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Lucendo A, Groetch M, Gonsalves N. Dietary Management of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:223-244. [PMID: 38575220 DOI: 10.1016/j.iac.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated food allergy-driven disease characterized by eosinophilic inflammation of the esophagus leading to symptoms of esophageal dysfunction. Prior studies have supported the key role of food allergen exposure as the main driver behind the etiopathogenesis showing that removal of food antigens can result in disease remission in both children and adults. These landmark studies serve as the basis for the rising interest and evolution of dietary therapy in EoE. This article will focus on the rationale for dietary therapy in EoE and provide helpful tools for the implementation of dietary therapy in practice.
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Affiliation(s)
- Alfredo Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd); Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Ciudad Real 13700, Spain
| | - Marion Groetch
- Department of Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, 676 North St. Claire, Suite 1400, Chicago, IL 60611, USA.
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2
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Biedermann L, Straumann A. Clinical Evaluation of the Adult with Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:185-196. [PMID: 38575217 DOI: 10.1016/j.iac.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Adult patients with eosinophilic esophagitis (EoE) typically present with a history of dysphagia for solids, sometimes with additional reflux-like pain and a history of prior food impactions. In contrast to these alarming symptoms, the general appearance and physical examination of adult patients with EoE is in line with apparently healthy individuals. Therefore, the diagnosis is based on a history of solid-food dysphagia and eosinophilic tissue infiltration. Importantly, the increasing prevalence of EoE variants, that is, typical EoE symptoms in the absence of a relevant eosinophilia, and several studies with eosinophil-targeting drugs, call the pathogenic role of eosinophils into question.
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Affiliation(s)
- Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrassse 100, CH-8091 Zurich, Switzerland.
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrassse 100, CH-8091 Zurich, Switzerland
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3
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Gupta M, Grinman M. Diagnostic et prise en charge de l’œsophagite à éosinophiles. CMAJ 2024; 196:E568-E576. [PMID: 38684286 PMCID: PMC11057888 DOI: 10.1503/cmaj.230378-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Affiliation(s)
- Milli Gupta
- Divisions de gastroentérologie et d'hépatologie (Gupta) et de médecine interne générale (Grinman), Département de médecine, École de médecine Cumming, Université de Calgary, Calgary, Alb.
| | - Michelle Grinman
- Divisions de gastroentérologie et d'hépatologie (Gupta) et de médecine interne générale (Grinman), Département de médecine, École de médecine Cumming, Université de Calgary, Calgary, Alb
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4
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Barchi A, Vespa E, Passaretti S, Dell’Anna G, Fasulo E, Yacoub MR, Albarello L, Sinagra E, Massimino L, Ungaro F, Danese S, Mandarino FV. The Dual Lens of Endoscopy and Histology in the Diagnosis and Management of Eosinophilic Gastrointestinal Disorders-A Comprehensive Review. Diagnostics (Basel) 2024; 14:858. [PMID: 38667503 PMCID: PMC11049211 DOI: 10.3390/diagnostics14080858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/13/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Eosinophilic Gastrointestinal Disorders (EGIDs) are a group of conditions characterized by abnormal eosinophil accumulation in the gastrointestinal tract. Among these EGIDs, Eosinophilic Esophagitis (EoE) is the most well documented, while less is known about Eosinophilic Gastritis (EoG), Eosinophilic Enteritis (EoN), and Eosinophilic Colitis (EoC). The role of endoscopy in EGIDs is pivotal, with applications in diagnosis, disease monitoring, and therapeutic intervention. In EoE, the endoscopic reference score (EREFS) has been shown to be accurate in raising diagnostic suspicion and effective in monitoring therapeutic responses. Additionally, endoscopic dilation is the first-line treatment for esophageal strictures. For EoG and EoN, while the literature is more limited, common endoscopic findings include erythema, nodules, and ulcerations. Histology remains the gold standard for diagnosing EGIDs, as it quantifies eosinophilic infiltration. In recent years, there have been significant advancements in the histological understanding of EoE, leading to the development of diagnostic scores and the identification of specific microscopic features associated with the disease. However, for EoG, EoN, and EoC, precise eosinophil count thresholds for diagnosis have not yet been established. This review aims to elucidate the role of endoscopy and histology in the diagnosis and management of the three main EGIDs and to analyze their strengths and limitations, their interconnection, and future research directions.
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Affiliation(s)
- Alberto Barchi
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Edoardo Vespa
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Sandro Passaretti
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Giuseppe Dell’Anna
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Ernesto Fasulo
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Mona-Rita Yacoub
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Luca Albarello
- Pathology Unit, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto S. Raffaele—G. Giglio, 90015 Cefalu, Italy;
| | - Luca Massimino
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Federica Ungaro
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
| | - Silvio Danese
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
- Faculty of Medicine, Università Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Francesco Vito Mandarino
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Via Olgettina 58, 20132 Milan, Italy; (A.B.); (E.V.); (S.P.); (G.D.); (E.F.); (L.M.); (F.U.); (S.D.)
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5
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Mărginean CO. Multidisciplinarity and Trandisciplinarity in the Diagnosis and Treatment of Pediatric Gastrointestinal Diseases. Diagnostics (Basel) 2024; 14:852. [PMID: 38667497 PMCID: PMC11049640 DOI: 10.3390/diagnostics14080852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
It is an honor and a privilege to have helped bring this Special Issue titled "Multidisciplinarity and Trandisciplinarity in the Diagnosis and Treatment of Pediatric Gastrointestinal Diseases" to you [...].
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Affiliation(s)
- Cristina Oana Mărginean
- Department of Pediatrics I, University of Medicine, Pharmacy, Sciences and Technology George Emil Palade of Târgu Mureș, 540136 Târgu Mureș, Romania
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6
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Rossi CM, Lenti MV, Di Sabatino A. Toning down the role of eosinophils in eosinophilic oesophagitis. Gut 2024; 73:874-875. [PMID: 37045590 DOI: 10.1136/gutjnl-2023-329864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Carlo Maria Rossi
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia, Italy
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7
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Elghoudi A, Zourob D, Al Atrash E, Alshamsi F, Alkatheeri M, Narchi H, Bitar R. Evolving strategies: Enhancements in managing eosinophilic esophagitis in pediatric patients. World J Clin Pediatr 2024; 13:89580. [PMID: 38596434 PMCID: PMC11000055 DOI: 10.5409/wjcp.v13.i1.89580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/26/2023] [Accepted: 01/16/2024] [Indexed: 03/06/2024] Open
Abstract
Eosinophilic esophagitis is a newly recognized disease first described about 50 years ago. The definition, diagnosis, and management have evolved with new published consensus guidelines and newly approved treatment available to pediatricians, enabling a better understanding of this disease and more targeted treatment for patients. We describe the definition, presentation, and diagnosis of eosinophilic esophagitis including management, challenges, and future directions in children. The definition, diagnosis, and management of eosinophilic esophagitis have evolved over the last 50 years. Consensus guidelines and newly approved biologic treatment have enabled pediatricians to better understand this disease and allow for more targeted treatment for patients. We describe the definition, presentation, diagnosis, management, and treatment in addition to the challenges and future directions of eosinophilic esophagitis management in children.
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Affiliation(s)
- Ahmed Elghoudi
- Department of Pediatric, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Doaa Zourob
- Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Eman Al Atrash
- Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Fatima Alshamsi
- Pediatric Residency Program, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Manal Alkatheeri
- Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Hassib Narchi
- College of Medicine and Health Sciences, United Arab Emirates University, Alain, Abu Dhabi, United Arab Emirates
| | - Rana Bitar
- Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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8
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Awadhi SA, Miqdady M, Abuzakouk M, Yousef O, Tzivinikos C, Georgopoulos F, Carr S, Sultan A, Bitar R, Dajani AI, Taha M, Alakrad E, Jazzar A, Banama M, Bamakhrama K, Alnahdi N, Elghoudi AA, Azaz A, Gutta R, Fahmy M, Raghib B, Murad S, Abdelmallek M. Expert Recommendations on the Diagnosis of Eosinophilic Esophagitis in the United Arab Emirates. Cureus 2024; 16:e56062. [PMID: 38618346 PMCID: PMC11009821 DOI: 10.7759/cureus.56062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/16/2024] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, progressive, type 2 inflammatory esophageal disease presenting as dysphagia to solid food and non-obstructive food impaction. Knowledge gaps exist in its diagnosis and management. These expert recommendations focused on the diagnosis of EoE in the United Arab Emirates. An electronic search of PubMed and Embase databases was used to gather evidence from systematic reviews, randomized controlled trials, consensus papers, and expert opinions from the last five years on the diagnosis of EoE. The evidence was graded using the Oxford system. Literature search findings were shared with the expert panel. A 5-point scale (strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree) was used, and a concordance rate of >75% among experts indicated agreement. Using a modified Delphi technique, 18 qualified experts provided 17 recommendations. Eleven statements achieved high agreement, four got moderate agreement, and two got low agreement. Challenges exist in diagnosing EoE, particularly in children. Esophageal biopsies were crucial in diagnosis, irrespective of visible mucosal changes. Further research on diagnostic tools like endoscopic mucosal impedance and biomarkers is needed. Diagnosis relies on esophageal biopsies and symptom-histology correlation; however, tools like EoE assessment questionnaires and endoscopic mucosal impedance could enhance the accuracy and efficiency of EoE diagnosis. The diagnosis of EoE is challenging since the symptoms seldom correlate with the histological findings. Currently, diagnosis is based on patient symptoms and endoscopic and histological findings. Further research into mucosal impedance tests and the role of biomarkers is needed to facilitate diagnosis.
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Affiliation(s)
- Sameer Al Awadhi
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | - Mohamad Miqdady
- Pediatric Gastroenterology, Hepatology, and Nutrition, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, ARE
- Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, ARE
| | - Mohamed Abuzakouk
- Allergy and Immunology, Respiratory Institute, Cleveland Clinic, Abu Dhabi, ARE
| | - Osama Yousef
- Gastroenterology, Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, ARE
| | - Christos Tzivinikos
- Pediatric Gastroenterology, Al Jalila Children's Speciality Hospital, Dubai, ARE
- Pediatric Gastroenterology, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, ARE
| | | | - Stuart Carr
- Immunology and Allergy, Snö Clinics, Abu Dhabi, ARE
| | - Ahmed Sultan
- Gastroenterology and Hepatology, Mediclinic Airport Road Hospital, Abu Dhabi, ARE
| | - Rana Bitar
- Pediatric Gastroenterology, Hepatology, and Nutrition, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, ARE
- Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, ARE
| | | | - Mazen Taha
- Gastroenterology and Hepatology, Tawam Hospital, Abu Dhabi, ARE
| | - Eyad Alakrad
- Gastroenterology and Hepatology, Sheikh Shakhbout Medical City, Abu Dhabi, ARE
| | - Ahmad Jazzar
- Gastroenterology and Hepatology, Burjeel Day Surgery Center, Abu Dhabi, ARE
| | - Mohammed Banama
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | - Khaled Bamakhrama
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | - Nawal Alnahdi
- Gastroenterology, Hepatology, and Endoscopy, Rashid Hospital, Dubai, ARE
| | | | - Amer Azaz
- Pediatric Gastroenterology, Hepatology, and Nutrition, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, ARE
- Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, ARE
| | - Ravi Gutta
- Immunology, Mediclinic City Hospital, Dubai, ARE
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Bredenoord AJ, Dellon ES, Hirano I, Lucendo AJ, Schlag C, Sun X, Glotfelty L, Mannent L, Maloney J, Laws E, Mortensen E, Shabbir A. Dupilumab demonstrated efficacy and was well tolerated regardless of prior use of swallowed topical corticosteroids in adolescent and adult patients with eosinophilic oesophagitis: a subgroup analysis of the phase 3 LIBERTY EoE TREET study. Gut 2024; 73:398-406. [PMID: 38050037 PMCID: PMC10894847 DOI: 10.1136/gutjnl-2023-330220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/24/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE To assess the effect of long-term dupilumab on histological, symptomatic and endoscopic aspects of eosinophilic oesophagitis (EoE) in adolescent and adult patients with and without prior use of swallowed topical corticosteroids (STC) or prior inadequate response, intolerance or contraindication to STC. DESIGN Pre-specified analysis of data from the phase 3 LIBERTY EoE TREET study on patients who received dupilumab 300 mg once a week or placebo for 24 weeks (W24) in parts A and B, and an additional 28 weeks (W52) in part C. Patients were categorised as with/without prior STC use and with/without inadequate/intolerance/contraindication to STC. The proportion of patients achieving ≤6 eosinophils per high-power field (eos/hpf), absolute change in Dysphagia Symptom Questionnaire (DSQ) score, mean change in Endoscopic Reference Score and Histologic Scoring System grade/stage scores were assessed for each subgroup. RESULTS Regardless of prior STC use, dupilumab increased the proportion of patients achieving ≤6 eos/hpf and improved DSQ score versus placebo at W24, with improvements maintained or improved at W52. The DSQ score and the proportion of patients achieving ≤6 eos/hpf after switching from placebo to dupilumab at W24 were similar to those observed in the dupilumab group at W24, regardless of prior STC use or inadequate/intolerance/contraindication to STC. Improvements in other outcomes with dupilumab were similar in patients with/without prior STC use or inadequate/intolerance/contraindication to STC. CONCLUSION Dupilumab 300 mg once a week demonstrated efficacy and was well tolerated in patients with EoE regardless of prior STC use or inadequate response, intolerance and/or contraindication to STC. TRIAL REGISTRATION NUMBER NCT03633617.
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Affiliation(s)
- Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Evan S Dellon
- Department of Medicine, Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Ikuo Hirano
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alfredo J Lucendo
- Instituto de Investigación Sanitaria Princesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Hospital General Tomelloso, Tomelloso, Spain
| | - Christoph Schlag
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Xian Sun
- Regeneron Pharmaceuticals Inc, Tarrytown, New York, USA
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Gupta M, Grinman M. Diagnosis and management of eosinophilic esophagitis. CMAJ 2024; 196:E121-E128. [PMID: 38316452 PMCID: PMC10843442 DOI: 10.1503/cmaj.230378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Affiliation(s)
- Milli Gupta
- Divisions of Gastroenterology and Hepatology (Gupta), and General Internal Medicine (Grinman), Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alta.
| | - Michelle Grinman
- Divisions of Gastroenterology and Hepatology (Gupta), and General Internal Medicine (Grinman), Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alta
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11
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Massironi S, Elvevi A, Panceri R, Mulinacci G, Colella G, Biondi A, Invernizzi P, Danese S, Vespa E. Eosinophilic esophagitis: does age matter? Expert Rev Clin Immunol 2024; 20:211-223. [PMID: 37870118 DOI: 10.1080/1744666x.2023.2274940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/20/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus with increasing prevalence worldwide. It is a multifactorial disease caused by a combination of immunologic, genetic, and environmental factors. The clinical presentation of EoE varies largely, especially between different age groups. While diagnostic criteria and therapeutic goals are similar in children and adults, there are differences in treatment, with a more cautious approach in children to avoid growth disturbances. In addition, close monitoring and follow-up are essential in children to ensure uninterrupted growth. AREAS COVERED A search in PubMed/MEDLINE, EMBASE, and SCOPUS databases was conducted to identify relevant studies published between January 2010 and January 2023 to give an overview of the state-of-the-art of EoE epidemiology, diagnosis, and treatment while focusing on similarities and differences between the adult and the pediatric population. EXPERT OPINION The current state of research indicates that while significant progress has been made in understanding and treating EoE, further research and advances are needed to optimize diagnostic strategies, tailored treatment approaches, monitoring, and follow-up, and improve long-term outcomes for patients. With further innovation, the management of EoE can become more precise and tailored, leading to better patient outcomes and improved quality of life.
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Affiliation(s)
- Sara Massironi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Alessandra Elvevi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Roberto Panceri
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Giacomo Mulinacci
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giacomo Colella
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Andrea Biondi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
| | - Pietro Invernizzi
- Division of Gastroenterology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italia
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy, and Vita-Salute, San Raffaele University, Milan, Italy
| | - Edoardo Vespa
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy, and Vita-Salute, San Raffaele University, Milan, Italy
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Ishii A, Shibata T, Tsunoda Y, Kayukawa T, Kobayashi M, Orinaka M, Miyamatsu S, Ryuge Y, Asano S, Tanaka I. Benralizumab treatment in an elderly patient with eosinophilic esophagitis resulted in remission: a case report. BMC Geriatr 2024; 24:92. [PMID: 38267847 PMCID: PMC10809539 DOI: 10.1186/s12877-024-04683-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 01/08/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Interleukin-5 (IL-5) has recently been shown to play a crucial role in eosinophil-mediated diseases, implying that an IL-5 receptor alpha chain (IL-5Rα) antibody (benralizumab) can be effective against eosinophilic esophagitis (EoE). Here, we present a case in which benralizumab significantly improved the symptoms and signs of an elderly Asian woman with EoE who had inadequate response to existing treatments. Case presentation A 73-year-old woman with an 8-year history of bronchial asthma (BA) and a 7-year history of dysphagia presented to our hospital with worsening dysphagia, vomiting, chest pain, and difficulty in eating. Blood biochemical findings revealed an increase in the eosinophil fraction of white blood cells (42.2%), and a conventional chest computed tomography scan revealed esophageal wall thickening. An upper gastrointestinal endoscopy revealed mucosal edema as well as multiple esophageal rings, and esophageal biopsy specimens showed an eosinophilic infiltrate of more than 15 cells/ high power field. Based on these findings, she was diagnosed as EoE complicated by BA. We firstly administrated 20 mg/day of prednisolone, rabeprazole sodium and liquid budesonide oral suspension for 5 months; however, they were ineffective and her dysphagia worsened over time. Then, benralizumab treatment in combination with these drugs was started. Her dysphagia completely disappeared 2 weeks after starting benralizumab, and an upper endoscopy showed that the clinical findings had completely disappeared after another 6 weeks. Benralizumab was then given to her for 41 months, and her symptoms remained in remission. In addition, she had no EoE recurrence for more than 12 months after discontinuing benralizumab. CONCLUSIONS Benralizumab in combination with other multiple drugs significantly improved the symptoms and examination findings of an elderly patients with EoE. Furthermore, she experienced no recurrence even after discontinuing benralizumab withdrawal, suggesting that benralizumab could be an appropriate therapeutic option for EoE.
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Affiliation(s)
- Azusa Ishii
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Tomofumi Shibata
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Yohei Tsunoda
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Takafumi Kayukawa
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Masahiro Kobayashi
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Masami Orinaka
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Shoko Miyamatsu
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Yoshio Ryuge
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Shuichi Asano
- Department of Respirology, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - Ichidai Tanaka
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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13
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Bredal K, Frandsen LT, Terkelsen JH, Nielsen MH, Melgaard D, Krarup AL. There is a long way from current clinical practice in Denmark compared to recent published English guideline on management of children with eosinophilic oesophagitis. BMC Pediatr 2024; 24:24. [PMID: 38191332 PMCID: PMC10773032 DOI: 10.1186/s12887-023-04483-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 12/13/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND A low incidence of eosinophilic esophagitis (EoE) in children in the North Denmark Region (NDR) were measured in 2007-2017. Few of the children diagnosed before 2017 were treated to remission suggesting a lack of awareness. While there currently are no guidelines for treating EoE in Denmark, a new English guideline was published in 2022 renewing focus on the disease. OBJECTIVE The aim of this study was to measure the difference of current Danish clinical practice for treatment and follow-up of EoE children in the NDR with the new English guideline from the British Society of Gastroenterology (BSG) and the British Society of Pediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN). METHODS This retrospective, register-based DanEoE cohort study included 31 children diagnosed with EoE between 2007 and 2021 in NDR. Medical records were reviewed and information about treatment and follow-up were collected. RESULTS In 32% of the children with EoE in the NDR, first-line treatment corresponded with the new English guideline. One in 6 children were never started on any treatment even though treatment always is recommended. Histologic evaluation within 12 weeks as recommended was performed in 13% of the children. CONCLUSIONS In Denmark focus on improving EoE treatment and follow-up for children is needed, as there is a significant difference between current clinical practice and the recommendations in the new English guideline.
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Affiliation(s)
- Kasper Bredal
- Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Center for Clinical Research, North Denmark Regional Hospital, Hjørring, Denmark
| | - Line Tegtmeier Frandsen
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, Aalborg, DK-9000, Denmark
| | - Jacob Holmen Terkelsen
- Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Center for Clinical Research, North Denmark Regional Hospital, Hjørring, Denmark
| | - Martin Hollænder Nielsen
- Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Center for Clinical Research, North Denmark Regional Hospital, Hjørring, Denmark
| | - Dorte Melgaard
- Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, Aalborg, DK-9000, Denmark
| | - Anne Lund Krarup
- Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark.
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, Aalborg, DK-9000, Denmark.
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14
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Terkelsen JH, Hollænder M, Bredal K, Nielsen SM, Thomsen KVK, Baggerman A, Ofverlind E, Koc AM, Pakes H, Mahdi MB, Larsen SØ, Gonzalez VP, Riis J, Frandsen LT, Melgaard D, Krarup AL. A retrospective cohort study on oesophageal food bolus obstruction in the North Denmark region in 2021-two thirds were never diagnosed with a cause. BMC Gastroenterol 2024; 24:3. [PMID: 38166672 PMCID: PMC10759704 DOI: 10.1186/s12876-023-03077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Food bolus obstruction (FBO) leading to hospital treatment is often associated with eosinophilic oesophagitis (EoE), stenosis, or oesophageal cancer (1). Danish national guidelines recommend that patients with FBO undergo a diagnostic upper endoscopy within two weeks of presentation to exclude possible malignancy, and histological evaluation of eight biopsies (2, 3). AIMS The aims of this study were to (1) report the incidence and describe the causes and treatment of FBO in the North Denmark Region (NDR), (2) determine the proportion of patients who underwent upper endoscopy and biopsy according to regional and national guidelines, and (3) identify International Classification of Diseases 10th Revision (ICD-10) diagnosis and procedure codes applied to the hospital visits due to FBO in the NDR. METHODS Among all acute hospital visits in the NDR in 2021, all visits with ICD-10 codes possibly reflecting FBO, as well as a random sample of 14,400 visits with unspecific ICD-10 codes (R and Z codes), were screened manually for possible FBO. Diagnosis, follow-up, and treatment of all patients with FBO were recorded. RESULTS The median patient age was 66.0 (Q1-Q3: 49.8-81.0) years, and half of the patients had experienced FBO before. Two thirds of patients (66.0%) were never diagnosed with a cause of FBO, followed by 17.3% with EoE. 30% of patients did not undergo upper endoscopy within two weeks of the hospital visit, and 50.7% were never biopsied in the oesophagus. Of 1886 hospital visits with registry ICD-10 codes that possibly reflected FBO, 8.4% were due to FBO, while FBO was present in 0.028% of the random sample of unspecific ICD-10 codes. CONCLUSIONS Most hospitalized FBO patients in the NDR in 2021 were never diagnosed with a cause. In these patients there is a high risk of overlooked EoE or upper gastrointestinal cancers. The area needs immediate focus and changed routines to improve treatment and prevent new FBO.
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Affiliation(s)
| | - Martin Hollænder
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Kasper Bredal
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | | | - Kristoffer Vittrup Koed Thomsen
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Amanda Baggerman
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Emilia Ofverlind
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Alptug Mertcan Koc
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Hannah Pakes
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Marco Bassam Mahdi
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Sanne Ørnfeldt Larsen
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Vanessa Parra Gonzalez
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
- School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - Johannes Riis
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
| | - Line Tegtmeier Frandsen
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark
- Department of Gastroenterology, North Denmark Regional Hospital, Hjørring, Denmark
| | - Dorte Melgaard
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Lund Krarup
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, DK-9000, Aalborg, Denmark.
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.
- Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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15
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Shalem T, Cohen DL, Epstein-Rigbi N, Elizur A, Eindor-Abarbanel A, Broide E, Richter V. Proton pump inhibitors in eosinophilic esophagitis (EoE) related to oral immunotherapy: is it as effective as in other EoE? Eur J Pediatr 2023; 182:5409-5416. [PMID: 37750913 DOI: 10.1007/s00431-023-05228-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/07/2023] [Accepted: 09/17/2023] [Indexed: 09/27/2023]
Abstract
Oral immunotherapy (OIT) may induce eosinophilic esophagitis (EoE). Proton pump inhibitors (PPIs) are an effective treatment for EoE. However, the effect of PPI treatment is not well established in patients with EoE induced by OIT. Our primary aim was to compare the clinical, endoscopic, and histological response rates to PPIs in children with EoE induced by OIT (EoE+OIT) versus EoE patients without OIT (EoE-OIT). The secondary aims are to describe the clinical and histological features of EoE+OIT. Demographic, clinical, endoscopic, and histological findings of patients with EoE in the gastroenterology clinic at Shamir Medical Center between March 2015 and December 2022 were collected. Comparisons were performed between EoE+OIT and EoE-OIT patients. The study included 42 children (74% male, mean age 11.2), of whom 31 had EoE-OIT and 11 had EoE+OIT. There were no significant differences between groups regarding sex, comorbidities, symptoms, or endoscopic and histological characteristics at diagnosis. All 42 children were treated with PPIs after diagnosis with or without diet changes. The rates of any clinical response were 83.9% and 90.1% in the EoE-OIT group and EoE+OIT group, respectively (p = 1.0). The rate of any endoscopic response was 74.2% for EoE-OIT and 81.8% for EoE+OIT (p = 0.54). Histologically, PPIs were even more effective in the EoE+OIT group, where only 18.2% had no histological response at all compared to 51.6% in the EoE-OIT group (p = 0.1). CONCLUSION PPI treatment is as effective in EoE with OIT as it is in EoE due to other etiologies. WHAT IS KNOWN • Proton pump inhibitor (PPI) treatment is effective for achieving clinical response and histologic remission in some patients with eosinophilic esophagitis (EoE). • EoE has also been reported to be triggered by oral immunotherapy (OIT). WHAT IS NEW • PPI treatment in EoE with OIT is as effective as treatment for EoE due to other etiologies.
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Affiliation(s)
- Tzippora Shalem
- The Jecheskiel Sigi Gonczarowski Pediatric Gastroenterology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
| | - Daniel L Cohen
- The Gonczarowski Family Institute of Gastroenterology and Liver Disease, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
| | - Na'ama Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Eindor-Abarbanel
- The Jecheskiel Sigi Gonczarowski Pediatric Gastroenterology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
| | - Efrat Broide
- The Jecheskiel Sigi Gonczarowski Pediatric Gastroenterology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
- The Gonczarowski Family Institute of Gastroenterology and Liver Disease, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vered Richter
- The Gonczarowski Family Institute of Gastroenterology and Liver Disease, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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16
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Visaggi P, Barberio B, Del Corso G, de Bortoli N, Black CJ, Ford AC, Savarino E. Comparison of drugs for active eosinophilic oesophagitis: systematic review and network meta-analysis. Gut 2023; 72:2019-2030. [PMID: 37491157 DOI: 10.1136/gutjnl-2023-329873] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND There is currently no recommendation regarding preferred drugs for active eosinophilic oesophagitis (EoE) because their relative efficacy is unclear. We conducted an up-to-date network meta-analysis to compare proton pump inhibitors, off-label and EoE-specific topical steroids, and biologics in EoE. METHODS We searched MEDLINE, Embase, Embase Classic and the Cochrane Central Register of Controlled Trials from inception to June 2023. We included randomised controlled trials (RCTs) comparing efficacy of all drugs versus each other, or placebo, in adults and adolescents with active EoE. Results were reported as pooled relative risks with 95% CIs to summarise effect of each comparison tested, with drugs ranked according to P score RESULTS: Seventeen RCTs were eligible for systematic review. Of these, 15 studies containing 1813 subjects with EoE reported extractable data for the network meta-analysis. For histological remission defined as ≤6 eosinophils/high-power field (HPF), lirentelimab 1 mg/kg monthly ranked first. For histological remission defined as ≤15 eosinophils/HPF, budesonide orally disintegrating tablet (BOT) 1 mg two times per day ranked first. For failure to achieve symptom improvement, BOT 1 mg two times per day and budesonide oral suspension (BOS) 2 mg two times per day were significantly more efficacious than placebo. For failure to achieve endoscopic improvement based on the EoE Endoscopic Reference Score, BOT 1 mg two times per day and BOS 1 mg two times per day or 2 mg two times per day were significantly more efficacious than placebo. CONCLUSIONS Although this network meta-analysis supports the efficacy of most available drugs over placebo for EoE treatment, significant heterogeneity in eligibility criteria and outcome measures among available trials hampers the establishment of a solid therapeutic hierarchy.
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Affiliation(s)
- Pierfrancesco Visaggi
- Department of Translational Research and New Technologies in Medicine and Surgery, Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Brigida Barberio
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
| | - Giulio Del Corso
- Institute of Information Science and Technologies 'A. Faedo', National Research Council of Italy (CNR), Pisa, Italy
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Alexander C Ford
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padova, Italy
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17
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Attwood SE. Multiple inflammatory mechanisms in eosinophilic oesophagitis make it unlikely that single pathway inhibition by monoclonal biological therapies would succeed. Gut 2023; 72:1806-1807. [PMID: 37640444 DOI: 10.1136/gutjnl-2023-330590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
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18
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White E, Mutalib M. Use of endolumenal functional lumen imaging probe in investigating paediatric gastrointestinal motility disorders. World J Clin Pediatr 2023; 12:162-170. [PMID: 37753495 PMCID: PMC10518749 DOI: 10.5409/wjcp.v12.i4.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/09/2023] [Accepted: 08/23/2023] [Indexed: 09/06/2023] Open
Abstract
Investigating gastrointestinal (GI) motility disorders relies on diagnostic tools to assess muscular contractions, peristalsis propagation and the integrity and coordination of various sphincters. Manometries are the gold standard to study the GI motor function but it is increasingly acknowledged that manometries do not provide a complete picture in relation to sphincters competencies and muscle fibrosis. Endolumenal functional lumen imaging probe (EndoFLIP) an emerging technology, uses impedance planimetry to measure hollow organs cross sectional area, distensibility and compliance. It has been successfully used as a complementary tool in the assessment of the upper and lower oesophageal sphincters, oesophageal body, the pylorus and the anal canal. In this article, we aim to review the uses of EndoFLIP as a tool to investigate GI motility disorders with a special focus on paediatric practice. The majority of EndoFLIP studies were conducted in adult patients but the uptake of the technology in paediatrics is increasing. EndoFLIP can provide a useful complementary data to the existing GI motility investigation in both children and adults.
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Affiliation(s)
- Emily White
- Department of Paediatric Gastroenterology, Evelina London Children’s Hospital, London SE1 7EH, United Kingdom
| | - Mohamed Mutalib
- Department of Paediatric Gastroenterology, Evelina London Children’s Hospital, London SE1 7EH, United Kingdom
- Faculty of Life Sciences and Medicine, King’s College London, London SE1 7EH, United Kingdom
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19
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Schreiner P, Balcar L, Schlager H, Madl C, Ziachehabi A, Mader M, Steidl K, Dinkhauser P, Reider S, Dolak W, Dejaco C, Gröchenig HP, Novacek G. Management of suspected and known eosinophilic esophagitis-a nationwide survey in Austria. Wien Klin Wochenschr 2023; 135:406-413. [PMID: 37071203 PMCID: PMC10444684 DOI: 10.1007/s00508-023-02198-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 03/19/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus with increasing incidence and dysphagia as the main symptom. The management of suspected or known EoE by Austrian endoscopists has not been investigated yet. METHODS A web-based survey with 13 questions about the management of EoE was sent to endoscopists via the Austrian Society of Gastroenterology and Hepatology (ÖGGH). RESULTS A total of 222 endoscopists (74% gastroenterologists, 23% surgeons, and 2% pediatricians; 68% working in a hospital) from all 9 states participated. In patients with dysphagia but a normal appearing esophagus, 85% of respondents reported always taking biopsies; however, surgeons were less likely to obtain biopsies compared to gastroenterologists ("always" 69% vs. 90%, "sometimes" 29% vs. 10%, "never" 2% vs. 0%, p < 0.001). The approved budesonide orodispersible tablet is the preferred first-line drug used in EoE, ahead of proton pump inhibitors (PPI). Only 65% of participants monitor the patients by endoscopy and histology after 12 weeks of induction therapy, 26% do not continue maintenance therapy, and 22% monitor patients only when symptomatic. CONCLUSION The vast majority of Austrian endoscopists adhere to the European and US guidelines in cases of suspected EoE. In contrast, despite the chronic disease course, a significant percentage of providers indicate not to use maintenance therapy and monitor the patients routinely.
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Affiliation(s)
- Philipp Schreiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Hansjörg Schlager
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, University Hospital Graz, Graz, Austria
| | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | | | - Markus Mader
- Department of Internal Medicine II, Universitätsklinikum St. Pölten, St. Pölten, Austria
| | - Karin Steidl
- Department of Internal Medicine, Hospital Brothers of Mercy, St. Veit an der Glan, Austria
| | - Patrick Dinkhauser
- Department of Internal Medicine I, Division of Gastroenterology and Hepatology, Endocrinology and Rheumatology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Simon Reider
- Department of Internal Medicine 2 (Gastroenterology and Hepatology), Faculty of Medicine, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Werner Dolak
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Clemens Dejaco
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Hans Peter Gröchenig
- Department of Internal Medicine, Hospital Brothers of Mercy, St. Veit an der Glan, Austria
| | - Gottfried Novacek
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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20
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Alkhowaiter S. Eosinophilic esophagitis. Saudi Med J 2023; 44:640-646. [PMID: 37463709 PMCID: PMC10370381 DOI: 10.15537/smj.2023.44.7.20220812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is an atopic disease in which eosinophils infiltrate the esophageal mucosa and may result in a variety of upper gastrointestinal symptoms. Chief among these are dysphagia, heartburn, and food bolus obstruction in adults whereas children often present with abdominal pain or vomiting. Eosinophilic esophagitis is a chronic condition that if not detected and left untreated could lead to the development of subepithelial fibrosis and esophageal stenosis. The diagnosis of EoE is confirmed in a patient presenting with characteristic EoE symptoms, classic signs on endoscopy, and biopsy results showing >15 eosinophils/hpf. A number of useful treatments against EoE are currently available with new therapeutics on the horizon. The former include PPIs, topical steroids, and elimination diet; the latter comprise novel biologics including the monoclonal antibody dupilumab. All these treatments can improve symptoms and reduce esophageal eosinophil count. This brief introductory review describes the detection, diagnosis, and management of EoE.
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Affiliation(s)
- Saad Alkhowaiter
- From the Department of Gastroenterology, King Khalid University Hospital; and from the Department of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
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21
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Walgraeve S, Vanuytsel T. Novel corticosteroid formulations in the treatment of eosinophilic esophagitis: what is the evidence? Acta Gastroenterol Belg 2023; 86:437-448. [PMID: 37814560 DOI: 10.51821/86.3.11757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Background and study aims Eosinophilic esophagitis (EoE) is a food allergen-induced disease of the esophagus. Chronic, eosinophil-predominant inflammation eventually leads to fibrosis, esophageal dysfunction and severe morbidity. Swallowed topical corticosteroids (STCs) are a mainstay of anti-inflammatory therapy in the treatment of active EoE. Data on the efficacy of novel corticosteroid formulations, developed specifically for esophageal delivery, have recently become available. Methods A comprehensive review was performed aiming to summarize evidence on the role of STCs in the treatment of EoE. Two biomedical bibliographic databases (PubMED, EMBASE) were searched for articles providing original information on the efficacy and safety of STCs in adult EoE patients. Results Budesonide orodispersible tablet (BOT) and budesonide oral suspension (BOS) both surpassed placebo formulations regarding the efficacy of inducing and maintaining histologic, symptomatic and endoscopic remission. Overall, BOT displayed the highest grade of efficacy with clinico-histologic remission rates up to 75% after 1 year. Fluticasone propionate (APT-1011) achieved and maintained histologic and endoscopic responses in the majority of patients, whereas only a positive trend was demonstrated for symptomatic improvement. Mometasone and ciclesonide were studied in a limited number of smaller-scale trials and placebo-controlled data are required to substantiate the promising findings. All STCs displayed a similar side effects profile and were generally considered safe and well-tolerated. Conclusions Current evidence supports long-term treatment with novel corticosteroid formulations, challenging the established treatment paradigm of EoE. BOT appears to be the most effective steroid therapy, although head-to-head comparative trials between STCs are needed.
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Affiliation(s)
- S Walgraeve
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - T Vanuytsel
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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22
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Thakker C, Booth HL, Lambert J, Morgan S, Checkley AM. Investigating eosinophilia. BMJ 2023; 380:e070295. [PMID: 36737076 DOI: 10.1136/bmj-2022-070295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Clare Thakker
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - Helen L Booth
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Jonathan Lambert
- University College London Hospitals NHS Foundation Trust, London, UK
- UCL Cancer Institute, University College London, London, UK
| | - Sarah Morgan
- Camden Directorate, North Central London Integrated Care Board, London, UK
- Hampstead Group Practice, London, UK
| | - Anna M Checkley
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
- London School of Hygiene and Tropical Medicine, London, UK
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23
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Alkhowaiter SS. Eosinophilic Esophagitis in a 75-Year-Old Saudi Man: A Case Report. Cureus 2023; 15:e34705. [PMID: 36909115 PMCID: PMC9995558 DOI: 10.7759/cureus.34705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/10/2023] Open
Abstract
The incidence and prevalence of eosinophilic esophagitis (EoE) are increasing in adults and children worldwide. Once thought primarily to affect children and young adults, EoE is now recognized in all age groups. To our knowledge, this case study is the first known report of EoE diagnosed in an elderly man in Saudi Arabia. The 75-year-old patient presented with a chief complaint of dry mouth and mild heartburn symptoms. Further history inquiry disclosed that he experienced dysphagia occasionally. His endoscopy findings revealed signs associated with EoE, which was confirmed by biopsy showing marked infiltration of eosinophils (>30/hpf) in upper and lower esophagus. Following treatment with dexlansoprazole for eight weeks, the patient reported no further symptoms, and he remained in remission three months thereafter. Elderly patients with EoE may display atypical signs and symptoms and rarely have concomitant allergy; EoE should be considered in older patients especially those with dysphagia.
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Affiliation(s)
- Saad S Alkhowaiter
- Medicine/Gastroenterology, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, SAU
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Mechanisms and clinical management of eosinophilic oesophagitis: an overview. Nat Rev Gastroenterol Hepatol 2023; 20:101-119. [PMID: 36253463 DOI: 10.1038/s41575-022-00691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/03/2023]
Abstract
Since the first description of eosinophilic oesophagitis (EoE) less than three decades ago, we have observed a striking increase in the number of patients diagnosed with EoE and the understanding of its clinical and immunopathogenic background. Nonetheless, a plethora of open questions await elucidation. In this Review, we discuss the current state of knowledge regarding the underlying mechanisms, particularly environmental factors and their interaction with genetic susceptibility. Subsequently, we discuss how to translate these factors into the diagnostic and therapeutic management of this chronic, immune-mediated disorder. Finally, we dissect the still long list of unmet needs, such as reasons for and handling refractory EoE and atypical clinical presentations. These open questions can guide us through future research steps and potentially foster reconsideration of the diagnostic guidelines of EoE.
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Vales A, Coyle C, Plehhova K, Hobson A, Woodland P. Randomised clinical trial: the use of alginates during preinvestigation proton pump inhibitor wash-out and their impact on compliance and symptom burden. BMJ Open Gastroenterol 2023; 10:bmjgast-2022-001026. [PMID: 36627148 PMCID: PMC9835863 DOI: 10.1136/bmjgast-2022-001026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/18/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND/AIMS Investigation of gastro-oesophageal reflux disease is usually performed off proton pump inhibitors (PPIs). This can exacerbate symptoms, potentially impacting investigation accuracy if patients circumvent the preinvestigation instructions. There are no standard recommendations on how to manage PPI withdrawal. We aimed to assess the impact of structured alginate use on symptom burden. METHODS Participants were already established on ≥4 weeks of PPI therapy and being referred for manometry and 24-hour pH/impedance testing. Preinvestigation instructions involved stopping PPIs and H2 receptor antagonists for 1 week, but antacids and alginates were allowed until the night before. Participants were randomised to follow these standard instructions (control group), or the same instructions with the provision of Gaviscon Advance to be taken four times daily (treatment group). The primary outcome assessed change in Gastro-Oesophageal Reflux Disease Health-Related Quality of Life Score. KEY RESULTS Data for 48 patients were available for primary outcome assessment. While patients in the control group had a significant increase in symptoms (median difference 6.5, 95% CI (1 to 7), p=0.04), no change occurred in the treatment arm (median difference -1.5, 95% CI (-2, 3.5), p=0.54). There were no serious adverse events. CONCLUSIONS Structured alginate use prevents symptom exacerbation during preinvestigation PPI wash-out. These findings are limited to the 1-week wash-out period but can benefit thousands of patients undergoing investigation for gastro-oesophageal reflux each year. Further research is required to assess this effect in other settings, such as sustained PPI deprescription. The trial was funded by Reckitt Benckiser. TRIAL REGISTRATION NUMBER EudraCT registration 2019-004561-41.
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Montoro-Huguet MA. Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus. Nutrients 2022; 14:nu14224819. [PMID: 36432505 PMCID: PMC9697263 DOI: 10.3390/nu14224819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/06/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett's esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.
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Affiliation(s)
- Miguel A. Montoro-Huguet
- Unit of Gastroenterology, Hepatology & Nutrition, University Hospital San Jorge, 22005 Huesca, Spain;
- Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain
- Aragón Health Sciences Institute (IACS), 50009 Zaragoza, Spain
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Aktualisierte Leitlinien für die eosinophile Ösophagitis. ZEITSCHRIFT FÜR GASTROENTEROLOGIE 2022. [DOI: 10.1055/a-1898-8412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Larey A, Aknin E, Daniel N, Osswald GA, Caldwell JM, Rochman M, Wasserman T, Collins MH, Arva NC, Yang GY, Rothenberg ME, Savir Y. Harnessing artificial intelligence to infer novel spatial biomarkers for the diagnosis of eosinophilic esophagitis. Front Med (Lausanne) 2022; 9:950728. [PMID: 36341260 PMCID: PMC9633847 DOI: 10.3389/fmed.2022.950728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory condition of the esophagus associated with elevated esophageal eosinophils. Second only to gastroesophageal reflux disease, EoE is one of the leading causes of chronic refractory dysphagia in adults and children. EoE is a clinicopathologic disorder and the histological portion of the diagnosis requires enumerating the density of esophageal eosinophils in esophageal biopsies, and evaluating additional features such as basal zone hyperplasia is helpful. However, this task requires time-consuming, somewhat subjective manual analysis, thus reducing the ability to process the complex tissue structure and infer its relationship with the patient's clinical status. Previous artificial intelligence (AI) approaches that aimed to improve histology-based diagnosis focused on recapitulating identification and quantification of the area of maximal eosinophil density, the gold standard manual metric for determining EoE disease activity. However, this metric does not account for the distribution of eosinophils or other histological features, over the whole slide image. Here, we developed an artificial intelligence platform that infers local and spatial biomarkers based on semantic segmentation of intact eosinophils and basal zone distributions. Besides the maximal density of eosinophils [referred to as Peak Eosinophil Count (PEC)] and a maximal basal zone fraction, we identify the value of two additional metrics that reflect the distribution of eosinophils and basal zone fractions. This approach enables a decision support system that predicts EoE activity and potentially classifies the histological severity of EoE patients. We utilized a cohort that includes 1,066 biopsy slides from 400 subjects to validate the system's performance and achieved a histological severity classification accuracy of 86.70%, sensitivity of 84.50%, and specificity of 90.09%. Our approach highlights the importance of systematically analyzing the distribution of biopsy features over the entire slide and paves the way toward a personalized decision support system that will assist not only in counting cells but can also potentially improve diagnosis and provide treatment prediction.
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Affiliation(s)
- Ariel Larey
- Department of Physiology, Biophysics and Systems Biology, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Faculty of Computer Science, Technion Israel Institute of Technology, Haifa, Israel
| | - Eliel Aknin
- Department of Physiology, Biophysics and Systems Biology, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Faculty of Industrial Engineering, Technion - Israel Institute of Technology, Haifa, Israel
| | - Nati Daniel
- Department of Physiology, Biophysics and Systems Biology, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Garrett A Osswald
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Julie M Caldwell
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Mark Rochman
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Tanya Wasserman
- Department of Physiology, Biophysics and Systems Biology, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Margaret H Collins
- Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Yonatan Savir
- Department of Physiology, Biophysics and Systems Biology, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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