Correlation between number of eosinophils and reflux index on same day esophageal biopsy and 24 hour esophageal pH monitoring

Number of bottles of esophageal biopsies in the evaluation of eosinophilic esophagitis and clinical outcomes

BACKGROUND

The number of bottles of esophageal biopsies needed for the evaluation of eosinophilic esophagitis (EoE) is unclear, despite cost differences.

AIMS

Assess the clinical outcomes between patients with one and two bottles of esophageal biopsies for the assessment of EoE.

METHODS

Retrospective study of adults who underwent esophagogastroduodenoscopy (EGD) for esophageal symptoms between January 2015 and June 2021 and findings of ≥15 eosinophils per high power field (eos/hpf). Patients with one bottle (1 bottle-EoE) had biopsies from the entire or proximal esophagus. Patients with two bottles had biopsies separated from the distal and proximal esophagus and were separated into those with ≥ 15 eos/hpf in both bottles (2 bottle Dif-EoE), or the distal bottle alone (2 bottle Lim-EoE). The primary outcomes were endoscopic findings at follow-up EGD as assessed by the Eosinophilic Esophagitis Endoscopic Reference Score (EREFS) and the presence of ≥15 eos/hpf.

RESULTS

Of 85 patients with esophageal eosinophilia who met inclusion criteria, 49 had 2 bottle Dif-EoE, 18 had 2 bottle Lim-EoE, and 18 had 1 bottle-EoE. At median follow-up of 3.3-5.6 months, more patients with 1 bottle EoE had dysphagia (p = 0.029), however there were no differences in the EREFS (p = 0.14) or presence of ≥15 eos/hpf (p = 0.39). More patients with 2 bottle Dif-EoE were treated with topical steroids (16.3% vs. 0% vs. 0%, p = 0.039) and diet (20.4% vs. 0% vs. 5.6%, p = 0.05).

CONCLUSION

Endoscopic and histologic outcomes were similar in patients who had one and two bottles for esophageal biopsies in the evaluation of EoE.

IgE-mediated gastroallergic anisakiasis with eosinophilic oesophagitis: a case report

BACKGROUND

Anisakiasis is an emerging zoonosis caused by the fish parasitic nematode Anisakis infecting the gastrointestinal tract.

CASE PRESENTATION

We describe a case of a 58-year-old woman diagnosed with gastro-allergic anisakiasis, in which the patient developed an acute food-induced IgE-mediated hypersensitivity reaction as well as concurrent gastro-intestinal manifestations after consumption of raw fish. The patient presented with epigastric pain, anaphylaxis and acute dysphagia caused by eosinophilic oesophagitis.

DISCUSSION

Anisakis allergy should be considered as causative agent in patients presenting with acute urticarial rash, anaphylaxis and/or abdominal manifestations, especially when symptoms occur after consumption of seafood. Moreover, eosinophilic oesophagitis may be a rare but important complication of Anisakis infection. Endoscopic evaluation with esophageal biopsies should therefore be considered if suggestive symptoms are present. Patients with confirmed gastroallergic anisakiasis are advised to properly freeze or cook fish prior to consumption, although caution is advised, since heat-stable allergen proteins have been described. An adrenaline auto-injector should be prescribed.

Diagnostic Value of Mid-esophageal Biopsies in Pediatric Patients With Eosinophilic Esophagitis

INTRODUCTION

Eosinophilic esophagitis (EoE) is histologically defined as the presence of 15 or more intraepithelial eosinophils per high-power fields. Limited consensus exists on where to sample the esophagus in pediatrics. This study aimed to identify whether endoscopic and histologic examination of the mid esophagus offers diagnostic value compared to proximal/distal esophageal biopsies.

METHODS

A retrospective chart review of pediatric patients with EoE was performed. Endoscopic and histologic parameters were assessed at the initial and follow-up visits, and concordance between proximal/distal biopsy and mid biopsy was determined.

RESULTS

A total of 100 patients with a mean age of 9.6 ± 4.07 years were included. Endoscopic parameters between proximal/distal and mid esophagus were concordant in 84% to 97% of patients (initial assessment) and in 80% to 97% of patients (at follow-up). Mid esophagus showed endoscopic abnormalities, which were absent at the proximal/distal esophagus in 1% to 5% of patients, as well as histologic abnormalities in 2% to 8% of patients overall at initial and follow-up examinations.

CONCLUSIONS

We recommend continued endoscopic and histologic assessment of the proximal/distal biopsy; however, examination of the mid esophagus does offer small diagnostic value in our subset of patients. Future studies need to be conducted before conclusive recommendations supporting the use of mid-esophageal biopsies can be made.

Esophagitis in Pediatric Esophageal Atresia: Acid May Not Always Be the Issue

OBJECTIVE

Esophagitis is highly prevalent in patients with esophageal atresia (EA). Peptic esophagitis has long been assumed to be the primary cause of esophagitis in this population, and prolonged acid suppressive medication usage is common; such treatment is of unknown benefit and carries potential risk.

METHODS

To better understand the role of commonly used antireflux treatments in EA, we analyzed all patients with repaired EA who underwent endoscopy with biopsies at our institution between January 2016 and August 2018. Macroscopic erosive and histologic esophagitis on biopsy was graded per predefined criteria. Clinical characteristics including acid suppressive medication usage, type of EA and repair, presence of hiatal hernia, and history of fundoplication were reviewed.

RESULTS

There were 310 unique patients (33.5% long gap EA) who underwent 576 endoscopies with biopsies during the study period. Median age at endoscopy was 3.7 years (interquartile range 21-78 months). Erosive esophagitis was found in 8.7% of patients (6.1% of endoscopies); any degree of histologic eosinophilia (≥1 eosinophil/high power field [HPF]) was seen in 56.8% of patients (48.8% of endoscopies), with >15 eosinophils/HPF seen in 15.2% of patients (12.3% of endoscopies). Acid suppression was common; 86.9% of endoscopies were preceded by acid suppressive medication use. Fundoplication had been performed in 78 patients (25.2%). Proton pump inhibitor (PPI) and/or H2 receptor antagonist (H2RA) use were the only significant predictors of reduced odds for abnormal esophageal biopsy (P = 0.011 for PPI, P = 0.048 for H2RA, and P = 0.001 for PPI combined with H2RA therapy). However, change in intensity of acid suppressive therapy by either dosage or frequency was not significantly associated with change in macroscopic erosive or histologic esophagitis (P > 0.437 and P > 0.13, respectively). Presence or integrity of a fundoplication was not significantly associated with esophagitis (P = 0.236).

CONCLUSIONS

In EA patients, acid suppressive medication therapy is associated with reduced odds of abnormal esophageal biopsy, though histologic esophagitis is highly prevalent even with high rates of acid suppressive medication use. Esophagitis is likely multifactorial in EA patients, with peptic esophagitis as only one of multiple possible etiologies for esophageal inflammation. The clinical significance of histologic eosinophilia in this population warrants further investigation.

Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference

BACKGROUND & AIMS

Over the last decade, clinical experiences and research studies raised concerns regarding use of proton pump inhibitors (PPIs) as part of the diagnostic strategy for eosinophilic esophagitis (EoE). We aimed to clarify the use of PPIs in the evaluation and treatment of children and adults with suspected EoE to develop updated international consensus criteria for EoE diagnosis.

METHODS

A consensus conference was convened to address the issue of PPI use for esophageal eosinophilia using a process consistent with standards described in the Appraisal of Guidelines for Research and Evaluation II. Pediatric and adult physicians and researchers from gastroenterology, allergy, and pathology subspecialties representing 14 countries used online communications, teleconferences, and a face-to-face meeting to review the literature and clinical experiences.

RESULTS

Substantial evidence documented that PPIs reduce esophageal eosinophilia in children, adolescents, and adults, with several mechanisms potentially explaining the treatment effect. Based on these findings, an updated diagnostic algorithm for EoE was developed, with removal of the PPI trial requirement.

CONCLUSIONS

EoE should be diagnosed when there are symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (or approximately 60 eosinophils per mm²) on esophageal biopsy and after a comprehensive assessment of non-EoE disorders that could cause or potentially contribute to esophageal eosinophilia. The evidence suggests that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criterion, and we have developed updated consensus criteria for EoE that reflect this change.

The Role of Proton Pump Inhibitors in the Management of Pediatric Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, local, immune-mediated disorder characterized by symptoms of esophageal dysfunction and the presence of a dense eosinophilic infiltrate in the esophageal mucosa. Consensus diagnostic recommendations for EoE diagnosis included absence of histological response to a proton-pump inhibitor (PPI) trial, to exclude gastro-oesophageal reflux disease (GERD)-associated esophagitis. This recommendation exposed an entity known as "proton pump inhibitor-responsive esophageal eosinophilia" (PPI-REE), which refers to patients with EoE phenotype who are PPI-responsive and do not present GERD. In recent years, there is evidence which indicates that PPI-REE is a sub-phenotype of EoE with similar clinical, endoscopic, histological and genetic characteristics, as well as Th2-related inflammatory response. As a result, PPIs should be considered another treatment for EoE and not a diagnostic tool. PPI-REE was originally described in a case series which included two children and in two retrospective pediatric series. Later, a prospective pediatric study showed a high rate of response to PPIs at high doses with long-term maintenance at lower doses. PPI monotherapy in children with esophageal eosinophilia (EE) has been observed to reduce eotaxin-3 expression in epithelial cells and to practically reverse the allergy and inflammatory transcriptome. These data reveal that PPIs are also an effective treatment for EoE in pediatric patients, although more studies are necessary in order to define the best induction and maintenance treatment regimen, the long-term safety profile and their influence on the occurrence of fibrosis and esophageal remodeling.

Lack of compliance with consensus recommendations on the diagnosis of eosinophilic esophagitis (EoE) in published prevalence studies. A clinical and systematic review

OBJECTIVE

According to consensus recommendations, the presence of esophageal symptoms, >15 eosinophils/high-power field and unresponsiveness to proton pump inhibitors are required for a diagnosis of eosinophilic esophagitis (EoE). Nevertheless, inconsistency in using these guidelines has been reported in recent publications. The objective of this study was to assess compliance with EoE diagnostic guidelines in published studies on EoE prevalence and to evaluate other clinical and methodological parameters.

METHODS

A systematic review was conducted in articles published between 2008 and 2015 on the prevalence of EoE in unselected adults. Studies using EoE diagnostic definitions were judged to be compliant if they included all three components of the definition, partially compliant if they included two and non-compliant if they included one or none. Esophageal biopsy protocol differences and descriptions of patients' characteristics were determined.

RESULTS

Among the 20 studies included, eight were performed in a hospital setting and 12 in the general population. Only 40.0% of studies were compliant, 35.0% were partially compliant and 25.0% were non-compliant with the EoE diagnostic definition guidelines. In 60.0% of the studies a proton pump inhibitor trial was not administered. Only 30.0% adhered to the recommendations in the esophageal biopsy protocol. A lack of description of the history of atopia and endoscopic characteristics was observed in many studies.

CONCLUSIONS

Partial or non-compliance with the EoE diagnostic definition was observed in most of the published prevalence studies after the publication of the first consensus. The results of these studies might be interpreted taking into account this context.

Eosinophilic oesophagitis in children: an uncommon occurrence in a predominantly Chinese population in Singapore

INTRODUCTION

We aimed to determine the prevalence and clinical manifestations of eosinophilic oesophagitis (EoE) in children who presented to a tertiary care hospital in Singapore.

METHODS

We conducted a retrospective review of all oesophageal biopsies taken during oesophagogastroduodenoscopy (OGD) from March 2010 to December 2011. The patients' demographics and clinical characteristics were collected. Biopsies were reviewed by a single pathologist who was blinded to the original reports, using the current consensus criteria for the histological diagnosis of EoE.

RESULTS

Of the 88 children who had biopsies during OGD, 4 (4.5%) children (three boys, one girl; three Chinese, one Caucasian) were diagnosed with EoE. Their median age was 9.5 (range 4.0-12.0) years. The main clinical presentations were abdominal pain (in the three older children) and vomiting (in the youngest child). Three children had a history of atopy. Three children were diagnosed with EoE in the original histology reports, while one was diagnosed after the second review following histology demonstrating > 15 eosinophil granulocytes per high power field and microabscess formation. Endoscopy findings revealed oesophagitis in two children, one of whom was already on acid suppression therapy. Although three children were started on acid suppression therapy, they continued to be symptomatic. One child was also treated with swallowed fluticasone and two with food allergen avoidance, resulting in symptom improvement.

CONCLUSION

Although EoE is uncommon in Singapore, greater awareness is needed among family physicians and general paediatricians. Paediatric gastroenterologists should alert pathologists when sending biopsy specimens that are suspicious for EoE.

Distinguishing GERD from eosinophilic oesophagitis: concepts and controversies

Over the past three decades, the detection of oesophageal mucosal eosinophils has transitioned from a biomarker of GERD to a diagnostic criterion for eosinophilic oesophagitis (EoE). In GERD, oesophageal eosinophils are considered part of the chronic inflammatory response to acid reflux, whereas the marked eosinophilia in EoE is viewed as a central feature of the immune response to ingested food and/or environmental antigen stimulation. Descriptions of a considerable subset of patients with symptomatic, endoscopic and histological findings of EoE that resolve with PPI therapy has led to confusion and controversy regarding the distinction of EoE from GERD. Study findings indicate that PPI-responsive oesophageal eosinophilia (PPI-REE) more closely resembles EoE than GERD, both from a clinical and immunological aspect. Although responsiveness to PPI therapy should not be utilized to exclude EoE, PPI therapy is effective at reducing oesophageal eosinophilia in ∼40% of patients, and PPI therapy is both a safe and practical initial step in the management of patients with oesophageal eosinophilia. Ongoing studies elucidating the mechanism behind PPI-REE will improve our understanding and management of EoE. In this Review, the mechanisms and evidence that underlie the controversy in the distinction between GERD and EoE are evaluated.

Eosinophilic esophagitis: interactions with gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE) are not mutually exclusive. The notion that GERD and EoE can be distinguished by the response to proton pump inhibitor (PPI) treatment is based on the mistaken assumption that gastric acid suppression is the only important therapeutic effect of PPIs, and therefore only GERD can respond to PPIs. We believe that a clinical or histologic response to PPIs does not rule in GERD or rule out EoE. We recommend a trial of PPI therapy for patients with symptomatic esophageal eosinophilia, even if the diagnosis of EoE seems clear-cut.

Eosinophilic esophagitis prevalence in an adult population undergoing upper endoscopy in southeastern Mexico

Eosinophilic esophagitis (EoE) prevalence fluctuates according to the population studied and varies from 0.4% in an open population to 6.5% in subjects with esophageal symptoms. Even though this entity has been described in North American and European populations, it is still considered an 'unusual' condition in Latin America. The study aimed to determine EoE prevalence in patients undergoing elective endoscopy in a tertiary referral center in southeastern Mexico. Consecutive patients were evaluated that had been referred to the Medical and Biological Research Institute, Veracruz, Mexico, for upper endoscopy due to gastrointestinal symptoms. Demographic variables and symptoms were analyzed in all the cases. Eight mucosal biopsies of the esophagus (four proximal and four distal) were obtained and were reviewed by a blinded pathologist. Histological diagnosis was established when the mean eosinophil count at a large magnification was ≥15. A total of 235 subjects (137 women, 51.16 years) were evaluated, and EoE prevalence was 1.7% (4/235 95% confidence interval 0.2-3.6%). In all four cases, pH test were normal. Among patients with histological diagnosis of EoE, a greater number of patients with a past history of asthma (50% vs. 19.3%, P = 0.04) and a tendency for a greater frequency of dysphagia (50% vs. 25%, P = 0.10). There were no differences in the endoscopic findings (rings, grooves, plaques, or stricture) when compared with the patients presenting with erosive esophagitis. EoE prevalence among patients undergoing upper endoscopy from southeastern Mexico was 1.7%, which can be regarded as intermediate to low.

Proton pump inhibitors for eosinophilic oesophagitis

PURPOSE OF REVIEW

To review the significance and plausible mechanisms underlying 'proton pump inhibitor (PPI) responsive oesophageal eosinophilia' in eosinophilic oesophagitis (EoE).

RECENT FINDINGS

EoE is defined as an immune-mediated clinicopathologic condition characterized by oesophageal dysfunction and eosinophil-predominant inflammation. This new conceptual definition has been proposed partly due to a recently identified disease phenotype called 'PPI-responsive oesophageal eosinophilia'. Emerging data support the possibility that this condition represents a clinical response to anti-inflammatory properties of PPIs that are independent of effects on gastric acid.

SUMMARY

Currently, the diagnosis of EoE is reserved for patients with oesophageal eosinophilia and symptoms that do not respond to PPIs. This practice may not be appropriate, however, both because gastric acid suppression by PPIs might benefit EoE patients and because PPIs have anti-inflammatory properties that also might benefit EoE patients. More studies are sorely needed to understand the mechanisms underlying PPI-responsive oesophageal eosinophilia. Currently, a favourable response to PPI therapy should not be regarded as a proof of an underlying acid peptic disorder such as gastroesophageal reflux disease (GERD) nor should it preclude a diagnosis of EoE. Furthermore, it seems prudent to recommend a trial of PPI therapy for patients with oesophageal eosinophilia and symptoms, even when the diagnosis of EoE seems clear-cut.

Transient PPI responsive esophageal eosinophilia may be a clinical sub-phenotype of pediatric eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) and gastroesophageal reflux (GERD) both cause esophageal eosinophilia. Reports show that esophageal eosinophilia meeting criteria for EoE may respond to acid suppression mono-therapy. Consensus guidelines have termed this entity "PPI-responsive esophageal eosinophilia" (PPIRee) and recommend a trial with proton-pump inhibitors (PPIs) prior to a definitive EoE diagnosis. The mechanisms of PPIRee and whether this represents a sub-phenotype of GERD, a sub-phenotype of EoE, or its own distinct entity remain unclear.

METHODS

A database search revealed children who had an initial histologic response to PPI monotherapy but had recurrence of esophageal eosinophilia and symptoms despite continued PPI therapy. In order to understand the patterns of esophageal inflammatory cells during PPI therapy we performed quantitative immunohistochemistry for mast cells, CD1a positive antigen presenting cells, and CD45RO memory T cells.

RESULTS

Four pediatric patients (mean age 9.5 years) had a mean peak eosinophil count of 52 eos/hpf which initially resolved completely during PPI mono-therapy. However, despite continued PPI therapy, endoscopic abnormalities and pan-esophageal eosinophilia recurred (mean peak eosinophil count of 64 eos/hpf). There was no seasonal variation or lack of PPI adherence that explained the return of eosinopihlia. Similar to eosinophilia, mastocytosis and CD45RO cells were transiently decreased during PPI therapy.

CONCLUSION

PPIs appear to be capable of transiently resolving multiple inflammatory cell subsets including eosinophils, mast cells, and CD45RO cells. Our data suggest that patients with PPIRee should have continued monitoring for EoE during PPI monotherapy. The numbers of patients in whom PPIRee is a transient phenomenon and whether PPIRee represents a sub-phenotype of EoE in children merits further investigation.

The otolaryngologic manifestations in children with eosinophilic esophagitis

OBJECTIVES

(1) To describe the incidence of eosinophilic esophagitis (EoE) in the population of patients undergoing esophagoscopy with biopsy by a pediatric otolaryngology service. (2) To elucidate the demographics, presenting symptoms, and endoscopic findings in children with EoE.

DESIGN

Case series.

PATIENTS/METHODS

The reports of esophageal biopsy specimens taken over 5 years in 2429 patients were reviewed. Ninety-two patients who received their initial diagnosis of EoE by the pediatric otolaryngology service with specimens showing 15 or greater eosinophils per high power field (HPF) were included.

INTERVENTIONS

The demographic data, history, presenting symptoms, and endoscopic findings were reviewed retrospectively for the patients.

MAIN OUTCOME MEASURE

The percentage of children diagnosed with EoE of all children undergoing esophageal biopsy.

RESULTS

A total of 92 children were diagnosed with EoE (3.8% of total children biopsied). The mean age at biopsy was 4.4 years, much lower than previously reported in the literature (approximately 8 years); 73% were boys and 27% girls. The main presenting symptom was cough (46%) followed by hoarseness, throat clearing, burping/vomiting, and abdominal pain. Forty three percent had a history of asthma and 17% a history of GERD. Half of patients had esophageal edema, a third were normal, and only a quarter had mucosal furrowing on endoscopic examination.

CONCLUSIONS

EoE is increasingly diagnosed as a clinical entity with a distinct symptom profile and etiology. Increased understanding of EoE and its predisposing factors requires a multidisciplinary approach to diagnosis and management involving the pediatric otolaryngologist.

Gastrointestinal manifestations of food allergies

The rates of eosinophilic gastrointestinal disorders appear to be increasing. The most common of these is eosinophilic esophagitis (EoE) which is a clinicopathologic condition consisting of characteristic symptoms and endoscopic features accompanied by a pan-esophageal, acid resistant epithelial eosinophilia of greater than equal to 15 per high power field. Typical symptoms include dysphagia and abdominal pain. Typical endoscopic features include pallor, plaques, furrows, concentric rings. Complications include food impactions and strictures. EoE resolution with food elimination diets provides evidence that EoE is a food-antigen driven process. In vitro and microarray studies have identified specific immunologic factors underlying EoE pathogenesis. Other gastrointestinal manifestations of food intolerances/allergy include food protein induced enterocolitis syndrome.

Sensitization to foods in gastroesophageal reflux disease and its relation to eosinophils in the esophagus: is it of clinical importance?

BACKGROUND

Refractory gastroesophageal reflux disease (GERD) can be related to greater sensitization to foods.

OBJECTIVE

To evaluate sensitization to foods in patients with refractory GERD.

METHODS

Patients with refractory GERD after using at least 40 mg of a proton pump inhibitor were given a restriction diet based on the results of skin prick testing and atopy patch testing with foods. The characteristics of sensitized patients were compared with those of nonsensitized patients in relation to atopy and number of eosinophils in the esophageal mucosa.

RESULTS

The prevalence of sensitization to foods was 27.7%. Asthmatic patients showed higher sensitization to foods (P = .008). Eosinophils were determined to be present in the esophageal mucosa in 15.8% of patients, and this correlated with greater sensitization to foods (P = .01). One case of eosinophilic esophagitis was confirmed. A diet excluding identified sensitizing foods led to clinical improvement regarding GERD symptoms (P = .004).

CONCLUSION

The presence of eosinophils in esophageal mucosa associated with greater sensitization to foods and the response to a restriction diet in patients with positive test results suggest that refractory GERD can represent an initial stage of eosinophilic esophagitis.

Do eosinophil numbers differentiate eosinophilic esophagitis from gastroesophageal reflux disease?

CONTEXT

Although the healthy esophageal mucosa contains no eosinophils, eosinophilic infiltration is observed in 2 major clinicopathologic settings: gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EE). The prevalence of EE is increasing in many countries, and this increase seems only partly to be due to a better awareness of the pathology, following the relatively recent description of EE. Gastroesophageal reflux disease and EE represent 2 entities that do not respond to the same treatment modalities and, thus, need to be distinguished. However, diagnostic criteria of EE have been defined arbitrarily, and the more recent articles tend to prove that the overlap with GERD is probably greater than initially believed, leading the authors to advise strict exclusion of GERD before considering the diagnosis of EE.

OBJECTIVES

To provide pathologists with the currently proposed histologic criteria of GERD and EE, to stress the need to combine these criteria with clinical data and endoscopic findings, and to outline the remaining controversies.

DATA SOURCES

This review is based on selected articles identified by a PubMed (US National Library of Medicine, Bethesda, Maryland) search of the literature in English for GERD and EE, a recent review by the American Gastroenterological Association (Bethesda), the Proceedings of the First International Gastrointestinal Eosinophil Research Symposium, and the authors' experience.

CONCLUSION

Proper identification of the etiology of eosinophilic infiltration of the esophagus allows accurate medical or surgical treatment and follow-up. Eosinophilic esophagitis and GERD diagnoses require integration of the histologic findings with the clinical and endoscopic data.

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.

The link between allergies and eosinophilic esophagitis: implications for management strategies

Eosinophilic esophagitis (EE) has an increased incidence of diagnosis similar to other atopic diseases. We present a recent literature review of the common features between atopic diseases (i.e., asthma, allergic rhinitis and atopic dermatitis) and EE. All of the disorders have allergen triggers and evidence of a possible Th2 inflammation at the site of disease. Murine models have also shown similar features with the importance of T cells and Th2 cytokines for the development of disease. The diseases share underlying inflammation with the potential for remodeling with an increase in TGF-beta expression in asthma and EE. However, differences do exist between the diseases in treatment and pathogenesis. For EE, there are two basic treatment options: avoidance of the food triggers or treatment of the eosinophilic inflammation with corticosteroids.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Eosinophilic esophagitis in adults: An ear, nose, and throat perspective

OBJECTIVES/HYPOTHESIS

Eosinophilic esophagitis is a rather new disease entity diagnosed with increasing frequency. The main symptoms in adults are dysphagia and food impaction. The aim of this review is to summarize the present knowledge about adult eosinophilic esophagitis, and in particular to cast light on certain issues of concern for the ear, nose, and throat (ENT) specialist.

STUDY DESIGN

Scientific review.

METHODS

The biomedical literature on adult eosinophilic esophagitis was reviewed regarding epidemiology, etiology, subjective symptoms and objective signs, diagnosis, treatment, and prognosis with an emphasis on matters of interest for the ENT specialist. PubMed was used as the search engine.

RESULTS

Among the 393 papers on eosinophilic esophagitis published in PubMed, only 162 deal with adults. During the last few decades, the annual number of papers has been exponentially increasing. A high prevalence of eosinophilic esophagitis in combination with a diagnostic delay suggests the existence of an unacceptable number of undiagnosed cases. This calls for increased attention. Endoscopic examination, including proper biopsies, verifies the diagnosis. Untreated, the disease will lead to substantial distress and in some cases even strictures. Keeping the diagnosis in mind will avoid improper treatment and the risk of accidental perforation.

CONCLUSIONS

It is imperative that ENT specialists recognize patients with eosinophilic esophagitis.

A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population

OBJECTIVES

To develop an international consensus on the definition of gastroesophageal reflux disease (GERD) in the pediatric population.

METHODS

Using the Delphi process, a set of statements was developed and voted on by an international panel of eight pediatric gastroenterologists. Statements were based on systematic literature searches using Medline, EMBASE, and CINAHL. Voting was conducted using a six-point scale, with consensus defined, a priori, as agreed by 75% of the group. The strength of each statement was assessed using the GRADE system.

RESULTS

There were four rounds of voting. In the final vote, consensus was reached on 98% of the 59 statements. In this vote, 95% of the statements were accepted by seven of eight voters. Consensus items of particular note were: (i) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of approximately 8 years; (ii) histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other conditions; (iii) Barrett's esophagus should be defined as esophageal metaplasia that is intestinal metaplasia positive or negative; and (iv) extraesophageal conditions may be associated with GERD, but for most of these conditions causality remains to be established.

CONCLUSIONS

The consensus statements that comprise the Definition of GERD in the Pediatric Population were developed through a rigorous process. These statements are intended to be used for the development of future clinical practice guidelines and as a basis for clinical trials.

Prevalence of eosinophilic esophagitis in an adult population undergoing upper endoscopy: a prospective study

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophagus. The purpose of this prospective study was to determine the prevalence and clinical predictors of EoE in patients undergoing elective upper endoscopy.

METHODS

We enrolled 400 consecutive adults (median age, 50 years; range, 19-92 years) who underwent routine upper endoscopy from March to September 2007 at a tertiary care military hospital. All patients completed a symptom questionnaire. All endoscopic findings were noted. Eight biopsies were obtained from proximal and distal esophagus and were reviewed by a blinded gastrointestinal pathologist. Patients had EoE if > or =20 eosinophils/high-power field were present.

RESULTS

The prevalence of EoE in this cohort was 6.5% (25/385; 95% confidence interval, 4.3%-9.4%). Compared with EoE negative patients, EoE positive patients were more likely to be male (80.0% vs 48.1%, P = .003), younger than 50 years (72.0% vs 48.9%, P = .037), and have asthma (32.0% vs 10.8%, P = .006), a food impaction (32.0% vs 8.9%, P = .002), dysphagia (64.0% vs 38.1%, P = .018), and classic endoscopic findings (rings, furrows, plaques, or strictures) of EoE (all P < .01). Logistic regression identified asthma (odds ratio [OR], 4.48), male gender (OR, 4.23), and esophageal rings (OR, 13.1) as independent predictors of EoE. The presence of classic endoscopic findings of EoE had a sensitivity of 72% (54%-88%), specificity of 89% (87%-90%), and negative predictive value of 98% (95.6%-99.1%).

CONCLUSIONS

The prevalence of EoE in an outpatient population undergoing upper endoscopy was 6.5%. The characteristic findings of EoE patients included male gender, history of asthma, and the presence of classic findings of EoE on endoscopy, which is the strongest predictor of this disease process.

Seasonal distribution in newly diagnosed cases of eosinophilic esophagitis in adults

OBJECTIVES

The etiology of eosinophilic esophagitis (EoE) is not well understood. It has been proposed that eosinophils migrate to the esophagus in response to various ingested and inhaled allergens. Recent reports in children found an increased proportion of cases of EoE during months with higher outdoor aeroallergens. To our knowledge, this has not been evaluated in adults. We aimed to determine whether there is a seasonal distribution in the number of newly diagnosed cases of EoE in an adult population.

METHODS

We conducted a retrospective review of consecutive adult cases newly diagnosed with EoE in 1 year. Cases were grouped based on the index month when the diagnosis was made at endoscopy. To test the consistency of the observations, a second cohort of consecutive cases of similar sample size diagnosed at a different period in time was also analyzed.

RESULTS

In total, 41 patients were diagnosed with EoE at our center during the study period, providing an annual prevalence of 0.98%. More cases were diagnosed with EoE during the months of April and May than any other month (P<0.001). When patients were grouped seasonally, there was a significant increase of EoE cases in spring and summer months (n=28) when compared with the fall and winter months (n=13) (P=0.019). Analysis of the second cohort of cases (n=37) from 2002 to 2006 confirmed a similar seasonal diagnostic pattern for EoE during the outdoor seasons.

CONCLUSIONS

Our data demonstrate that EoE has a seasonal prevalence in adults. The seasonal variation pattern found in newly diagnosed EoE cases in adults supports the potential role of aeroallergens in the pathogenesis of EoE.

Histopathologic variability in children with eosinophilic esophagitis

OBJECTIVES

The diagnosis of eosinophilic esophagitis (EoE) is based on histologic findings of eosinophilia in the esophageal squamous epithelium in patients presenting with esophageal symptoms. Variability in the degree of squamous epithelial eosinophil infiltration presents a challenge to diagnostic accuracy. We examined the histopathologic features in a well-defined cohort of children with EoE to derive an optimal number of biopsies needed for diagnosis.

METHODS

A total of 30 patients diagnosed with EoE based on>15 eosinophils per high-power field (eos/HPF) were evaluated. The diagnosis of EoE was based on persistent esophageal eosinophilia following acid suppression therapy. All patients had mid and distal biopsy specimens that were analyzed along with 24-h pH probe studies.

RESULTS

A total of 221 biopsy specimens were reviewed with a median of 7.8 (range, 5-8) specimens per patient. Eight patients demonstrated abnormal pH studies. The median eos/HPF was 41 (range, 0-288 eos/HPF). Using a criterion of>15 eos/HPF, the diagnostic sensitivity of a single biopsy was 73%, which increased to 84%, 97% and 100% for two, three and six biopsies, respectively. Five patients (17%) would not have met the criteria for diagnosis if biopsies were only taken from the mid esophagus whereas one patient (3%) would have been missed if only distal biopsies were analyzed.

CONCLUSIONS

Significant histologic variability exists among biopsy specimens from pediatric patients with EoE. Using the criterion of>15 eos/HPF, three biopsy specimens achieved a diagnosis of EoE in 97% of patients. Histopathologic changes consistent with EoE can persist following proton pump inhibitor therapy in patients with EoE and gastroesophageal reflux disease when the latter is defined by increased distal esophageal acid exposure.

Pathology of eosinophilic esophagitis: what the clinician needs to know

Eosinophilic esophagitis (EOE) is a clinical pathologic syndrome characterized by influx of numerous eosinophils into the esophageal epithelium. It is important for clinicians to be aware of the spectrum, as well as the characteristic location and distribution, of morphologic changes in EOE to maximize the diagnostic yield in mucosal biopsy specimens. The major pathologic features of EOE include eosinophilic microabscesses, surface layering of eosinophils often associated with surface sloughing of necrotic squamous cells, and peak eosinophil counts usually greater than 15 per high power field (hpf) within the squamous epithelium. Minor features, which are frequent but less specific, include marked basal cell hyperplasia, lengthening of lamina propria papillae, intercellular edema, and lamina propria fibrosis with chronic inflammation. The number, distribution, and location of intraepithelial eosinophils in EOE vary greatly between previously published studies. Thus, utilization of a diagnostic cutoff point for intraepithelial eosinophils in EOE, particularly in the absence of other major features of EOE, is currently considered unwise. In fact, some patients may show combined features of both gastroesophageal reflux disease (GERD) and EOE, which complicates the histologic analysis of these patients. In contrast to GERD, EOE typically involves longer lengths of the esophagus, affects the proximal equally, or even more, than the distal esophagus, and the pathologic findings are often patchy in distribution. As a result, it is highly recommended that clinicians obtain biopsies from patients suspected of have EOE only after treatment with high-dose proton pump inhibitor therapy, and that biopsies be obtained from both the proximal and distal esophagus in both normal and abnormal appearing areas.

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.

Contribution of histology to the diagnosis of reflux disease

Histology in reflux disease is still regarded as having low sensitivity and specificity. During the last three decades several histological parameters have been developed, including thickness of basal cell layer, length of epithelial papillae, intraepithelial inflammatory cells and dilation of intercellular spaces. Unfortunately classification of these parameters was often not related to the clinical symptoms of the reflux affected individuals, proper control subjects were often missing and often no interobserver variation was given. Another reason for the proposed low value of biopsies is the fact that biopsies were often taken in a non-standardised way. Recent studies point towards an area of predominantly epithelial damage close to the lesser curvature or around the right oesophageal wall. In parallel, some large, careful studies carried out recently showed a good correlation with the clinical picture of reflux disease due to a standardised biopsy protocol and proper controls. But biopsies are not recommended in all routine classical cases of reflux disease since it is believed that little further information in addition to endoscopy can be obtained. However, histology can deliver much more information than the diagnosis of reflux induced lesions (e.g. the exclusion of malignancy or other oesophageal diseases).

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.

Eosinophilic esophagitis: a prevalent disease in the United States that affects all age groups

BACKGROUND & AIMS

Most reports on eosinophilic esophagitis (EE) are limited to small series from single institutions. This study describes features of EE in a broader population.

METHODS

A national pathology database (Caris Diagnostics, Irving, TX) was used to identify EE cases from a cohort of upper endoscopies. Slides from potential cases were reviewed by pathologists. Study inclusion required a mean of (1) 20 eosinophils or more in 5 high-power fields, or (2) 30 eosinophils in 2-4 high-power fields. Endoscopists provided demographic and clinical information.

RESULTS

There were 363 cases identified from 74,162 patients and 26 states. EE had a male predominance (odds ratio, 3.0; 95% confidence interval, 2.4-3.8). Ages ranged from 1 to 98 years, including 42 children and 321 adults. The most common endoscopy indications in adults were dysphagia (70.1%) and gastroesophageal reflux disease (GERD)/heartburn (27.1%). Children most frequently reported GERD/heartburn (38.1%) and abdominal pain/dyspepsia (31.0%). A total of 25.1% of cases had a peak mucosal eosinophil count of 20-59, 29.2% had a peak mucosal eosinophil count of 60-100, and 45.7% had a peak mucosal eosinophil count of more than 100. There was no difference in the peak counts between age groups or sexes, but patients with dysphagia had higher counts (P < .001). The prevalence of EE increased during the study period (P < .001).

CONCLUSIONS

EE is a national disease found in all age groups, more frequently in males. Dysphagia and GERD symptoms are common indications for endoscopy. The degree of eosinophilic infiltration is high throughout all ages and may be related to patients' symptoms. Our series highlights important elements of this disease, the prevalence and/or recognition of which is increasing.

Clinical and pathological features of eosinophilic oesophagitis: a review

Eosinophilic oesophagitis (EOE) is a newly described clinicopathological entity that is being diagnosed with increasing frequency both in children and in adults. It is presumed to be an atopic disease involving both immediate and delayed-type hypersensitivity to inhaled and ingested allergens. Because of the reflux-type symptomatology, it is commonly misdiagnosed and treated as severe gastro-oesophageal reflux disease (GORD) before an appropriate diagnosis is made. Pathologically, EOE is an inflammatory disorder with a predominantly eosinophilic infiltrate that is unresponsive to acid suppression therapy. The diagnosis of this disease requires histological confirmation with oesophageal biopsy specimens showing an intense eosinophilic infiltration. Although precise criteria or a specific cutoff point for the diagnosis of eosinophilic oesophagitis have not been established, many authors suggest that one high-power field with >20 eosinophils or multiple high-power fields with >15 eosinophils, together with clinical and endoscopic findings, should be sufficient for diagnosis. Recognition of EOE and differentiation from GORD are important, since allergen elimination or anti-inflammatory therapy appears to be more effective than acid suppression in these patients. This review focuses on clinicopathological features and diagnosis of EOE in adults and children.

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.

Comparison of oral prednisone and topical fluticasone in the treatment of eosinophilic esophagitis: a randomized trial in children

BACKGROUND & AIMS

Although eosinophilic esophagitis is recognized increasingly, outcome data guiding therapy are limited. We conducted a prospective randomized trial comparing oral prednisone (P) and swallowed fluticasone (F) for histologic and clinical response.

METHODS

Patients were randomized to receive P or F for 4 weeks, followed by an 8-week weaning protocol. Esophageal histology was evaluated at baseline and after 4 weeks of therapy. Clinical assessments were performed at weeks 0, 4, 12, 18, and 24.

RESULTS

Eighty patients with eosinophilic esophagitis were enrolled: 40 in the P arm and 40 in the F arm. Histologic improvement was seen in 30 of 32 P and 34 of 36 F patients, with a greater degree of histologic improvement in the P group. All P and 35 of 36 F patients were free of presenting symptom(s) at week 4. Symptom relapse was seen in 45% of patients by week 24. Kaplan-Meier analysis showed no difference between P and F with regard to relapse rate (P = .7399). No significant difference in time to relapse was found between groups (P = .2529). Systemic adverse effects were noted in 40% of the P arm, whereas esophageal candidal overgrowth was seen in 15% of the F arm.

CONCLUSIONS

Systemic and topical corticosteroids were effective in achieving initial histologic and clinical improvement. P resulted in a greater degree of histologic improvement, without evidence of an associated clinical advantage over F in terms of symptom resolution, relapse rates, or time to relapse. Symptom relapse was common to both groups upon therapy discontinuation, highlighting the need for maintenance treatment protocols.

Histopathologic features of eosinophilic esophagitis

The pathology of eosinophilic esophagitis (EE) when fully developed in humans is highly characteristic and readily discriminated from the histology of the normal esophagus. The histologic alterations are not pathognomonic for any of the multiple causes of EE, and the correct diagnosis can be made only if the histology is correlated with clinical findings. The histology of the normal esophagus is reviewed and contrasted with the findings in EE. The characteristic findings in EE are illustrated. Selected research in humans and animal models pertinent to EE are briefly reviewed.

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.

Prevalence and predictive factors of eosinophilic esophagitis in patients presenting with dysphagia: a prospective study

OBJECTIVES

Eosinophilic esophagitis (EE) is an increasingly recognized cause of dysphagia. We prospectively assessed the prevalence of EE using midesophageal biopsies in patients presenting with no endoscopically evident cause of dysphagia. We also aimed to determine the clinical and endoscopic factors predictive of EE in outpatients undergoing endoscopy for dysphagia.

METHODS

Outpatients (18-60 yr of age) undergoing endoscopy for dysphagia at Mayo Clinic, Rochester between June 2005 and June 2006 were enrolled. Patients completed the validated Mayo Dysphagia Questionnaire (MDQ). Biopsies were obtained from the midesophagus if there was no endoscopically evident cause of dysphagia or there were endoscopic findings suggestive of EE. EE was defined as the presence of >20 eosinophils/high-power field. Logistic regression was performed to identify predictors of EE.

RESULTS

Of 376 patients enrolled, 238 (63%) completed the MDQ and 222 (59%) had midesophageal biopsies; 33 (15%, 95% CI 6%-12%) had EE by biopsy. Ten of 102 (9.8%) patients who appeared endoscopically normal had EE by biopsy, while 8 of 21 (38%) patients with endoscopic changes suggestive of EE had EE on biopsy. Predictors of EE were younger age, endoscopic features suggestive of EE, absence of use of proton pump inhibitors, and a history of any food impaction for greater than 5 min.

CONCLUSIONS

Midesophageal biopsies from normal-appearing mucosa should be obtained in all patients with unexplained solid food dysphagia; this may diagnose EE in about one in 10 cases.

Eosinophilic esophagitis disease in children from West Virginia: a review of the last decade (1995-2004)

BACKGROUND

Eosinophilic esophagitis (EoE) is a newly established disease in adults and children. The incidence and prevalence of the disease among children from the United States are largely unknown. We examined the endoscopy reports of children who attended our gastroenterology clinic in the last 10 yr. MATERIALS A AND METHODS: retrospective review of all diagnostic upper endoscopy procedures was executed between 1995-2004, of which a quarter (25%) per each year was randomly selected for pathological reevaluation of the number of Eos. The diagnosis of EoE was established when higher than 15 Es/hpf was detected in the esophageal biopsy; and the prevalence of EoE was calculated. The clinical symptoms, endoscopic presentation, and treatment of the patients with EoE disease were also reviewed.

RESULTS

A total of 1,424 procedures were reviewed, of which 355 esophageal samples were reevaluated. During the study period, 44 patients were diagnosed with EoE. The prevalence rate of EoE disease was 0.73/10,000 children during the study period. Similar results were found when the number of Eos was established at >20 Es/hpf. Abdominal pain (55%), vomiting (43%), and heartburn (39%) were the most common symptoms, and characteristic mucosal appearance was found in only 11% of the patients.

CONCLUSION

The rate of EoE in our pediatric patient population is low. Prospective studies are needed to establish the incident and prevalence of EoE disease in children living in the United States.

Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review

BACKGROUND

Eosinophilic esophagitis (EoE) is an emerging clinicopathologic entity defined by abnormal esophageal eosinophilic infiltration. Our understanding of this disease is hampered by the lack of a uniform diagnostic standard. The aim of this systematic review was to determine the range of diagnostic strategies and histologic criteria in the EoE literature.

METHODS

The MEDLINE-indexed literature from 1950 through December 31, 2006 was independently searched by two investigators. To identify additional relevant studies, bibliographies were hand searched, as were the published proceedings of the 2000-2006 American College of Gastroenterology and American Gastroenterological Association national meetings. Data were extracted from all human EoE case reports, case series, cross-sectional and cohort studies, and clinical trials.

RESULTS

Of 318 publications initially identified, 116 original articles, 39 abstracts, and 69 reviews were included. We found 10 different histologic definitions of EoE, ranging from 5 to 30 eosinophils per high-powered field (hpf), though 41 (35%) of the original articles did not state their diagnostic criteria. In the 13 original articles (11%) reporting an hpf area, the eosinophil density per mm(2) varied 23-fold. There was also variation in esophageal biopsy protocols, but specific protocols were reported in just 45 (39%) original articles.

CONCLUSIONS

Significant variability in diagnostic criteria for eosinophilic esophagitis exists, and in a large proportion of studies, criteria are not reported. Because of this lack of a common disease definition, conclusions drawn from the cumulative EoE literature should be viewed with caution. A consensus research-quality standard for diagnosis of eosinophilic esophagitis is needed.

Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment

During the last decade, clinical practice saw a rapid increase of patients with esophageal eosinophilia who were thought to have gastroesophageal reflux disease (GERD) but who did not respond to medical and/or surgical GERD management. Subsequent studies demonstrated that these patients had a "new" disease termed eosinophilic esophagitis (EE). As recognition of EE grew, so did confusion surrounding diagnostic criteria and treatment. To address these issues, a multidisciplinary task force of 31 physicians assembled with the goal of determining diagnostic criteria and making recommendations for evaluation and treatment of children and adults with suspected EE. Consensus recommendations were based upon a systematic review of the literature and expert opinion. EE is a clinicopathological disease characterized by (1) Symptoms including but not restricted to food impaction and dysphagia in adults, and feeding intolerance and GERD symptoms in children; (2) > or = 15 eosinophils/HPF; (3) Exclusion of other disorders associated with similar clinical, histological, or endoscopic features, especially GERD. (Use of high dose proton pump inhibitor treatment or normal pH monitoring). Appropriate treatments include dietary approaches based upon eliminating exposure to food allergens, or topical corticosteroids. Since EE is a relatively new disease, the intent of this report is to provide current recommendations for care of affected patients and defining gaps in knowledge for future research studies.

Oral viscous budesonide: a potential new therapy for eosinophilic esophagitis in children

BACKGROUND

Eosinophilic esophagitis (EE) is a disorder characterized typically by pan-esophageal eosinophilia. We evaluate a palatable, long-acting topical corticosteroid preparation for the treatment of EE.

STUDY DESIGN

This is a retrospective analysis of symptoms, endoscopic and histologic findings, efficacy, and safety of treatment in children with EE receiving oral viscous budesonide. Response to therapy was determined histologically by the number of eos/hpf. Patients were classified by histology into responders (0-7 eos/hpf), partial responders (8-23 eos/hpf), and nonresponders (>/=24 eos/hpf). A symptom score (max. 14) and an EE endoscopy score (max. 8) were used to compare data.

RESULTS

In 20 children (mean age 5.5 yr, median age 4.1 yr) the mean highest eosinophil count was 87 eos/hpf (range 30-170) before and 7 eos/hpf (range 0-50, P < 0.0001) after therapy. There were 16 (80%) responders, 1 partial responder, and 3 nonresponders. Commonest pretreatment symptoms were nausea, vomiting, pain, and heartburn. The mean symptom score fell from 4.4 to 0.8 (P < 0.0001) and the mean endoscopy score from 3.6 to 0.8 (P < 0.0001). No significant adverse events were reported. Morning cortisol levels were within normal limits.

CONCLUSIONS

Topical viscous budesonide is a safe and effective therapy for EE in young children.

Emerging eosinophilic (allergic) esophagitis: increased incidence or increased recognition?

CONTEXT

Eosinophilic esophagitis is a disease of the esophagus with distinct histologic features (prominent intraepithelial eosinophils, particularly superficial with clustering) and characteristic endoscopic features (trachealization, white plaques). The presence of intraepithelial eosinophils had been recognized since 1982 as indicative of reflux esophagitis but little attention was initially paid to their numbers or location. Eosinophilic esophagitis has been recently described and there have been a number of reports that its incidence is on the rise. It had been our impression that eosinophilic esophagitis was being seen more frequently, perhaps resulting from some environmental change.

OBJECTIVE

To investigate the increased prevalence of eosinophilic esophagitis.

DESIGN

We analyzed a similar group of cases from 2005 (n = 150) as compared with 1990 (n = 115). Consecutive patients with mucosal esophageal biopsies from May through June of the respective years were included in the analysis. Patients with Barrett metaplasia or with carcinoma were excluded. The highest density of intraepithelial eosinophils for each patient was recorded as the number of intraepithelial eosinophils per single high-power field. The patients were categorized by the number of intraepithelial eosinophils per high-power field with those cases with greater than 20 intraepithelial eosinophils per high-power field representing eosinophilic esophagitis.

RESULTS

There was no difference in the incidence of eosinophilic esophagitis between 1990 and 2005.

CONCLUSIONS

The apparent increased incidence of eosinophilic esophagitis is largely a result of an increase in recognition rather than an increase in disease resulting from an environmental factor.

Thoughts on the complex relationship between gastroesophageal reflux disease and eosinophilic esophagitis

Recent data suggest that the interaction between gastroesophageal reflux disease (GERD) and eosinophilic esophagitis can be complex, and that the notion of establishing a clear distinction between the two disorders may be too simplistic. There are at least four situations in which GERD might be associated with esophageal eosinophils: (a) GERD causes esophageal injury that results in a mild eosinophilic infiltration, (b) GERD and eosinophilic esophagitis coexist but are unrelated, (c) eosinophilic esophagitis contributes to or causes GERD, or (d) GERD contributes to or causes eosinophilic esophagitis. The high frequency of GERD described in adult patients with eosinophilic esophagitis suggests that there may be more than a chance association between the two disorders. This report discusses potential mechanisms for the complex interaction between GERD and eosinophilic esophagitis. We hope that this information will serve as a conceptual basis for future studies on the relationship between the two disorders. Whereas there are a number of plausible mechanisms whereby GERD might contribute to the accumulation of eosinophils in the esophageal epithelium, it seems prudent to recommend a clinical trial of proton pump inhibitor (PPI) therapy even when the diagnosis of eosinophilic esophagitis seems clear-cut. Furthermore, we suggest that a favorable response to PPI therapy does not preclude a diagnosis of eosinophilic esophagitis.

Eosinophilic esophagitis: an allergist's approach

OBJECTIVE

To enhance the recognition of eosinophilic esophagitis by reviewing the presentation, diagnosis, and pathogenesis and then summarizing the epidemiology and treatment options.

DATA SOURCES

MEDLINE was searched for articles using the keywords esophagitis and either allergy or eosinophil. Additional sources include searches limited to therapy, including corticosteroids and leukotrienes, and those limited to review articles, including chemokines and cytokines, from January 1990 to April 2006. All searches were limited to the English language.

STUDY SELECTION

The authors selected relevant and current sources for inclusion in this review.

RESULTS

Eosinophilic esophagitis is a diagnosis made by identifying 20 to 24 eosinophils per high-power field on examination of esophageal biopsy specimens. In recent years, a marked increase in incidence worldwide may have occurred. Although the pathogenesis is still unclear, therapy involves the use of corticosteroids and appropriate dietary elimination.

CONCLUSION

Patients with atopy, especially males, who present with dysphagia, reflux symptoms, vomiting, abdominal pain, or failure to thrive should be considered for endoscopy to establish the diagnosis of eosinophilic esophagitis.