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Alexander R, Alexander JA, Akambase J, Harmsen WS, Geno D, Tholen C, Katzka DA, Ravi K. Proton Pump Inhibitor Therapy in Eosinophilic Esophagitis: Predictors of Nonresponse. Dig Dis Sci 2021; 66:3096-3104. [PMID: 32995996 DOI: 10.1007/s10620-020-06633-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/20/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Identification of clinical predictors of response to first-line therapies for EoE is needed to guide initial medical management. STUDY DESIGN A retrospective analysis of patients diagnosed with EoE from 2011 to 2018 was conducted. Clinical and diagnostic variables including demographics, endoscopic, and esophagram findings were compared between PPI responders and PPI nonresponders. All patients underwent a standard 8-week twice-daily PPI trial, with PPI responsiveness defined as < 15 eos/hpf on repeat EGD. Univariate and multivariable analyses were conducted to identify risk factors for nonresponse, and ROC curves were created to identify cutoff values. RESULTS A total of 223 EoE patients (135 male, median age 39 (29-51)) were identified, with PPI nonresponse (PPI-NR) in 71% of patients. PPI-NR was seen in all 10 patients with failure of scope passage, with an OR of 9.06 by univariate analysis (P = 0.1485). In a multivariable model, age per 10 years (OR 0.71; P = 0.007), BMI per 1 kg/m2 (OR 0.94; P = 0.03), and peripheral eosinophil count per 100 per mm3 (OR 1.37; P = 0.003) were independent risk factors. Dichotomization to maximize sensitivity and specificity identified age ≤ 36 years old, BMI ≤ 25.2 kg/m2, and peripheral eos > 460 per mm3 as predictive thresholds for PPI-NR. The probability of PPI-NR was 72.4-84.5% with 1 risk factor, 87.9-93.8% with 2 risk factors, and 97.2% with all 3 risk factors. CONCLUSIONS Young age, reduced BMI, elevated peripheral eosinophil count, and likely inability to pass an endoscope predict lack of response to PPIs in patients with EoE.
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Affiliation(s)
- Ryan Alexander
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA
| | - Jeffrey A Alexander
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA
| | - Joseph Akambase
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA
| | - William Scott Harmsen
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Debra Geno
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA
| | - Crystal Tholen
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA
| | - David A Katzka
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA
| | - Karthik Ravi
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
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Abstract
AIM To analyze the clinical features, diagnosis, and prognosis of eosinophilic gastroenteritis (EG).
METHODS A retrospective analysis was performed of clinical data of 88 cases with EG at our hospital between June 2013 and August 2018.
RESULTS Eighty-eight patients were included, with a male to female ratio of 1.2:1. The patients ranged in age from 14 to 73 years, with a mean age 45.1 years. Abdominal pain was the most common symptom, 73.3% of patients had positive allergen screening results, and some patients had negative endoscopic findings. Common endoscopic abnormalities were mainly congestion, erosion, ulcers, polyps and so on, and pathological examination revealed a large number of eosinophils infiltrated in the gastrointestinal tract, with the highest average value detected in the cecum. Treatment with proton pump inhibitors was effective. Glucocorticoid therapy was useful, but the disease could recur.
CONCLUSION The pathogenesis of EG is still unclear, although it is known that allergens play an important role in it. The clinical manifestations are atypical. An increase of eosinophilic granulocytes in peripheral blood and bone marrow smear can support the diagnosis. Imaging and endoscopic manifestations are not specific. Pathology is the key to diagnosis. Glucocorticoid therapy can obtain good results, but there have been no unified criteria on the specific dosage and course of treatment .
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Affiliation(s)
- Zheng-Yang Yu
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Dong-Ying Li
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
| | - Jian-Sheng Li
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, Henan Province, China
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Philpott H, Dellon ES. The role of maintenance therapy in eosinophilic esophagitis: who, why, and how? J Gastroenterol 2018; 53:165-171. [PMID: 29018965 PMCID: PMC5794528 DOI: 10.1007/s00535-017-1397-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/26/2017] [Indexed: 02/04/2023]
Abstract
In patients with eosinophilic esophagitis (EoE) who do not respond to proton pump inhibitors, initial anti-inflammatory/anti-eosinophilic treatment is with either topical corticosteroids or dietary elimination. A large body of literature supports the efficacy of these approaches, with histologic response rates in the 50-90% range for steroids and 70% range for the six-food elimination diet. However, these studies are almost all short-term and data evaluating long-term safety and efficacy of either treatment are limited. Nevertheless, because EoE is chronic, symptomatic, endoscopic, and histologic disease activity recurs when successful treatments are stopped. An emerging body of data also suggest that left untreated, persistent eosinophilic esophageal inflammation may progress to fibrostenosis over time. Therefore, maintenance therapy in EoE is intuitively attractive. This paper reviews the rationale for maintenance treatment in EoE, the available long-term pharmacologic and dietary response data for EoE, and discusses who may benefit the most from ongoing treatment. While all patients with EoE can be offered maintenance treatment, this option should be strongly recommended in patients with severe disease phenotypes or complications, including malnutrition or failure to thrive, esophageal fibrostenosis, strictures requiring dilation, recurrent food bolus impaction, history of perforation, and symptoms that recur quickly after treatment discontinuation. In all EoE patients, regular follow-up is also advised.
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Affiliation(s)
- Hamish Philpott
- Northern Adelaide Local Health Network (NALHN), Department of Gastroenterology Lyell McEwin and Modbury Hospitals, University of Adelaide, Adelaide, SA, Australia
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, CB#7080, Bioinformatics Building, 130 Mason Farm Rd., Chapel Hill, NC, 27599-7080, USA.
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Straumann A, Katzka DA. Diagnosis and Treatment of Eosinophilic Esophagitis. Gastroenterology 2018; 154:346-359. [PMID: 28756235 DOI: 10.1053/j.gastro.2017.05.066] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/16/2017] [Accepted: 05/19/2017] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is a new disease. It is caused by a T-helper type 2 cell response to food antigens in contact with the esophageal mucosa. Although no single feature defines EoE, a constellation of compatible demographic, clinical, endoscopic, and histologic findings establish the diagnosis. Children present with symptoms and endoscopic patterns characteristic of inflammation, whereas adolescents and adults have manifestations of fibrosis and gross esophageal strictures. Clinical and endoscopic scoring systems have helped to standardize diagnosis. There is controversy in EoE research over the optimal endpoint for treatment. Although the most common endpoint is a reduced number of eosinophils in biopsies, changes in symptoms and endoscopic features are becoming important targets of therapy. We should improve our understanding of EoE progression and the need for maintenance therapy, and continue development of diagnostic tools that avoid endoscopy and biopsy analyses to more easily monitor disease activity.
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Affiliation(s)
- Alex Straumann
- Swiss EoE Clinic, Praxis Römerhof, Olten, Switzerland; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David A Katzka
- Swiss EoE Clinic, Praxis Römerhof, Olten, Switzerland; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Lucendo AJ, Arias-González L, Molina-Infante J, Arias Á. Determinant factors of quality of life in adult patients with eosinophilic esophagitis. United European Gastroenterol J 2017; 6:38-45. [PMID: 29435312 DOI: 10.1177/2050640617707095] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/03/2017] [Indexed: 12/23/2022] Open
Abstract
Background Eosinophilic esophagitis (EoE) affects health-related quality of life (HRQoL). Data on determinant factors and the influence of dietary interventions are scarce. Objective The objective of this article is to evaluate factors influencing HRQoL in adult EoE patients. Methods We conducted a multicenter observational, cross-sectional study. A validated Spanish version of the self-administered Adult Eosinophilic Esophagitis Quality of Life (EoE-QoL-A) questionnaire and specific surveys were used. Multiple linear regression was used to identify and quantify determinant factors of HRQoL. Results Responses provided by 170 patients were assessed (73.5% male; mean age 33.5 ± 11.4 years). Overall mean score for the EoE-QoL-A index was 1.4 ± 0.8, with no differences between patients on dietary or pharmacological therapy (1.82 ± 0.8 vs. 1.62 ± 0.8; p = 0.132). Disease anxiety showed the highest mean score (2.13 ± 0.9 points), followed by choking anxiety (1.97 ± 1.1); social impact (1.77 ± 1.1), and diet/eating impact (1.68 ± 0.9). Emotional impact had the lowest rating (1.15 ± 0.9), and only with a significantly worse score in patients under dietary restrictions. Recurrent food impaction, a higher educational level, dietary interventions and symptom duration were all independent determinant factors significantly impairing HRQoL. Female gender and empiric elimination diets negatively influenced on diet/eating impact. Conclusion Recurrent food impaction, dietary interventions and symptom duration are the most important factors influencing the perception of HRQoL in adults with EoE.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Laura Arias-González
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier Molina-Infante
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology, Hospital Universitario San Pedro de Alcántara, Cáceres, Spain
| | - Ángel Arias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Research Support Unit, Complejo Hospitalario La Mancha Centro, Alcázar de San Juan, Spain
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Philpott H, Gibson PR. Letter: dietary therapy in eosinophilic oesophagitis - do not test, just eliminate and reintroduce the most common food triggers. Authors' reply. Aliment Pharmacol Ther 2016; 44:905-6. [PMID: 27634233 DOI: 10.1111/apt.13787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- H Philpott
- Eastern Health Clinical School, Melbourne, Vic., Australia.
| | - P R Gibson
- The Alfred Hospital, Melbourne, Vic., Australia
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