms are poor predictors of disease activity, difficulties in disease activity assessment) and therapeutic issues (similar natural history and therapeutic goals, induction and maintenance phases, combination of drug and endoscopic treatment, potential drug interchangeability, long-term unsolved issues). Physicians devoted to EoE should learn from the extraordinary achievements fulfilled in Crohn's disease: increased disease awareness, multidisciplinary specialized clinics, structured childhood and transition programs, and an ongoing roadmap for personalized treatments, including genetic susceptibility, risk factors for progression, genotype-phenotype correlation, drug monitoring and microbial data.
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Affiliation(s)
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Esophagectomy for eosinophilic esophagitis: how to avoid it. Eur Surg 2016. [DOI: 10.1007/s10353-016-0441-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hua S, Cook D, Walker MM, Talley NJ. Pharmacological treatment of eosinophilic gastrointestinal disorders. Expert Rev Clin Pharmacol 2016; 9:1195-209. [PMID: 27191032 DOI: 10.1080/17512433.2016.1190268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Eosinophilic gastrointestinal disorders (EGIDs) are increasingly prevalent chronic inflammatory diseases characterized by eosinophilic infiltration of the gastrointestinal (GI) tract, in the absence of other known causes of eosinophilia. AREAS COVERED Clinical management of EGIDs is challenging, as there are currently limited therapeutic options available. The most common EGID is eosinophilic esophagitis (EoE), and rarer forms are eosinophilic gastritis, eosinophilic gastroenteritis, and eosinophilic colitis. Clinical presentation depends on the affected GI site. Recently duodenal eosinophilia has been recognized to commonly be present in patients with functional dyspepsia. This review will provide an overview of the pathogenesis and therapeutic management of EGIDs, with particular focus on the pharmacological strategies for these conditions. Expert commentary: Despite the considerable progress made in understanding the pathogenesis of EGIDs, there is still an urgent need for the development of specific and effective therapeutic approaches. Therapeutic management protocols are required that are based on rigorous clinical investigation in large prospective controlled trials to better understand the risks, benefits and limitations of each therapy. More well-defined and consistent end-points are also required to assess treatment outcomes, as there has been variability between patient reported outcomes, clinical outcomes, and histological outcomes in the studies to date.
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Affiliation(s)
- Susan Hua
- a School of Biomedical Sciences and Pharmacy , University of Newcastle , Callaghan , NSW , Australia
- b Hunter Medical Research Institute , New Lambton Heights , NSW , Australia
| | - Dane Cook
- c John Hunter Hospital , New Lambton Heights , NSW , Australia
| | - Marjorie M Walker
- b Hunter Medical Research Institute , New Lambton Heights , NSW , Australia
- d School of Medicine & Public Health , University of Newcastle , Callaghan , NSW , Australia
| | - Nicholas J Talley
- b Hunter Medical Research Institute , New Lambton Heights , NSW , Australia
- d School of Medicine & Public Health , University of Newcastle , Callaghan , NSW , Australia
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Rawson R, Yang T, Newbury RO, Aquino M, Doshi A, Bell B, Broide DH, Dohil R, Kurten R, Aceves SS. TGF-β1-induced PAI-1 contributes to a profibrotic network in patients with eosinophilic esophagitis. J Allergy Clin Immunol 2016; 138:791-800.e4. [PMID: 27212082 PMCID: PMC5014565 DOI: 10.1016/j.jaci.2016.02.028] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 12/29/2015] [Accepted: 02/11/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is an allergic disease of increasing worldwide incidence. Complications are due to tissue remodeling and involve TGF-β1-mediated fibrosis. Plasminogen activator inhibitor 1 (PAI-1/serpinE1) can be induced by TGF-β1, but its role in EoE is not known. OBJECTIVE We sought to understand the expression and role of PAI-1 in patients with EoE. METHODS We used esophageal biopsy specimens and plasma samples from control subjects and patients with EoE, primary human esophageal epithelial cells, and fibroblasts from patients with EoE in immunohistochemistry, quantitative PCR, and immunoassay experiments to understand the induction of PAI-1 by TGF-β1, the relationship between PAI-1 and esophageal fibrosis, and the role of PAI-1 in fibrotic gene expression. RESULTS PAI-1 expression was significantly increased in epithelial cells of biopsy specimens from patients with active EoE compared with that seen in biopsy specimens from patients with inactive EoE or control subjects (P < .001). Treatment of primary esophageal epithelial cells with recombinant TGF-β1 increased PAI-1 transcription, intracellular protein expression, and secretion. Esophageal PAI-1 expression correlated with basal zone hyperplasia, fibrosis, and markers of esophageal remodeling, including vimentin, TGF-β1, collagen I, fibronectin, and matrix metalloproteases, and plasma PAI-1 levels correlated with plasma TGF-β1 levels. PAI-1 inhibition significantly decreased baseline and TGF-β1-induced fibrotic gene expression. CONCLUSIONS PAI-1 expression is significantly increased in the epithelium in patients with EoE and reflects fibrosis, and its inhibition decreases TGF-β1-induced gene expression. Epithelial PAI-1 might serve as a marker of EoE severity and form part of a TGF-β1-induced profibrotic network.
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Affiliation(s)
- Renee Rawson
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Tom Yang
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Robert O Newbury
- Department of Pediatric Pathology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Melissa Aquino
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Ashmi Doshi
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Braxton Bell
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - David H Broide
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Ranjan Dohil
- Division of Pediatric Gastroenterology and Nutrition, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Richard Kurten
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital Research Institute, Little Rock, Ark
| | - Seema S Aceves
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif.
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Andreae DA, Hanna MG, Magid MS, Malerba S, Andreae MH, Bagiella E, Chehade M. Swallowed Fluticasone Propionate Is an Effective Long-Term Maintenance Therapy for Children With Eosinophilic Esophagitis. Am J Gastroenterol 2016; 111:1187-97. [PMID: 27325220 PMCID: PMC5557271 DOI: 10.1038/ajg.2016.238] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 05/04/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although effective in the treatment of eosinophilic esophagitis (EoE) in children, limited data exist on long-term safety and efficacy of swallowed topical corticosteroids. We investigated whether long-term use of swallowed fluticasone in children with EoE leads to sustained reduction in esophageal eosinophils, and endoscopic and clinical improvement. METHODS In an open-label, prospective, single-center study, we offered pediatric patients with active EoE fluticasone 2 puffs to swallow twice a day (strengths in μg/puff: 2-4 years: 44, 5-11 years: 110, ≥12 years: 220). Clinical, endoscopic, and histological assessments were performed at baseline and shortly after therapy. If histological remission was seen, fluticasone was continued with clinical follow-ups every 4 months and endoscopic and histological follow-ups yearly. Clinical scores were derived from eight symptoms (abdominal pain, nausea, vomiting, regurgitation, chest pain, dysphagia, food impaction, and early satiety). Endoscopic scores were derived from six features (rings, exudates, furrows, edema, stricture, and shearing). Scores were expressed as ratio (features present/total). In addition to peak eosinophils/high power field (HPF) (primary outcome), histological features (eosinophilic microabscesses, degranulation, superficial layering, basal zone hyperplasia, dilated intercellular spaces, and lamina propria fibrosis) were assessed. Median clinical and endoscopic scores and individual histologic features were compared over 4 time intervals: <4 months, 4-12 months, 13-24 months, and >24 months. Growth and adverse effects were monitored. RESULTS We enrolled 54 patients, 80% male, median age 6.5 years (range 2-17 years), 85% atopic (57% asthma, 68% allergic rhinitis, and 31% atopic dermatitis), and 74% with food allergy. Mean follow-up was 20.4 months, the longest being 68 months (5.7 years). Esophageal eosinophil counts significantly decreased (median peak eosinophils/HPF at baseline 72, <4 months: 0.5, 4-12 months: 1.75, 13-24 months: 10, and >24 months: 12, all P<0.01). All histological features significantly decreased from baseline to all follow-up time points (all P<0.01). Lamina propria fibrosis significantly decreased (% patients with fibrosis at baseline 92, <4 months: 41, 4-12 months: 50, 13-24 months: 45, and >24 months: 39, all P<0.01). Endoscopic features improved (score at baseline 0.37, <4 months: 0.17, 4-12 months: 0.17, 13-24 months: 0, and >24 months: 0.1, all P<0.01, except at >24 months: P<0.05). Symptoms improved (score at baseline 0.22, <4 months: 0, 4-12 months: 0.11, 13-24 months: 0.11, and >24 months: 0.11, all P<0.05 except at >24 months: P=0.05). In a mixed linear regression model that accounts for correlation of repeated observations in the patient in a per-patient analysis, we found that treatment with swallowed fluticasone led to a statistically significant and sustained decrease in peak esophageal eosinophil counts. Asymptomatic esophageal candidiasis was seen in three children but resolved with anti-fungal therapy. Height and weight z-scores followed expected growth curves. CONCLUSIONS We demonstrate that swallowed fluticasone is effective as a long-term maintenance therapy for children with EoE, without growth impediment or serious side effects.
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Affiliation(s)
- Doerthe A Andreae
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New york, NY
| | - Matthew G Hanna
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Margret S Magid
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stefano Malerba
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael H Andreae
- Department of Anesthesiology, Albert Einstein College of Medicine, New York, NY
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mirna Chehade
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New york, NY
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Moawad FJ, Cheng E, Schoepfer A, Al-Haddad S, Bellizzi AM, Dawson H, El-Zimaity H, Guindi M, Penagini R, Safrooneva E, Chehade M. Eosinophilic esophagitis: current perspectives from diagnosis to management. Ann N Y Acad Sci 2016; 1380:204-217. [DOI: 10.1111/nyas.13164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/01/2016] [Accepted: 06/03/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Fouad J. Moawad
- Gastroenterology Service, Department of Medicine; Walter Reed National Military Medical Center; Bethesda Maryland
| | - Edaire Cheng
- Pediatric Gastroenterology, Hepatology & Nutrition Division; University of Texas Southwestern Medical Center; Dallas Texas
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology; Centre Hospitalier Universitaire; Vaudois/CHUV Lausanne Switzerland
| | - Sahar Al-Haddad
- Department of Laboratory Medicine; St. Michael's Hospital; Hamilton Ontario Canada
| | - Andrew M. Bellizzi
- Department of Pathology; University of Iowa Hospitals and Clinics, University of Iowa Carver College of Medicine; Iowa City Iowa
| | - Heather Dawson
- Institute of Pathology; University of Bern; Bern Switzerland
| | | | - Maha Guindi
- Department of Pathology and Laboratory Medicine; Cedars-Sinai Medical Center; Los Angeles California
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Pathophysiology and Transplantation; Università degli Studi; Milan Italy
| | - Ekaterina Safrooneva
- Institute of Social and Preventive Medicine; University of Bern; Bern Switzerland
| | - Mirna Chehade
- Department of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders; Icahn School of Medicine at Mount Sinai; New York New York
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Cheng E, Zhang X, Wilson KS, Wang DH, Park JY, Huo X, Yu C, Zhang Q, Spechler SJ, Souza RF. JAK-STAT6 Pathway Inhibitors Block Eotaxin-3 Secretion by Epithelial Cells and Fibroblasts from Esophageal Eosinophilia Patients: Promising Agents to Improve Inflammation and Prevent Fibrosis in EoE. PLoS One 2016; 11:e0157376. [PMID: 27310888 PMCID: PMC4911010 DOI: 10.1371/journal.pone.0157376] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 05/28/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Although most studies on treatments for eosinophilic esophagitis (EoE) have focused on effects in the epithelium, EoE is a transmural disease. Eosinophils that infiltrate the subepithelial layers of the esophagus lead to fibrosis and the serious complications of EoE, and current therapies have shown minimal effects on this fibrosis. We aimed to elucidate T helper (Th)2 cytokine effects on esophageal fibroblasts and to explore potential fibroblast-targeted therapies for EoE. METHODS We established telomerase-immortalized fibroblasts from human esophageal biopsies. We stimulated these esophageal fibroblasts with Th2 cytokines, and examined effects of omeprazole and inhibitors of the Janus kinase (JAK)-signal transducer and activator of transcription (STAT6) pathway (AS1517499, leflunomide, and ruxolitinib) on STAT6 phosphorylation, STAT6 nuclear translocation, and eotaxin-3 expression. We also measured the effects of these inhibitors in esophageal epithelial cells stimulated with Th2 cytokines. RESULTS As in esophageal epithelial cells, Th2 cytokines increased STAT6 phosphorylation, STAT6 nuclear translocation, eotaxin-3 transcription and protein secretion in esophageal fibroblasts. Unlike in epithelial cells, however, omeprazole did not inhibit cytokine-stimulated eotaxin-3 expression in fibroblasts. In contrast, JAK-STAT6 pathway inhibitors decreased cytokine-stimulated eotaxin-3 expression in both fibroblasts and epithelial cells. CONCLUSIONS Omeprazole does not inhibit Th2 cytokine-stimulated eotaxin-3 expression by esophageal fibroblasts, suggesting that PPIs will have limited impact on subepithelial EoE processes such as fibrosis. JAK-STAT6 pathway inhibitors block Th2 cytokine-stimulated eotaxin-3 expression both in fibroblasts and in epithelial cells, suggesting a potential role for JAK-STAT inhibitors in treating both epithelial inflammation and subepithelial fibrosis in EoE.
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Affiliation(s)
- Edaire Cheng
- Esophageal Diseases Center, Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Pediatrics, Children’s Health Children’s Medical Center, Dallas, Texas, United States of America
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Medical Services, Veterans Affairs North Texas Health Care System, Dallas, Texas, United States of America
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- * E-mail:
| | - Xi Zhang
- Esophageal Diseases Center, Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Medical Services, Veterans Affairs North Texas Health Care System, Dallas, Texas, United States of America
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Kathleen S. Wilson
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - David H. Wang
- Esophageal Diseases Center, Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Medical Services, Veterans Affairs North Texas Health Care System, Dallas, Texas, United States of America
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Jason Y. Park
- Esophageal Diseases Center, Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Pathology, Children’s Health Children’s Medical Center, Dallas, Texas, United States of America
| | - Xiaofang Huo
- Esophageal Diseases Center, Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Medical Services, Veterans Affairs North Texas Health Care System, Dallas, Texas, United States of America
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Chunhua Yu
- Esophageal Diseases Center, Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Medical Services, Veterans Affairs North Texas Health Care System, Dallas, Texas, United States of America
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Qiuyang Zhang
- Esophageal Diseases Center, Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Medical Services, Veterans Affairs North Texas Health Care System, Dallas, Texas, United States of America
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Stuart J. Spechler
- Esophageal Diseases Center, Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Medical Services, Veterans Affairs North Texas Health Care System, Dallas, Texas, United States of America
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Rhonda F. Souza
- Esophageal Diseases Center, Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Medical Services, Veterans Affairs North Texas Health Care System, Dallas, Texas, United States of America
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
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47
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Hefner JN, Howard RS, Massey R, Valencia M, Stocker DJ, Philla KQ, Goldman MD, Nylund CM, Min SB. A Randomized Controlled Comparison of Esophageal Clearance Times of Oral Budesonide Preparations. Dig Dis Sci 2016; 61:1582-90. [PMID: 26921083 DOI: 10.1007/s10620-015-3990-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 12/06/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Topical steroids prepared as oral viscous slurries have become common in the treatment of eosinophilic esophagitis. Esophageal mucosal contact time correlates with clinical and histologic improvement. AIM To compare the mucosal contact time of alternative oral viscous budesonide (OVB) slurries with the conventional sucralose OVB. METHODS A blinded randomized crossover trial investigating esophageal clearance of three OVB slurry preparations was done on healthy adults. Honey and xanthan gum OVB slurries were compared with standard sucralose OVB in 24 randomly assigned subjects. Each subject ingested the sucralose OVB and either the honey or xanthan gum OVB slurries. The esophageal clearance of each slurry was evaluated as an area under the curve (AUC) using 1 millicurie of technetium-99m-sulfur colloid (Tc99) co-administered in each OVB preparation using nuclear scintigraphy. A standardized taste survey was also administered. RESULTS Xanthan gum had greater mucosal contact time compared to sucralose as measured by a higher AUC at 3 min (P = 0.002), while honey showed no significant difference in esophageal clearance relative to sucralose. Taste scores were significantly higher in the honey group, while scores for xanthan gum were no different from standard sucralose. CONCLUSION OVB slurries utilizing xanthan gum may be a superior alternative to a sucralose-based slurry due to its increased mucosal contact time and similar taste tolerance. Honey may be a suitable alternative as well, due to its similar contact time and favorable taste.
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Affiliation(s)
- Jody N Hefner
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA. .,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Robin S Howard
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Robert Massey
- Department of Nuclear Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Miland Valencia
- Department of Nuclear Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Derek J Stocker
- Department of Nuclear Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Katherine Q Philla
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Matthew D Goldman
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Cade M Nylund
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Steve B Min
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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48
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Davis BP, Rothenberg ME. Mechanisms of Disease of Eosinophilic Esophagitis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2016; 11:365-93. [PMID: 26925500 DOI: 10.1146/annurev-pathol-012615-044241] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a recently recognized inflammatory disease of the esophagus with clinical symptoms derived from esophageal dysfunction. The etiology of EoE is now being elucidated, and food hypersensitivity is emerging as the central cornerstone of disease pathogenesis. Herein, we present a thorough picture of the current clinical, pathologic, and molecular understanding of the disease with a focus on disease mechanisms.
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Affiliation(s)
- Benjamin P Davis
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242;
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229;
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49
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Gómez-Torrijos E, García-Rodríguez R, Castro-Jiménez A, Rodríguez-Sanchez J, Méndez Díaz Y, Molina-Infante J. The efficacy of step-down therapy in adult patients with proton pump inhibitor-responsive oesophageal eosinophilia. Aliment Pharmacol Ther 2016; 43:534-40. [PMID: 26662868 DOI: 10.1111/apt.13496] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 08/26/2015] [Accepted: 11/16/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Proton pump inhibitor-responsive oesophageal eosinophilia (PPI-REE) is common in patients with suspected eosinophilic oesophagitis (EoE). However, the long-term efficacy of PPIs and the best maintenance doses are yet to be defined. AIM To evaluate the durability of the response to PPI therapy after tapering PPI doses in PPI-REE patients. METHODS Prospective study conducted on PPI-REE patients. Upon complete remission on high-dose PPI therapy (omeprazole 40 mg b.d. for 8 weeks), PPI doses were tapered followed by an endoscopic procedure after each dose reduction. The primary outcomes were sustained clinical and histological remission (<15 eos/HPF) after decreasing PPI doses. RESULTS From a total of 121 patients with suspected EoE, 40 (33%) achieved complete remission on high-dose PPIs and were given a diagnosis of PPI-REE. No patient in histological remission showed symptom relapse, but half of patients with relapsing oesophageal inflammation were in clinical remission. After reduction to omeprazole 40 mg once daily, 38/31 (81%) remained in complete remission. Among these latter patients, 15/18 (83%) were kept in remission with omeprazole 20 mg once daily. As for side effects, only asymptomatic hypertransaminasemia and oesophageal candidiasis were observed in two patients while receiving high doses of omeprazole. CONCLUSIONS Most PPI-responsive oesophageal eosinophilia patients show sustained clinical and histological remission with daily PPI doses equal to or below 40 mg of omeprazole. As adverse effects only appeared with the highest dose of omeprazole, it would be advisable to individualise the dose of PPIs for each patient, lowering it to the minimum capable of maintaining the disease controlled.
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Affiliation(s)
- E Gómez-Torrijos
- Department of Allergy Hospital, General Universitario de Ciudad Real, Ciudad Real, Spain
| | - R García-Rodríguez
- Department of Allergy Hospital, General Universitario de Ciudad Real, Ciudad Real, Spain
| | - A Castro-Jiménez
- Department of Allergy Hospital, General Universitario de Ciudad Real, Ciudad Real, Spain
| | - J Rodríguez-Sanchez
- Department of Gastroenterology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Y Méndez Díaz
- Department of Allergy Hospital, General Universitario de Ciudad Real, Ciudad Real, Spain
| | - J Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, Caceres, Spain
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50
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Rajan J, Newbury RO, Anilkumar A, Dohil R, Broide DH, Aceves SS. Long-term assessment of esophageal remodeling in patients with pediatric eosinophilic esophagitis treated with topical corticosteroids. J Allergy Clin Immunol 2016; 137:147-156.e8. [PMID: 26233926 PMCID: PMC4715736 DOI: 10.1016/j.jaci.2015.05.045] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 04/15/2015] [Accepted: 05/14/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic TH2 inflammatory disease characterized by tissue remodeling that leads to esophageal strictures and food impactions. Effects of therapy on long-term remodeling in patients with pediatric eosinophil-associated diseases have not been previously described. OBJECTIVE We sought to understand the long-term control of esophageal remodeling in patients with EoE. METHODS We assessed endoscopic and histologic remodeling and TGF-β1 expression in esophageal biopsy specimens from children (n = 32) with EoE treated with topical corticosteroids (TCSs) over 10 years (mean, 4.5 years). We used standardized EoE scoring tools to gauge endoscopic and symptom features. RESULTS Seven hundred thirty-eight biopsy specimens from 246 endoscopic procedures were evaluated over 10 years. Four hundred eighty-six biopsy specimens had adequate lamina propria for evaluation of subepithelial remodeling. The severity of epithelial esophageal eosinophilia correlated with epithelial remodeling (basal zone hyperplasia, desquamation, and dilated intercellular spaces; P < .0001), lamina propria eosinophilia (P < .0001), and fibrosis (P < .0001). Sixteen subjects were initial responders (<15 eosinophils/high-power field) to TCSs. Responders and nonresponders spent 54% and 97% of their total disease duration with active EoE (P < .001) and 23% and 53% (P < .02) with maximal fibrosis scores, respectively. Responders had lower endoscopy scores during their disease duration (P = .013). Having less than 15 eosinophils/high-power field at any time correlated with lower fibrosis and endoscopic severity. TGF-β1(+) cell counts decreased in responders at the first biopsy, but this was not sustained. Symptoms did not correlate with other disease features. CONCLUSIONS Children with EoE have substantial esophageal remodeling, which associates with inflammation and can improve in a sustainable manner with TCSs. Although endoscopic features correspond to histologic features, symptoms did not correlate with inflammation or fibrosis.
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Affiliation(s)
- Jessica Rajan
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Center for Immunity, Infection, and Inflammation, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif
| | - Robert O Newbury
- Division of Pathology, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif
| | - Arjun Anilkumar
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Center for Immunity, Infection, and Inflammation, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Department of Medicine, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif
| | - Ranjan Dohil
- Division of Gastroenterology, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Department of Medicine, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif
| | - David H Broide
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Department of Medicine, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif
| | - Seema S Aceves
- Division of Allergy and Immunology, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Center for Immunity, Infection, and Inflammation, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Department of Pediatrics, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif; Department of Medicine, University of California, San Diego, La Jolla, Rady Children's Hospital San Diego, San Diego, Calif.
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