The ringed esophagus: histological features of GERD

Endoscopic Diagnosis of Eosinophilic Esophagitis: Basics and Recent Advances

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease, characterized by esophageal dysfunction and intense eosinophil infiltration localized in the esophagus. In recent decades, EoE has become a growing concern as a major cause of dysphagia and food impaction in adolescents and adults. EoE is a clinicopathological disease for which the histological demonstration of esophageal eosinophilia is essential for diagnosis. Therefore, the recognition of the characteristic endoscopic features with subsequent biopsy are critical for early definitive diagnosis and treatment, in order to prevent complications. Accumulating reports have revealed that EoE has several non-specific characteristic endoscopic findings, such as rings, furrows, white exudates, stricture/narrowing, edema, and crepe-paper esophagus. These findings were recently unified under the EoE endoscopic reference score (EREFS), which has been widely used as an objective, standard measurement for endoscopic EoE assessment. However, the diagnostic consistency of those findings among endoscopists is still inadequate, leading to underdiagnosis or misdiagnosis. Some endoscopic findings suggestive of EoE, such as multiple polypoid lesions, caterpillar sign, ankylosaurus back sign, and tug sign/pull sign, will aid the diagnosis. In addition, image-enhanced endoscopy represented by narrow band imaging, endocytoscopy, and artificial intelligence are expected to render endoscopic diagnosis more efficient and less invasive. This review focuses on suggestions for endoscopic assessment and biopsy, including recent advances in optical technology which may improve the diagnosis of EoE.

Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome

Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of esophageal dysfunction, including dysphagia. While EoE is still considered a rare disease, in practice it seems that more and more cases are diagnosed every week, research in the field is exploding, and the pipeline for treatments contains multiple agents, some of which are quite far along the development pathway. After only scattered cases and small series were published in the late 1970s and 1980, Stephen Attwood, Thomas Smyrk, Tom DeMeester, and James Jones, published in Digestive Diseases and Sciences in 1993 a seminal report that described a clinicopathologic syndrome of esophageal eosinophilia with dysphagia. This review details the origins of this paper and compares and contrast what was observed then and what is known now about multiple aspects of EoE, including the clinical presentation, diagnosis, epidemiology, natural history, and treatments and outcomes. Moreover, it will highlight how the paper presaged a number of controversies in the field that have yet to be resolved, as well as foreshadowed the collaborative, multidisciplinary approach that has led to rapid advances.

Successful Esophageal Dilation of Eosinophilic Esophagitis (EoE) Patients With a Previous Postdilation Complication: Start Low and Go Slow

INTRODUCTION

Esophageal dilation is an effective and safe treatment option for fibrostenotic eosinophilic esophagitis (EoE). Despite the safety, adverse events occur, yet there is scarce literature on the best treatment postcomplications.

METHODS

Patients with diagnosis of EoE (≥15 eosinophils per high-power field) from 2011 to 2015 treated at our center were included. Thirty patients with fibrostenotic disease had records available regarding serial dilation therapy. Eight patients previously experienced complications by outside providers. Groups were created based on history of complication before our dilation versus a group without. Mean difference and odds ratio with 95% confidence interval (CI) were calculated.

RESULTS

There were 8 complications, 7 occurred during dilation and 1 during passage of the endoscope. Esophageal diameter at initial dilation was lower in patients with prior complications 9.0±1.51 versus 11.73±2.98 mm (95% CI: -4.44, -1.02; P=0.003). However, end-esophageal diameter was similar across both groups 15.8±1.8 versus 16.1±2.0 mm. Total number of dilation sessions: 4.0±1.8 versus 2.32±1.0 (95% CI: 0.17, 3.19; P=0.03), as well as sessions to reach 17 mm diameter 3.8±1.0 versus 2.3±1.0 (95% CI: -0.08, 2.89; P=0.04), were higher in the patients with complications. The length of time in months to reach an esophageal diameter of 17 mm was longer in patients with complications, but the difference was not statistically significant 3.50±0.6 versus 2.3±2.3 months (P=0.09).

CONCLUSIONS

Esophageal dilation is a safe and effective modality to treat severe fibrostenotic EoE in patients with prior history of complications. The keys to success are: (1) start with lower diameter bougies and (2) dilate slowly over a longer time course to reach targeted diameter and symptom resolution.

PPI Trial for Eosinophilic Esophagitis: Chaos in the Community

INTRODUCTION

Despite consensus eosinophilic esophagitis (EoE) statement published in 2011 calling for a 2-month trial of protons pump inhibitor (PPI), the guidelines are not followed by many. We studied the practice patterns in our community and response to a PPI retrial in patients previously diagnosed with "idiopathic EoE."

METHODS

All patients presenting to the senior author's practice with suspected EoE from 2011 to 2015. Two cohorts were studied: (1) patients diagnosed in the community as "idiopathic EoE"; (2) treatment naïve patients given a PPI trial at University of South Florida. PPI responsive eosinophilia was defined after 2 months of high dose PPIs after initial diagnosis of mucosal eosinophilia and histologic response of <15 eosinophils per HPF. SPSS v19.0 was used to calculate mean difference and odds ratios (OR) and 95% confidence intervals.

RESULTS

In total, 78 patients met inclusion criteria, 46 patients had outside diagnosis of "idiopathic EoE," and 41 patients received a PPI trial at University of South Florida. In total, 34/46 (73.9%) community patients were placed on a PPI, 3/46 (6.5%) were placed on elimination diets, 31/46 (67.4%) steroids, and 21/46 (45.7%) were treated with both steroids/PPIs. Fewer patients received PPI trials in the community 3/46 (6.5%) versus 26/34 (76.5%) at our center [OR, 46.6 (95% CI, 11.3-191.5); P<0.0001]. In total, 12/26 (46.2%) were PPI responders on our retrial despite previously being diagnosed with idiopathic EoE. The group initially diagnosed at our center had a higher PPI response rate 12/15 (80%) versus 12/26 (46.2%) in the community group [OR, 7.58 (1.42, 40.55; P=0.018)].

CONCLUSIONS

The importance of a PPI trial is misunderstood and may be confused with the more traditional PPI trial for gastroesophageal reflux disease. This algorithm is critical and should be done before empiric steroids/diet therapies.

Endoscopic Treatment of Eosinophilic Esophagitis

In eosinophilic esophagitis, the main cause of solid-food dysphagia is tissue remodeling resulting in strictures and narrowed esophagus. Endoscopy and biopsies help to identify the degree of inflammation but often miss the fibrosis. Although initially considered dangerous, esophageal dilation has evolved into an extremely effective and safe treatment in fibrostenotic disease. The key is starting low with small-diameter bougies or balloons, and gradually dilating the esophagus and strictures to 16 to 18 mm. Results in more than 1000 adults and children have shown low rates of complications, especially perforations, and no deaths, but postprocedure chest pain is common.

Esophageal dilation with either bougie or balloon technique as a treatment for eosinophilic esophagitis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Esophageal dilation is a now recognized to be an important therapeutic modality in eosinophilic esophagitis (EoE). We aimed to evaluate the safety of esophageal dilation in EoE, especially regarding perforation risk, and to examine perforation risk by dilator type.

METHODS

We conducted a systematic review of the published literature from January 1, 1950 to June 30, 2016 using PubMed, EMBASE, and Web of Science. Studies were included if they described patients with EoE who underwent elective esophageal dilation and also reported the presence or absence of at least 1 adverse event (eg, perforation, bleeding, pain, or hospitalization). We used random-effects meta-analysis to estimate the frequency of each adverse event.

RESULTS

Of 923 identified articles, 37 met inclusion criteria and represented 2034 dilations in 977 patients. On meta-analysis, postprocedure hospitalization occurred in .689% of dilations (95% confidence interval [CI], 0%-1.42%), clinically significant GI hemorrhage in .028% (95% CI, 0%-.217%), and clinically significant chest pain in 3.64% (95% CI, 1.73%-5.55%). Nine perforations were documented, at a rate of .033% (95% CI, 0%-.226%) per procedure after meta-analysis. None of the perforations resulted in surgical intervention or mortality. Most (5/9) were reported before 2009 (rate, .41% [95% CI, 0%-2.75%]); from 2009 forward the rate was .030% (95% CI, 0%-.225%). Dilation method was described in 30 studies (1957 dilations), in which 4 perforations were detected. The estimated perforation rate for bougies was .022% (95% CI, 0%-.347%) and for balloons was .059% (95% CI, 0%-.374%).

CONCLUSIONS

Perforation from esophageal dilation in EoE is rare, and there is no evidence of a significant difference in perforation risk related to dilator type. Esophageal dilation should be considered a safe procedure in EoE.

Eosinophilic esophagitis: What can we learn from Crohn's disease?

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.

2015 David Y. Graham Lecture: The First Two Decades Of Eosinophilic Esophagitis-From Acid Reflux To Food Allergy

Collaborative efforts by pediatric and adult gastroenterologists, allergists, dieticians, and pathologists have brought about marked progress in the recognition, understanding, and management of eosinophilic esophagitis (EoE) over the past two decades. Once an esoteric diagnosis, EoE is now increasingly identified as a major cause of morbidity, afflicting both children and adults. The detection of mucosal eosinophils has evolved from a diagnostic feature of acid reflux to a biomarker of food sensitization of the esophagus. Translational studies and murine models have elucidated Th-2 immune pathways in EoE, inspiring the development of targeted biologic therapeutics. At the same time, validation of patient-reported outcomes and endoscopic end points has facilitated the implementation of clinical trials of novel therapeutics. Ongoing investigations have elucidated the importance of "looking beneath the surface" of the epithelium, focusing greater attention on the impact of esophageal remodeling in the clinical consequences of EoE. Elimination diets continue to gain popularity as an intriguing, highly effective, and non-pharmacologic therapy that lends credence to the concept that EoE is a food-driven, immunologic disorder.

Impact of Diagnostic Delay and Other Risk Factors on Eosinophilic Esophagitis Phenotype and Esophageal Diameter

GOALS

Endoscopic features of eosinophilic esophagitis (EoE) are variable with at least 2 phenotypes. The goal of this study was to classify adult EoE patients based on esophageal phenotype and diameter, and assess an association between demographical and clinical histories to define EoE phenotypes and overall disease progression.

METHODS

All consecutive patients with a confirmed diagnosis of EoE from 1988 to 2013 treated at University of South Florida were included. Patients were grouped into inflammatory or fibrostenotic phenotype, and further characterized by esophageal diameter: group 1 (6 to 9.9 mm), group 2 (10 to 16.9 mm), and group 3 (>17 mm-control). Significance level was set at 5%.

RESULTS

Sixty-four adult patients met inclusion criteria. Sixty-one percent of patients (39/64) were defined as fibrostenotic and 39% (25/64) as inflammatory phenotype. There was a significant difference in mean time of delayed diagnosis in patients with <10 mm esophageal diameter (14.8 y) and patients with a diameter of 10 to 16.9 mm (11.1 y) compared with patients with an esophageal diameter of ≥17 mm (5 y); P=0.002 and 0.006, respectively. Patients on aspirin with delayed diagnosis (>7 y) were significantly more likely to present with strictures (<10 mm) compared with nonaspirin users [odds ratio (OR=7.0; 95% confidence interval (CI), 7.2-31.3; P=0.008]. Similar results were found with non-steroid anti-inflammatory drugs, smoking, and alcohol (OR=6.4; 95% CI, 1.6-26.4; P=0.01, OR=5.2; 95% CI, 1.4-20.1; P=0.02, and OR=6.4; 95% CI, 1.6-26.0; P=0.009), respectively.

CONCLUSIONS

In our US population, a delay in diagnosis was shown to be associated with stricture formation in EoE confirming the Swiss experience. The results show the importance of reducing the diagnostic delay in EoE as there appears to be progression to fibrosis over time, aggravated by common medications and social habits.

Current Management of Eosinophilic Esophagitis 2015

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by esophageal dysfunction and eosinophilic infiltrate (≥15/hpf) in the esophageal epithelium and the absence of other potential causes of eosinophilia. The prevalence is increasing and is the most common cause of solid food dysphagia in children and young adults. This article will review the diagnosis and management of EoE based on consensus conferences, systematic reviews, and meta-analysis and highlights seminal studies in our evolving treatment of this disease. However, all answers are not available and I will remark about the lessons learned in my clinical practice seeing EoE patients over the last 25 years. The complicated etiology of the complaint of dysphagia in EoE patients will be reviewed. The importance of utilizing endoscopy, biopsies, and barium esophagram to help define the 2 phenotypes (inflammatory, fibrostenosis) of EoE will be highlighted. The controversy about PPI-responsive esophageal eosinophilia will be discussed and contrasted with idiopathic EoE. Finally, the 3 treatment options for EoE (drugs, diet, dilation) will be reviewed in detail and a useful clinical management algorithm presented.

Esophageal dilation in eosinophilic esophagitis

Tissue remodeling with scaring is common in adult EoE patients with long standing disease. This is the major factor contributing to their complaints of solid food dysphagia and recurrent food impactions. The best tests to define the degree of remodeling are barium esophagram, high resolution manometry and endoscopy. Many physicians are fearful to dilate EoE patients because of concerns about mucosal tears and perforations. However, multiple recent case series attest to the safety of esophageal dilation and its efficacy with many patients having symptom relief for an average of two years. This chapter will review the sordid history of esophageal dilation in EoE patients and outline how to perform this procedure safely. The key is graduated dilation over one to several sessions to a diameter of 15-18 mm. Postprocedural pain is to be expected and mucosal tears are a sign of successful dilation, not complications. In some healthy adults, occasional dilation may be preferred to regular use of medications or restricted diets. This approach is now supported by recent EoE consensus statements and societal guidelines.

Extracellular Eosinophil Granule Protein Deposition in Ringed Esophagus with Sparse Eosinophils

BACKGROUND

Eosinophilic esophagitis (EoE) remains difficult to classify because of varying presentations. Not uncommonly, patients present with symptoms of esophageal dysfunction and have esophageal changes on endoscopy resembling EoE but without >15 eosinophils/HPF. Patients with low numbers of eosinophils in esophageal biopsy specimens may have esophageal changes and symptomatic disease brought about by eosinophil granule protein deposition without recognizable intact cells.

AIM

To determine whether extracellular eosinophil granule protein deposition is present in the esophagi of patients with low eosinophil numbers who have clinical symptoms and characteristic endoscopic esophageal changes of EoE including ringed esophagus (RE).

METHODS

Esophageal biopsy specimens were studied from eight EoE patients with >15 eosinophils per high power field (HPF) and nine patients with RE (<15 eosinophils/HPF). The specimens were analyzed for eosinophil granule proteins, major basic protein 1 (eMBP1) and eosinophil-derived neurotoxin (EDN), by indirect immunofluorescence.

RESULTS

Both EoE and RE showed positive EDN and eMBP1 extracellular deposition; control esophagus showed minimal or none. Comparing EoE and RE, extracellular EDN and eMBP1 were similar except that EDN in EoE was greater in the distal esophagus.

CONCLUSIONS

This study highlights the importance of assessing eosinophil granule protein deposition in esophageal disease with potential eosinophil involvement. Persistent/progressive esophageal changes may be brought about by eosinophil granule proteins despite low numbers of intact cells. The meaning of "resolution" in EoE may need to be redefined based on numbers of esophageal eosinophils, extracellular eosinophil granule protein deposition, and subsequent clinical course of patients.

The changing faces of eosinophilic esophagitis: the impact of consensus guidelines at the University of South Florida

BACKGROUND AND AIMS

Prior to the consensus guideline conference in 2007, eosinophilic esophagitis (EoE) was uncommon dominated by the fibrostenotic phenotype, but over the past decade has become a common cause of dysphagia with more inflammatory phenotypes diagnosed. We assessed the impact of guideline definitions on the characteristics of EoE phenotypes over the past 26 years at our institution.

METHODS

We reviewed the electronic health record of 75 consecutive patients meeting guideline definition EoE from 1/1988 to 5/2014. We separated groups based on 5-year intervals of diagnosis and phenotype. For continuous data, results were summarized as mean difference and standard deviation with 95 % confidence intervals.

RESULTS

Five groups based on 5-year intervals of diagnosis were identified: group 1-1988-1993 (n = 7), group 2-1994-1999 (n = 7), group 3-2000-2005 (n = 4), group 4-2006-2011 (n = 35), and group 5-2012-2014 (n = 22). Prior to 2000, all patients were diagnosed with fibrostenotic EoE. After the initial 2007 guideline conference, inflammatory EoE has predominated with only one-third diagnosed with fibrostenotic EoE. Prior to 2011, only two were diagnosed with PPI-REE. In the last 3 years, 8 out of 22 patients (32 %) had PPI-REE. Overall, 8 out of 10 (80 %) PPI-REE were the inflammatory phenotype. When comparing pre- (n = 18) and post (n = 57)-consensus definitions, there was a significant difference between age of diagnosis (30.710.2 vs. 41.3 ± 14.3; p = 0.001), age of symptom onset (18.4 +/15.2 vs. 32.4 ± 15.5), and initial esophageal diameter (10.5 ± 2.7 vs. 14.3 ± 4.2; p < 0.0001), respectively.

CONCLUSIONS

Fibrostenotic EoE has steadily decreased, and inflammatory EoE is now the most recognized form. Across our 26-year experience, there was a decrease in delay in diagnosis and severity of esophageal stricture. The pivotal change occurred around 2007 corresponding to the first EoE guideline emphasizing the impact and importance of early detection of disease.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Retrospective, single-center study.

SETTING

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

PATIENTS

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

INTERVENTIONS

Anti-acids and esophageal dilation.

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

LIMITATIONS

Retrospective, small sample.

CONCLUSION

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

Eosinophilic esophagitis: a paradigm shift for pathology

BACKGROUND

Eosinophilic esophagitis (EoE) is an increasingly recognized disease only reported in the adult literature since 1993. Our facility has the opportunity to evaluate steroid-naive EoE patients since 1988, allowing us to describe the evolution of the histologic diagnosis of EoE.

METHODS

This retrospective study analyzed 95 patient charts with initial diagnosis of congenital esophageal stenosis/EoE from 1988 to 2012. Patients had dysphagia and met endoscopic criteria consistent with current EoE histologic criteria while on chronic proton-pump inhibitor therapy. Histologic slides were obtained for only 10 patients because of limited slide availability; and the slides were reviewed by a single pathologist. EoE is defined as ≥1 biopsy specimens demonstrating >15 eosinophils/HPF.

RESULTS

Following review of histologic analysis reports, pathologists in our 2 academic hospitals began recognizing EoE as separate disease entity starting in 2007, coincidental with first EoE guidelines. After 2007, there was a clear surge in histologic diagnosis of EoE. Slides from 10 patients from 1988 to 2012 were reviewed. Of 35 biopsy sets, 19 were previously interpreted as reflux esophagitis (RE) or acute/chronic inflammation, 3 as RE with eosinophils, 2 as normal, and 11 as EoE. Reevaluation revealed EoE in 79% specimens with RE/inflammation and 100% with RE and eosinophils; remaining specimens had confirmed original diagnosis. All 10 patients had at least one set of slides meeting current EoE histologic criteria.

CONCLUSIONS

EoE as a disease has been present for at least 2 to 3 decades. This is the first report of a clearly demarcated time point reflecting a paradigm shift in the histologic diagnosis of EoE as a distinct entity resulting from a seminal consensus report.

A phenotypic analysis shows that eosinophilic esophagitis is a progressive fibrostenotic disease

BACKGROUND

Phenotypes of eosinophilic esophagitis (EoE) are not well-characterized.

OBJECTIVE

To describe clinical features of patients with EoE with predefined phenotypes, determine predictors of these phenotypes, and make inferences about the natural history of EoE.

DESIGN

Retrospective study.

SETTING

Tertiary-care center.

PATIENTS

Incident EoE cases from 2001 to 2011 that met consensus diagnostic guidelines.

INTERVENTION

Review of records.

MAIN OUTCOME MEASUREMENTS

Endoscopic phenotypes, including fibrostenotic, inflammatory, or mixed. Other groups of clinical characteristics examined included atopy, level of esophageal eosinophilia, and age of symptom onset. Multinomial logistic regression assessed predictors of phenotype status.

RESULTS

Of 379 cases of EoE identified, there were no significant phenotypic differences by atopic status or level of eosinophilia. Those with the inflammatory phenotype were more likely to be younger than those with mixed or fibrostenotic (13 vs 29 vs 39 years, respectively; P < .001) and less likely to have dysphagia, food impaction, and esophageal dilation (P < .001 for all). The mean symptom length before diagnosis was shorter for inflammatory (5 vs 8 vs 8 years; P = .02). After multivariate analysis, age and dysphagia independently predicted phenotype. The odds ratio (OR) for fibrostenosis for each 10-year increase in age was 2.1 (95% CI, 1.7-2.7). The OR for dysphagia was 7.0 (95% CI, 2.6-18.6).

LIMITATIONS

Retrospective, single-center study.

CONCLUSION

In this large EoE cohort, the likelihood of fibrostenotic disease increased markedly with age. For every 10-year increase in age, the odds of having a fibrostenotic EoE phenotype more than doubled. This association suggests that the natural history of EoE is a progression from an inflammatory to a fibrostenotic disease.

Eosinophilic esophagitis in adults: an update on medical management

Management of eosinophilic esophagitis (EoE) centers around the 3 Ds: diet, drug therapy, and dilation. Unfortunately, there is not a consistent relationship between symptom relief and resolution of mucosal eosinophilia. Elemental diets are very successful in children, but poorly tolerated by adults. The 6-food elimination diet is more attractive to adults, especially for those individuals with multiple food allergies. Steroids are the preferred anti-eosinophil drug for EoE. Oral prednisone is infrequently used because of side effects. Topical swallowed preparations (fluticasone, budesonide) are preferred for acute and possibly maintenance therapy. Relapses off steroids are frequent and dysphagia does not predictably improve. Esophageal dilation is key treatment for patients with the fibrostenotic phenotype of EoE. Long-term symptom relief for 1-2 years is common. Post-procedure chest pain is to be expected but perforation is very rare. A suggested algorithm for the treatment of EoE based on endoscopic phenotypes is outlined.

Meta-analysis: the safety and efficacy of dilation in eosinophilic oesophagitis

BACKGROUND

Oesophageal dilation is one of the most effective options in the management of symptoms of eosinophilic oesophagitis (EoE). However, earlier reports described an increased rate of complications.

AIM

To perform a meta-analysis of population-based studies of the risks associated with dilation and the clinical efficacy and duration of response to dilation in EoE.

METHODS

Using MEDLINE and EMBASE, a systematic search was performed for published articles since 1977 describing cohort or randomised controlled trials of dilation in EoE. Summary estimates, including 95% confidence interval (CI), were calculated for the occurrence of complications associated with dilations (perforations, haemorrhage, chest pain, lacerations) and percentage of patients with symptom improvement following dilation. Heterogeneity was calculated using the I² statistic.

RESULTS

The search resulted in 232 references, of which 9 studies were included in the final analysis. The studies described 860 EoE patients, of whom 525 patients underwent at least one oesophageal dilation and a total of 992 dilations. There were three cases of perforation (95% CI 0-0.9%, I² 0%) and one haemorrhage (95% CI 0-0.8%, I² 0%). Six studies reported postprocedural chest pain in 2% of cases (95% CI 1-3, I² 53%). Clinical improvement from dilation occurred in 75% of patients (95% CI 58-93%, I² 86%).

CONCLUSIONS

Dilation in patients with eosinophilic oesophagitis is a safe procedure with a low rate of serious complications (<1%), and seems to result in at least a short-term improvement of symptoms in the majority of patients.

The management of eosinophilic esophagitis in adults

Eosinophilic esophagitis (EoE), typically a pediatric disease, is becoming more frequently recognized in adults. The optimal treatment of EoE in this population has not yet been established. This paper reviews the literature detailing the treatments for EoE in adults, and provides a treatment strategy. To accomplish this task a comprehensive literature search of Medline was undertaken for studies evaluating the treatment of EoE in adults. High-dose topical corticosteroids and specific elimination diets have been found to improve symptoms, reduce eosinophilic infiltrate in esophageal mucosa, and improve endoscopic markers of inflammation. Dilation therapy does improve symptoms but not underlying inflammation. Other treatments including leukotriene inhibitors and immunomodulatory drugs have been unsuccessful. An effective strategy for treating EoE in adults is using topical corticosteroids and elimination diets for inflammatory disease, and esophageal dilation for fibrotic disease. The conclusion that inflammatory and fibrotic components of EoE respond to different treatment modalities should be evaluated in future clinical trials.

Review article: proton pump inhibitor therapy for suspected eosinophilic oesophagitis

BACKGROUND

Recent advances in eosinophilic oesophagitis (EoE) have confirmed the existence of a new disease phenotype, proton pump inhibitor (PPI)-responsive oesophageal eosinophilia (PPI-REE).

AIM

To summarise evidence supporting the use of PPI therapy in patients with suspected EoE (oesophageal dysfunction plus >15 eos/HPF in oesophageal biopsies).

METHODS

A literature search was conducted through MEDLINE, using the MeSH search terms 'eosinophilic oesophagitis', 'proton pump inhibitors' and 'oesophageal eosinophilia'. Relevant articles and their reference lists were identified through manual review.

RESULTS

Ten articles, including 258 patients with suspected EoE (152 children, 106 adults) undergoing clinico-histological re-evaluation after PPI therapy, were identified. In children, clinical response ranged from 78% to 86% and histological remission from 23% to 40%. In adults, symptom response ranged from 25% to 80% and histological remission from 33% to 61%. Among PPI-REE patients with oesophageal pH-monitoring, 35 showed pathological and 10 normal studies. PPI-REE was significantly commoner with documented gastro-oesophageal reflux disease (GERD) when compared to patients with negative pH monitoring (70% vs. 29%, P < 0.001). Symptom improvement/resolution occurred in 50-85% of patients without histological remission on PPI therapy. Six PPI-REE patients demonstrated clinico-histological relapse on PPI therapy.

CONCLUSIONS

At least one third of patients with suspected EoE achieve clinico-histological remission on PPI therapy. Response is more limited in children compared with that in adults. pH monitoring does not accurately predict response to PPI therapy, albeit histological remission is significantly higher, up to 70%, upon documented GERD. Symptom improvement is common with PPI therapy despite persistent eosinophilic infiltration.

Differential diagnosis in allergy

The otolaryngic allergist must be able to distinguish between common nonallergic diagnoses that present very similarly to allergic conditions. This article describes a few of the vast myriad of conditions that must be ruled out before a diagnosis of allergy may be made. After reading this article clinicians will be able to identify various conditions, which will enhance their ability to appropriately make correct decisions for prompt and efficient management of their patients with allergic or nonallergic diseases of the head and neck.

Eosinophilic esophagitis: updated consensus recommendations for children and adults

Eosinophilic esophagitis (EoE) is a clinicopathologic condition of increasing recognition and prevalence. In 2007, a consensus recommendation provided clinical and histopathologic guidance for the diagnosis and treatment of EoE; however, only a minority of physicians use the 2007 guidelines, which require fulfillment of both histologic and clinical features. Since 2007, the number of EoE publications has doubled, providing new disease insight. Accordingly, a panel of 33 physicians with expertise in pediatric and adult allergy/immunology, gastroenterology, and pathology conducted a systematic review of the EoE literature (since September 2006) using electronic databases. Based on the literature review and expertise of the panel, information and recommendations were provided in each of the following areas of EoE: diagnostics, genetics, allergy testing, therapeutics, and disease complications. Because accumulating animal and human data have provided evidence that EoE appears to be an antigen-driven immunologic process that involves multiple pathogenic pathways, a new conceptual definition is proposed highlighting that EoE represents a chronic, immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. The diagnostic guidelines continue to define EoE as an isolated chronic disorder of the esophagus diagnosed by the need of both clinical and pathologic features. Patients commonly have high rates of concurrent allergic diatheses, especially food sensitization, compared with the general population. Proved therapeutic options include chronic dietary elimination, topical corticosteroids, and esophageal dilation. Important additions since 2007 include genetic underpinnings that implicate EoE susceptibility caused by polymorphisms in the thymic stromal lymphopoietin protein gene and the description of a new potential disease phenotype, proton pump inhibitor-responsive esophageal eosinophila. Further advances and controversies regarding diagnostic methods, surrogate disease markers, allergy testing, and treatment approaches are discussed.

Review article: oesophageal dilation in adults with eosinophilic oesophagitis

BACKGROUND

Eosinophilic oesophagitis is a chronic inflammatory disorder of the oesophagus, characterised by the proton pump inhibitor-refractory accumulation of eosinophils in the oesophageal epithelium (>15 intraepithelial eosinophils/high powered field). Adults present with solid food dysphagia and recurrent food impactions. Oesophageal remodelling produces the characteristic endoscopic feature of adult eosinophilic oesophagitis including strictures, rings and a narrow calibre oesophagus.

AIM

To evaluate the safety and efficacy of oesophageal dilation as the initial therapy for adults with eosinophilic oesophagitis.

METHODS

Medline search from 1975 to November 2010 for all reports of the treatment of patients with eosinophilic oesophagitis using search words: eosinophilic oesophagitis treatment, dilation and eosinophilic oesophagitis, steroids and eosinophilic oesophagitis.

RESULTS

Our systematic review found that 92% of patients treated with oesophageal dilation had improvement in their dysphagia symptoms for up to 1-2 years. Three case series clearly showed clinical resolution of dysphagia symptoms, independent of the degree of eosinophil infiltration, which was unchanged after dilation. Postprocedure pain for several days is common, due to some degree of mucosal tear, but true perforation very rare (<0.1%).

CONCLUSIONS

Oesophageal dilation is an acceptable option for healthy adult eosinophilic oesophagitis patients with anatomic narrowing, possibly followed by a course of topical steroids to reduce inflammation and retard remodelling. Future studies should include a head-to-head comparison of topical steroids and oesophageal dilation, bougie vs through-the-scope balloon dilation and maintenance topical steroids compared with on-demand treatment.

Boerhaave's syndrome as the primary manifestation of adult eosinophilic esophagitis. Two case reports and a review of the literature

Eosinophilic esophagitis (EoE) has been associated with an increased risk of esophageal mucosal tears induced by vomiting to dislodge impacted food or following endoscopic procedures. However, Boerhaave's syndrome or transmural perforation of the organ resulting from vomiting induced to dislodge impacted food has rarely been reported. In this article, we present two male adult patients with long-term esophageal symptoms who suffered from Boerhaave's syndrome after the impaction of food in the esophagus. Both patients required surgical management because of clinical and radiological signs of perforation. This rare complication of EoE has been documented in 11 other reports, predominantly affecting young men in whom EoE had not been previously diagnosed, despite the majority having esophageal symptoms and a history of atopy. There are only two published cases of esophageal perforation that presented in children, which were managed conservatively. Our two patients and 4 out of the 11 described in literature required surgery because of esophageal perforation. Our two cases involved closure of the perforation, while in three published reports, perforation resulted in a partial or complete esophagectomy. No cases have been published on Boerhaave's syndrome caused by EoE that ended in fatalities. It is important to note that esophageal perforation caused by vomiting is a potentially severe complication of EoE that is being increasingly described in literature. Therefore, patients with non-traumatic Boerhaave's syndrome should be assessed for EoE, especially if they are young men who have a prior history of dysphagia and allergic manifestations.

Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults

BACKGROUND & AIMS

Despite consensus recommendations, eosinophilic esophagitis (EoE) is commonly diagnosed upon esophageal eosinophilic infiltration (EEI; based on ≥ 15 eosinophils per high power field; eo/HPF). We evaluated the prevalence of EEI before and after proton pump inhibitor (PPI) therapy and assessed the accuracy of EEI and pH monitoring analyses.

METHODS

Biopsies were taken from the upper-middle esophagus of 712 adults with upper gastrointestinal symptoms who were referred for endoscopy due to upper gastrointestinal symptoms. Patients with EEI were treated with rabeprazole (20 mg, twice daily) for 2 months. EoE was defined by persistent symptoms and >15 eo/HPF following PPI therapy.

RESULTS

Thirty-five patients (4.9%) had EEI, of whom 55% had a history of allergies, and 70% had food impaction or dysphagia as their primary complaint. Twenty-six EEI patients (75%) achieved clinicopathological remission with PPI therapy; of these, 17 had GERD-like profile (EEI <35 eo/HPF and objective evidence of reflux, based on endoscopy or pH monitoring), and 9 had EoE-like profile (EEI 35-165 eo/HPF, typical EoE symptoms and endoscopic findings). The PPI response was 50% in the EoE-like profile patients. The PPI-response was 50% in EoE-like profile patients. Likewise, PPI-responsive EEI occurred with normal (33%) and pathologic (80%) pH monitoring. Higher histologic cut-off values improved specificity and positive predictive for EoE (35%-35% for >20 eo/HPF; 46%-39% for >24 eo/HPF; 65%-50% for 35 eo/HPF).

CONCLUSIONS

In adults with EEI, 75% of unselected patients and 50% with an EoE phenotype respond to PPI therapy; pH monitoring is poorly predictive of response. Patients with PPI-responsive EEI >35 eo/HPF are phenotypically undistinguishable from EoE patients. EoE might be overestimated without clinical and pathologic follow-up of patient response to PPI.

Treatment of eosinophilic esophagitis: how should we manage the disease?

Eosinophilic esophagitis (EE) is a chronic clinicopathologic syndrome and is the latest inflammatory disease of the esophagus described in literature. It seems to have a multifactorial etiology. Its causes include exposure to food or airborne allergens that affect individuals who may be genetically predisposed and exposure to the acid could also modulate the inflammatory response at esophageal level. However, we currently do not know how each of these possible etiologic factors contribute to the development of the disease that is essential to define specific treatment. We have used 3 different therapeutic approaches that were effective in patients with EE: various antiinflammatory drugs that are useful in treating asthma, controlling the exposure to allergens, particularly with respect to dietary changes and dilation of the esophagus. Although none of these treatments have absolute advantages, they can efficiently control the symptoms and inflammation in a large number of patients. Each treatment option should be assessed on a case-by-case basis in accordance with the experience of each center, the patients' characteristics, their sensitivity to allergens and their preferences. This article provides the latest information on the different treatment options for patients with EE, analyzing the advantages and disadvantages of each pathology and it offers practical recommendations on how to manage these patients who are being more frequently diagnosed.

Esophageal dilation: simple and effective treatment for adults with eosinophilic esophagitis and esophageal rings and narrowing

The goal of this article is to present the results of the long-term treatment with esophageal dilation of a consecutive series of adults with eosinophilic esophagitis (EoE). EoE in adults is a disease of middle aged white males, with recurrent food impactions and dysphagia. The exact treatment of EoE is unknown due to the uncertainty of the pathogenesis. Currently, the long-term follow-up of adult EoE patients is limited. Sixteen consecutive adult patients (12 males/4 females between ages 27 and 58 years) with EoE underwent a detailed history and baseline upper gastrointestinal endoscopy (EGD) with multiple esophageal biopsies. Thirteen had esophageal dilation. Fifteen were on proton pump inhibitor (PPI) therapy. After dilation, one patient was treated with a restrictive diet. One patient took prn fluticasone. Most of the patients had allergy testing for food and aeroallergens. Follow-up evaluation with similar testing was on average 22 months (range: 12-40 months). Six patients were not available for follow-up. None of the remaining 10 patients had a food impaction; one required further esophageal dilation. Only two patients had intermittent dysphagia. The average dysphagia score decreased from 2.1 to 0.3 (P < 0.002). The average number of eosinophils at follow-up was not significantly different from baseline (120 eosinophils/HPF proximally and 165 eosinophils/HPF distally (P= 0.75). The gross endoscopy findings were unchanged in all patients except one who normalized. A total of 62% and 75% of patients had positive tests for aeroallergens and food allergens, respectively. Over an average of two years, esophageal dilation provided excellent symptomatic relief among 10 adult EoE patients despite no improvement in the mucosal eosinophilia or gross endoscopic appearance.

Comparison of esomeprazole to aerosolized, swallowed fluticasone for eosinophilic esophagitis

BACKGROUND

Both gastroesophageal reflux disease and allergy/atopy have been implicated in the pathogenesis of eosinophilic esophagitis (EoE). There are no prospective studies comparing treatment of EoE with acid suppression versus topical corticosteroids.

OBJECTIVE

To determine the outcome of adult eosinophilic esophagitis patients treated with esomeprazole versus topical fluticasone.

DESIGN

Prospective randomized controlled trial.

SETTING

Academic medical center.

PARTICIPANTS

Adults (18-80) diagnosed with EoE by symptoms of dysphagia and esophageal biopsies with >or=15 eosinophils/hpf.

INTERVENTIONS

Subjects were randomized to esomeprazole (40 mg by mouth every morning) or aerosolized, swallowed fluticasone (440 mcg by mouth twice a day) for 8 weeks.

MAIN OUTCOME MEASUREMENTS

Improvement in dysphagia (8-point scale), esophageal eosinophil infiltration before and after treatment, prevalence of GERD measured by validated questionnaire and baseline pH study.

RESULTS

About 56% (14/25) had acid reflux by pH study. There was no difference between treatment groups in improvement in dysphagia scores [3/12 (25%) of the esomeprazole group versus 6/12 (50%) in the fluticasone group, P = 0.40]. Eosinophil infiltration decreased with treatment in both groups, and there was no difference in the amount of decrease between groups (P = 0.70).

LIMITATIONS

Small sample size, unexpectedly high drop-out rate.

CONCLUSIONS

Gastroesophageal reflux disease is common in adult eosinophilic esophagitis patients. Dysphagia improves and esophageal eosinophilic infiltration decreases with either treatment. There was no difference in degree of improvement in dysphagia or eosinophil infiltration in patients treated with either topical fluticasone or oral esomeprazole. GERD may be important in the pathogenesis of adult EoE.

Esophageal dilation in eosinophilic esophagitis: effectiveness, safety, and impact on the underlying inflammation

OBJECTIVES

Esophageal dilation often leads to long-lasting relief of dysphagia in eosinophilic esophagitis (EoE). The aim of this study was to define the effectiveness, safety, and patient acceptance of esophageal dilation in EoE. In addition, we examined the influence of dilation on the underlying esophageal inflammation.

METHODS

Two databases including 681 EoE patients were reviewed. Cohort 1 consisted of patients treated with dilation alone, whereas cohort 2 included patients treated with a combination of dilation and antieosinophilic medication. Patients from cohort 1 underwent a prospective histological reexamination and an evaluation using a questionnaire.

RESULTS

In total, 207 EoE patients were treated with esophageal dilation, 63 in cohort 1 and 144 in cohort 2. Dilation led to a significant increase in esophageal diameter and to an improvement in dysphagia in both the cohorts (P<0.001). After dilation, dysphagia recurred after 23+/-22 months in cohort 1 and 20+/-14 months in cohort 2. No esophageal perforation or major bleeding occurred. Among the patients surveyed, 74% reported retrosternal pain after dilation; however, all were agreeable to repeated dilation if required. Eosinophil peak infiltration, eosinophil load, and EoE-associated histological signs were not significantly affected by esophageal dilation.

CONCLUSIONS

Esophageal dilation is highly effective in providing long-lasting symptom relief and can be performed safely with a high degree of patient acceptance. However, dilation is associated with postprocedural pain in most patients and does not influence the underlying inflammatory process. Symptom improvement despite persistence of inflammation suggests that tissue remodeling contributes substantially to symptom generation in EoE.

Approach to dysphagia in the young patient in the era of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) has emerged as an important cause of dysphagia and food impactions in young adults. Previously considered a rare condition, an increasing number of cases of EoE have been attributable to a rising incidence and a growing awareness of the condition. Typical endoscopic features include concentric mucosal rings, linear furrowing, white exudates, and a narrow caliber esophagus. Current consensus guidelines define EoE by 1) the presence of characteristic symptoms, especially dysphagia and food impactions in adults, 2) >or= 15 eosinophils per high power field in esophageal tissue, and 3) exclusion of other disorders with similar presentations (eg, gastroesophageal reflux disease). Current knowledge about the pathophysiology implicates food allergens, aeroallergens, and genetic factors. The main treatment options for EoE are proton pump inhibitors, dietary manipulation, and topical or oral glucocorticoids. Endoscopic dilation may be performed in patients who do not respond to medical therapy. This review highlights recent insights into the diagnosis and management of EoE in young adults.

Esophageal dilation in eosinophilic esophagitis: safety and predictors of clinical response and complications

BACKGROUND

Esophageal strictures resulting from eosinophilic esophagitis present management challenges, and high rates of rents and perforation have been reported.

OBJECTIVE

To assess the safety of esophageal dilation in eosinophilic esophagitis and to characterize predictors of both clinical response and complications of the procedure.

DESIGN

Retrospective study of the University of North Carolina eosinophilic esophagitis database.

SETTING

Tertiary care referral center.

PATIENTS

Cases of eosinophilic esophagitis were defined as per consensus guidelines.

INTERVENTION

Dilation with either Savary or through-the-scope balloon techniques.

MAIN OUTCOME MEASUREMENTS

Complications (deep mucosal rents, contained or free perforation, and chest pain requiring medical attention or hospitalization) and the global clinical symptom response.

RESULTS

Of 130 eosinophilic esophagitis cases identified, 70 dilations (12 Savary, 58 balloon) were performed in 36 patients. Esophageal size improved from 12 to 16 mm (P < .001), with an overall symptom response rate of 83%. The only predictor of clinical response was final dilation diameter. There were 5 complications (7%): 2 deep mucosal rents and 3 episodes of chest pain. There were no perforations. There was one hospitalization for chest pain. All complications occurred in patients being treated with topical steroids, who underwent balloon dilation. Complications were associated with younger age (23 vs 42; P = .02) and more dilations (4 vs 1.7; P = .009).

LIMITATIONS

Single center, retrospective study.

CONCLUSIONS

Esophageal dilation can be performed in eosinophilic esophagitis with low rates of tears, chest pain, and hospitalization. No perforations were found in our database. The effectiveness of dilation was best when a larger esophageal caliber was achieved, but patients undergoing more procedures was associated with complications.

Eosinophilic Esophagitis: Current Aspects of a Recently Recognized Disease

Eosinophilic esophagitis (EoE) is a chronic clinicopathological entity characterized by large numbers of intraepithelial eosinophils infiltrating the esophageal mucosa. The inflammation leads to alterations in the caliber and the motility of the organ, which determines esophageal symptoms, especially dysphagia and frequent food impaction. Firstly described in 1978, EoE represents today an increasingly recognized disease, with cases coming from all developed countries and rising epidemiology. The origin of EoE has been related to allergy to food components or inhalants, and a number of studies support a Th2-type reaction in the origin of the disease. Thus, several treatment strategies based on controlling the exposition to triggering allergens or therapies using anti-allergic drugs have demonstrated efficacy in EoE. Since EoE frequently presents with esophageal stenosis, endoscopic dilation has been also used in treating these patients, but a high risk of complications has been documented. However, single treatment strategies have not been compared to a placebo group in most of studies, and we do not know the long-term consequences of eosinophilic inflammation, esophageal fibrous remodeling or its possible modifications using different therapies. Furthermore, we lack of a common accepted therapeutic end-point to assess the efficacy of the treatment: from mere resolution of symptoms to full control of esophageal inflammation. This article summarizes the current knowledge about the epidemiology, origin and pathogenesis of the disease, and discuses several practical questions, especially those related to how the affected patients should be treated.

Advances in research of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is being recognized with increasing frequency. Numerous studies have investigated its pathogenesis, pathophysiologic manifestations, and effective diagnosis and treatment methods in recent years. In this article, we will review the recent advances in research on EE.

Putting the puzzle together: epidemiological and clinical clues in the etiology of eosinophilic esophagitis

The cause of eosinophilic esophagitis remains unknown, but its epidemiology and clinical features provide pieces to the puzzle. Eosinophilic esophagitis probably emerged in the 1950s or early 1960s, has an increasing incidence, occurs in most developed countries, is related to food allergies, affects adults and children, has a strong male predominance, clusters in families, and is commonly associated with other allergic and atopic disorders. Several theories have been proposed to explain its evolution, but none has been convincingly demonstrated.

Eosinophilic oesophagitis in adults

Previously considered a rare condition, eosinophilic oesophagitis (EoE) has become increasingly recognized as an important cause of dysphagia and food impactions in adults. This is likely attributable to a combination of an increasing incidence of EoE and a growing awareness of the condition. EoE may occur in isolation or in conjunction with eosinophilic gastroenteritis. However, the burgeoning field is likely attributable to the variant that uniquely affects the oesophagus. Adults classically present with symptoms of dysphagia, food impactions, and heartburn. Typical endoscopic features include concentric mucosal rings, linear furrowing, white plaques or exudates and a narrow caliber oesophagus. In some cases, the endoscopic features may appear normal. For years, EoE went unrecognized because eosinophilic infiltration was accepted as a manifestation of reflux, which continues to be a confounding factor in some patients. Current consensus is that the diagnosis of EoE is established by 1) the presence of symptoms, especially dysphagia and food impactions in adults, 2) > or =15 eosinophils per high power field in oesophageal tissue, and 3) exclusion of other disorders with similar presentations such as GERD. Current understanding of EoE pathophysiology and natural history are limited but the entity has been increasingly linked to food allergies and aeroallergens. The main treatment options for EoE are proton pump inhibitors, dietary manipulation, and topical or oral glucocorticoids. This review highlights recent insights into EoE in adults although, clearly, much of the available data overlap with pediatrics and, occasionally, with eosinophilic gastroenteritis.

Eosinophilic esophagitis

Eosinophilic esophagitis is a chronic inflammatory disorder characterized by dense eosinophilic infiltration of the esophageal mucosa. The pathogenesis is incompletely understood and food allergies and aeroallergens have been implicated. The most common clinical presentation in adults is dysphagia to solids. Its associated endoscopic findings are distinct and include concentric rings and longitudinal furrows, although endoscopy may be unremarkable in a minority of patients. A number of management strategies exist; however, data are limited in adults, and only a few are based on randomized controlled trials. Management options include dietary modifications, pharmacological therapy, and endoscopic dilation.

Predictors of response to proton pump inhibitor therapy among children with significant esophageal eosinophilia

OBJECTIVES

To determine predictors of histological response to proton pump inhibitor (PPI) therapy among children with significant esophageal eosinophilia (SEE), defined as >or=15 eosinophils per high powered field (eos/hpf) on esophageal mucosal biopsy (EMB).

STUDY DESIGN

Response to PPI therapy among children with SEE treated with PPI who underwent repeat EMB was studied retrospectively. Response was defined as <5 eos/hpf on repeat EMB. Characteristics of responders and nonresponders were analyzed.

RESULTS

Of 326 patients (ages 1 through 18 years) diagnosed with SEE over a 7-year period, 43 (mean age, 8.5 years; 67% males) met inclusion criteria. After PPI therapy, 17 patients (40%) were responders. There were no significant differences in demographics, presenting symptoms, endoscopic, or histological findings between responders and nonresponders. Among patients with 15 to 20 eos/hpf on EMB, 50% were responders; among patients with >20 eos/hpf on EMB, 29% were responders. Seven of 17 (41%) patients with abnormal pH monitoring and 5 of 11 (45%) patients with normal monitoring were responders.

CONCLUSIONS

Forty percent of patients with SEE demonstrated histological response to PPI therapy. None of the clinical characteristics evaluated predicted response, and response was not dependent on results of pH study. The role of PPI therapy in treating SEE warrants further prospective investigation.

Treatment of eosinophilic esophagitis: overview, current limitations, and future direction

Eosinophilic esophagitis (EE) is an increasingly recognized syndrome presenting with upper gastrointestinal (UGI) symptoms in association with hypereosinophilia (>15 eosinophils/HPF) on esophageal mucosal biopsies. The pathogenesis is unknown, but the candidate etiologies include food and aeroallergen hypersensitivity and an unusual presentation of gastroesophageal reflux disease. This review will highlight the treatments of EE in children and adults. Current treatments are controversial, few data are available in adults, and long-term studies are almost nonexistent. We outline the limitations in the current studies and suggest seven major issues in the study design that must be addressed in future drug trials.

3-yr-follow-up of topical corticosteroid treatment for eosinophilic esophagitis in adults

BACKGROUND

Eosinophilic esophagitis (EE) is a clinicopathologic syndrome comprising isolated eosinophilic inflammation of the esophagus, with symptoms of dysphagia, and possibly, reflux. It was initially described in children, and in recent years, there is a heightened awareness in adults. The etiology is not completely understood. The treatments include dietary manipulation, topical corticosteroids, systemic corticosteroids, Montelukast, and endoscopic dilation. In adults, there are no randomized trials demonstrating the efficacy of any particular treatment, and no prospective studies describing the natural history of the disease following treatment.

METHODS

We performed an interval follow-up of patients treated with a swallowed corticosteroid inhaler. We contacted 51 adult patients who were diagnosed with EE and treated with a swallowed corticosteroid inhaler between September 1, 1999, and May 31, 2003. All patients had received 6 wk of treatment with fluticasone 220 mEq/puff, four puffs swallowed twice daily for 6 wk.

RESULTS

Thirty-two patients replied (63%) with a mean follow-up duration of 3.3 yr. Ninety-one percent of patients reported recurrent symptoms; a mean of 8.8 months after treatment was completed. Sixty-nine percent of patients repeated treatment with the steroid inhaler at least once.

CONCLUSIONS

It appears that EE is a chronic remitting disorder that requires more than one topical steroid treatment course.

Scope of drug-induced, infectious and allergic esophageal injury

PURPOSE OF REVIEW

The most common cause of esophageal injury is gastroesophageal reflux disease, however other less recognized causes may affect the esophagus. In this review we will focus on pill-induced esophageal injury, infections of the esophagus and eosinophilic esophagitis.

RECENT FINDINGS

Esophageal infections are less frequent since HIV infection has become better controlled with antiviral therapies. The most emergent 'allergic' disease of the esophagus is eosinophilic esophagitis, which has become increasingly recognized in children and adults over the last decade. Eosinophilic esophagitis is a clinicopathologic disorder characterized by a dense esophageal eosinophilia generally occurring in association with upper gastrointestinal symptoms, primarily intermittent dysphagia, and refractory to proton pump inhibitor therapy.

SUMMARY

Drug-induced esophageal injury remains underdiagnosed and should be better recognized.

Eosinophilic esophagitis in adults

Eosinophilic esophagitis in adults is a disease characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of long-standing solid food dysphagia and food impactions. First described in 1978, this syndrome is being recognized increasingly in the developed world, with multiple case series reported from the United States, Europe, and Australia during the past decade. Diagnosis requires the presence of greater than or equal to 15 eosinophils/high-power field on esophageal biopsies. Successful treatment in adults has been reported with the use of systemic and topical swallowed steroids. Endoscopic treatment has been associated with increased an risk for tears and perforations.

Idiopathic eosinophilic disorders of the gastrointestinal tract in children

Over the last decade, eosinophilic gastrointestinal diseases have emerged as increasingly recognised diseases affecting both adults and children. While the exact morbidity is uncertain, it has become evident that they carry a significant cost to affected patients. Recent investigations shed light on basic mechanisms of eosinophilic recruitment and inflammation, and suggest a critical role for Th2 cytokines, such as eotaxin, and allergen exposure in their pathogenesis. Eosinophilic oesophagitis (EO) is the best characterised of these diseases, and improved understanding of its basic biology stimulated development of new treatment regimens. Current evidence supports the use of elemental diets and systemic or topical corticosteroids to treat EO. A major clinical problem is the fact that most patients relapse when medical treatment is discontinued, thus making nutritional management an attractive long term option. Many areas remain unanswered in the management of patients with EGIDs, including identification of optimal treatment protocol, development of appropriate non-invasive monitoring, and choice of appropriate therapeutic endpoints.

High intraepithelial eosinophil counts in esophageal squamous epithelium are not specific for eosinophilic esophagitis in adults

OBJECTIVES

The histologic criterion of >20 eosinophils per high power field (hpf) is presently believed to establish the diagnosis of idiopathic eosinophilic esophagitis (IEE). This is based on data that the number of intraepithelial eosinophils in gastroesophageal reflux disease (GERD) is less than 20/hpf. This study tests this belief.

METHODS

Pathology records were searched for patients who had an eosinophil count >20/hpf in an esophageal biopsy. This patient population was biased toward adults with GERD who had routine multilevel biopsies of the esophagus. The clinical, radiological, and manometric data and biopsies were studied.

RESULTS

Forty patients out of a total of 3,648 reports examined had an eosinophil count >20/hpf in squamous epithelium of an esophageal biopsy. Analysis of these 40 cases indicated that 6 (15%) patients had IEE, 2 (5%) had coincident IEE and GERD, 28 (70%) had GERD, and 2 (5%) each had achalasia and diverticulum. There was no significant difference among these groups in terms of maximum eosinophil number, biopsy levels with >20 esoinophils/hpf, presence of eosinophilic microabscesses, involvement of surface layers by eosinophils, and severity of basal cell hyperplasia and dilated intercellular spaces.

CONCLUSION

All histologic features presently ascribed to IEE can occur in other esophageal diseases, notably GERD. As such, the finding of intraepithelial eosinophilia in any number is not specific for IEE. When a patient with GERD has an esophageal biopsy with an eosinophil count >20/hpf, it does not mean that the patient has IEE.

How to manage refractory GERD

Patients who are unresponsive to 4-8 weeks' treatment with PPIs twice daily might have so-called refractory GERD. The first investigation these patients should undergo is upper endoscopy to exclude a diagnosis of peptic ulcer disease or cancer and identify the presence of esophagitis. The presence of esophagitis in these patients is suggestive of a pill-induced injury, an autoimmune skin disease involving the esophagus, eosinophilic esophagitis or, less likely, a hypersecretory syndrome or a genotype that confers altered metabolism of PPIs. Refractory reflux syndromes associated with normal endoscopy findings are more problematic to diagnose and further testing may be required, including prolonged 48 h pH testing, impedance measurements (for nonacid reflux), esophageal manometry and gastric function tests. For patients with refractory GERD who do not have esophagitis, possible etiologies include nocturnal gastric acid breakthrough, nonacid GER, missed GER or other diseases such as achalasia, gastroparesis or functional heartburn.

Integrated approach to treatment of children and adults with eosinophilic esophagitis

Over the last decade, treatment plans for eosinophilic esophagitis included the use of elemental formula, elimination diets, systemic corticosteroids, and the gavage of aerosolized steroids. Except for one placebo-controlled blinded prospective study, most decision making has been based on retrospective or uncontrolled studies and clinical experience. In this article, three authors from diverse backgrounds combine their resources to propose treatment paths with justification based on their clinical experience and interpretation of the literature.

Treatment of eosinophilic esophagitis: drugs, diet, or dilation?

A number of recent studies have demonstrated that a variety of treatments effectively improve symptoms and histology in the majority of patients with eosinophilic esophagitis. Therapeutic options include pharmacologic treatments, such as oral and topical corticosteroids and leukotriene-receptor antagonists. In children, the high response rates to dietary modification and elimination suggest that certain foods may serve as environmental triggers for the eosinophilic infiltration. Because many adults present with strictures, endoscopic esophageal dilation is another management modality. Despite these treatment options, several controversies exist in the recommended treatment strategy. Whether the goal of therapy is resolution of symptoms, tissue eosinophilia, or both remains uncertain owing to the paucity of data on the natural history of the condition. Furthermore, important differences in the clinical presentations of eosinophilic esophagitis in children and adults point toward the possible need for different treatment approaches in the two patient populations.