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Wenzel AA, Kagalwalla AF, Wechsler JB. Pre-endoscopy Symptoms and Age, But Not Esophageal Biopsy Number Are Associated With Post-endoscopy Adverse Events. J Pediatr Gastroenterol Nutr 2022; 75:656-660. [PMID: 36305884 PMCID: PMC9627599 DOI: 10.1097/mpg.0000000000003594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Esophagogastroduodenoscopy (EGD) is a frequently utilized investigative tool in the management of gastrointestinal conditions in children. Biopsies obtained during EGD may pose risk for post-operative adverse events (AEs), and further understanding of risk is imperative to provide informed consent to families and safe patient care. In particular, the impact of biopsy number and location on the development of AEs has not been studied in pediatric patients. We prospectively assessed for AEs by telephone survey 3-7 days after 209 EGDs performed on patients ages 1-21 years over a 1-year period. Demographic, endoscopic, and histologic data were collected. The most common symptoms reported were throat pain (61%), chest pain (26%), and dysphagia (26%). Binary regression models identified age and pre-operative symptoms as factors that influenced the likelihood of post-operative morbidity. Multiple biopsies from 3 different locations of the esophagus did not impact the risk of post-operative AEs.
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Affiliation(s)
- Amanda A Wenzel
- From the Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Amir F Kagalwalla
- From the Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- the Division of Pediatric Gastroenterology John H Stroger Hospital of Cook County, Chicago, IL
| | - Joshua B Wechsler
- From the Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Wechsler JB, Bolton SM, Gray E, Kim KY, Kagalwalla AF. Defining the Patchy Landscape of Esophageal Eosinophilia in Children With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2022; 20:1971-1976.e2. [PMID: 34954340 PMCID: PMC9552248 DOI: 10.1016/j.cgh.2021.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/30/2021] [Accepted: 12/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) is a patchy disease of the esophagus with significant variability in intraepithelial eosinophilia. Three biopsies each from distal and proximal esophagus are recommended for identification of active EoE. Recent work suggests 3 biopsy sites are more optimal. We sought to evaluate 2-site vs 3-site esophageal biopsy combinations for utility to identify active EoE. METHODS We prospectively obtained 3-site esophageal biopsies based on rigorous endoscopic measurements of the proximal, mid, and distal esophagus and gastroesophageal junction. Biopsies were reviewed by a pathologist, and those with at least 15 eosinophils per high-power field were considered active EoE. The sensitivity of one or more sites to identify active EoE was determined, and endoscopic measurements were correlated to height and age. RESULTS Five hundred ninety-six endoscopies were performed in 217 patients; of these, 304 endoscopies in 167 patients had active EoE. Among the initial esophagogastroduodenoscopies with active EoE, distal biopsies had greater than 80% sensitivity, whereas mid and proximal biopsies had sensitivity of 65% and 62%, respectively, and distal + proximal biopsies had the highest diagnostic sensitivity for a 2-site combination. Among the 304 endoscopies with active EoE, 9 had focal eosinophilia restricted to the mid esophagus, and 8 were restricted to the proximal esophagus. For patients with multiple endoscopies with active EoE, nearly one fourth had reduced sites with eosinophilia at the second time point. Endoscopic measurements strongly correlated with height and age. CONCLUSIONS This study supports endoscopic measurement-guided 3-site biopsies for optimal disease assessment of active EoE in children.
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Affiliation(s)
- Joshua B Wechsler
- Northwestern University Feinberg School of Medicine, Chicago, Illinois; Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Scott M Bolton
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Elizabeth Gray
- Department of Preventive Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Kwang-Youn Kim
- Department of Preventive Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Amir F Kagalwalla
- Northwestern University Feinberg School of Medicine, Chicago, Illinois; Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; John H. Stroger Hospital of Cook County, Chicago, Illinois
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Wechsler JB, Schwartz S, Arva NC, Kim KYA, Chen L, Makhija M, Amsden K, Keeley K, Mohammed S, Dellon ES, Kagalwalla AF. A Single-Food Milk Elimination Diet Is Effective for Treatment of Eosinophilic Esophagitis in Children. Clin Gastroenterol Hepatol 2022; 20:1748-1756.e11. [PMID: 33823291 PMCID: PMC10123872 DOI: 10.1016/j.cgh.2021.03.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Cow's milk protein (CMP) is the most common trigger of inflammation in children and adults with eosinophilic esophagitis (EoE). We sought to assess the clinical, endoscopic, and histologic efficacy of dietary elimination of all CMP-containing foods in EoE. METHODS We performed a prospective observational study in children with EoE treated with the 1-food elimination diet (1FED), excluding all CMP. Children and their caretakers were educated by a registered dietitian regarding dietary elimination of all CMP-containing foods, with substitutions to meet nutritional needs for optimal growth and development, and daily meal planning. Upper endoscopy with biopsies was performed after 8 to 12 weeks of treatment. The primary end point was histologic remission, defined as fewer than 15 eosinophils per high-power field. Secondary end points were symptomatic, endoscopic, and quality-of-life (QOL) improvements. RESULTS Forty-one children (76% male; ages, 9 ± 4 years; 88% white) underwent 1FED education and post-treatment endoscopy with biopsies. Histologic remission occurred in 21 (51%) children, with a decrease in peak eosinophils per high-power field from a median of 50 (interquartile range, 35-70) to a median of 1 (interquartile range, 0-6; P < .0001). Endoscopic abnormalities improved in 24 (59%) patients, while symptoms improved in 25 (61%). Improved symptoms included chest pain, dysphagia, and pocketing/spitting out food. Parents perceived worse QOL, while children perceived improved QOL with the 1FED. CONCLUSIONS One-food elimination of CMP-containing foods from the diet induced histologic remission in more than 50% of children with EoE and led to significant improvement in symptoms and endoscopic abnormalities. The ease of implementation and adherence supports the 1FED as first-line dietary treatment.
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Affiliation(s)
- Joshua B Wechsler
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition
| | - Sally Schwartz
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition
| | - Nicoleta C Arva
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Pathology and Laboratory Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Kwang-Youn A Kim
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Preventive Medicine
| | - Liqi Chen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Preventive Medicine
| | - Melanie Makhija
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Allergy and Clinical Immunology, Department of Pediatrics
| | - Katie Amsden
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition
| | - Kaitlin Keeley
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition
| | - Saeed Mohammed
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Amir F Kagalwalla
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition; Department of Pediatrics, John H Stroger Hospital of Cook County, Chicago, Illinois.
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4
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Ma C, Bredenoord AJ, Dellon ES, Alexander JA, Biedermann L, Hogan M, Guizzetti L, Zou G, Katzka DA, Chehade M, Falk GW, Furuta GT, Gupta SK, Kagalwalla AF, Schoepfer AM, Miehlke S, Moawad FJ, Peterson K, Gonsalves NP, Straumann A, Wechsler JB, Rémillard J, Shackelton LM, Almonte HS, Feagan BG, Jairath V, Hirano I. Reliability and responsiveness of endoscopic disease activity assessment in eosinophilic esophagitis. Gastrointest Endosc 2022; 95:1126-1137.e2. [PMID: 35120883 DOI: 10.1016/j.gie.2022.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/21/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic outcomes have become important measures of eosinophilic esophagitis (EoE) disease activity, including as an endpoint in randomized controlled trials (RCTs). We evaluated the operating properties of endoscopic measures for use in EoE RCTs. METHODS Modified Research and Development/University of California Los Angeles appropriateness methods and a panel of 15 international EoE experts identified endoscopic items and definitions with face validity that were used in a 2-round voting process to define simplified (all items graded as absent or present) and expanded versions (additional grades for edema, furrows, and/or exudates) of the EoE Endoscopic Reference Score (EREFS). Inter- and intrarater reliability of these instruments (expressed as intraclass correlation coefficients [ICC]) were evaluated using paired endoscopy video assessments of 2 blinded central readers in patients before and after 8 weeks of proton pump inhibitors, swallowed topical corticosteroids, or dietary elimination. Responsiveness was measured using the standardized effect size (SES). RESULTS The appropriateness of 41 statements relevant to EoE endoscopic activity (endoscopic items, item definitions and grading, and other considerations relevant for endoscopy) was considered. The original and expanded EREFS demonstrated moderate-to-substantial inter-rater reliability (ICCs of .472-.736 and .469-.763, respectively) and moderate-to-almost perfect intrarater reliability (ICCs of .580-.828 and .581-.828, respectively). Strictures were least reliably assessed (ICC, .072-.385). The original EREFS was highly responsive (SES, 1.126 [95% confidence interval {CI}, .757-1.534]), although both expanded versions of EREFS, scored based on worst affected area, were numerically most responsive to treatment (expanded furrows: SES, 1.229 [95% CI, .858-1.643]; all items expanded: SES, 1.252 [95% CI, .880-1.667]). The EREFS and its modifications were not more reliably scored by segment and also not more responsive when proximal and distal EREFSs were summed. CONCLUSIONS EREFS and its modifications were reliable and responsive, and the original or expanded versions of the EREFS may be preferred in RCTs. Disease activity scored based on the worst affected area optimizes reliability and responsiveness.
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Affiliation(s)
- Christopher Ma
- Division of Gastroenterology & Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc, London, Ontario, Canada
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | | | - Guangyong Zou
- Alimentiv Inc, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gary W Falk
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Children's Hospital, Indiana University School of Medicine, Community Health Network, Indianapolis, Indiana, USA
| | - Amir F Kagalwalla
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA; Division of Pediatric Gastroenterology, Department of Pediatrics, John H. Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Stephan Miehlke
- Center for Esophageal Diseases, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fouad J Moawad
- Division of Gastroenterology, Scripps Clinic, La Jolla, California, USA
| | - Kathryn Peterson
- Division of Gastroenterology and Hepatology, University of Utah, Salt Lake City, Utah, USA
| | - Nirmala P Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alex Straumann
- Swiss EoE Clinics and Research Network, Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | - Hector S Almonte
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brian G Feagan
- Alimentiv Inc, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Division of Gastroenterology and Hepatology, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Division of Gastroenterology and Hepatology, Western University, London, Ontario, Canada
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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5
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Ma C, Schoepfer AM, Dellon ES, Bredenoord AJ, Chehade M, Collins MH, Feagan BG, Furuta GT, Gupta SK, Hirano I, Jairath V, Katzka DA, Pai RK, Rothenberg ME, Straumann A, Aceves SS, Alexander JA, Arva NC, Atkins D, Biedermann L, Blanchard C, Cianferoni A, Ciriza de Los Rios C, Clayton F, Davis CM, de Bortoli N, Dias JA, Falk GW, Genta RM, Ghaffari G, Gonsalves N, Greuter T, Hopp R, Hsu Blatman KS, Jensen ET, Johnston D, Kagalwalla AF, Larsson HM, Leung J, Louis H, Masterson JC, Menard-Katcher C, Menard-Katcher PA, Moawad FJ, Muir AB, Mukkada VA, Penagini R, Pesek RD, Peterson K, Putnam PE, Ravelli A, Savarino EV, Schlag C, Schreiner P, Simon D, Smyrk TC, Spergel JM, Taft TH, Terreehorst I, Vanuytsel T, Venter C, Vieira MC, Vieth M, Vlieg-Boerstra B, von Arnim U, Walker MM, Wechsler JB, Woodland P, Woosley JT, Yang GY, Zevit N, Safroneeva E. Development of a core outcome set for therapeutic studies in eosinophilic esophagitis (COREOS). J Allergy Clin Immunol 2022; 149:659-670. [PMID: 34242635 PMCID: PMC8733049 DOI: 10.1016/j.jaci.2021.07.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/07/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND End points used to determine treatment efficacy in eosinophilic esophagitis (EoE) have evolved over time. With multiple novel therapies in development for EoE, harmonization of outcomes measures will facilitate evidence synthesis and appraisal when comparing different treatments. OBJECTIVE We sought to develop a core outcome set (COS) for controlled and observational studies of pharmacologic and diet interventions in adult and pediatric patients with EoE. METHODS Candidate outcomes were generated from systematic literature reviews and patient engagement interviews and surveys. Consensus was established using an iterative Delphi process, with items voted on using a 9-point Likert scale and with feedback from other participants to allow score refinement. Consensus meetings were held to ratify the outcome domains of importance and the core outcome measures. Stakeholders were recruited internationally and included adult and pediatric gastroenterologists, allergists, dieticians, pathologists, psychologists, researchers, and methodologists. RESULTS The COS consists of 4 outcome domains for controlled and observational studies: histopathology, endoscopy, patient-reported symptoms, and EoE-specific quality of life. A total of 69 stakeholders (response rate 95.8%) prioritized 42 outcomes in a 2-round Delphi process, and the final ratification meeting generated consensus on 33 outcome measures. These included measurement of the peak eosinophil count, Eosinophilic Esophagitis Histology Scoring System, Eosinophilic Esophagitis Endoscopic Reference Score, and patient-reported measures of dysphagia and quality of life. CONCLUSIONS This interdisciplinary collaboration involving global stakeholders has produced a COS that can be applied to adult and pediatric studies of pharmacologic and diet therapies for EoE and will facilitate meaningful treatment comparisons and improve the quality of data synthesis.
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Affiliation(s)
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Alimentiv Inc, London, Ontario, Canada
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brian G Feagan
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Colorado School of Medicine, Aurora, Colo
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children/Indiana University School of Medicine, Indianapolis, Ind
| | - Ikuo Hirano
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Vipul Jairath
- Alimentiv Inc, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minn
| | - Rish K Pai
- Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Seema S Aceves
- Division of Allergy Immunology, University of California, San Diego, Rady Children's Hospital, San Diego, Calif
| | | | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, Children's Hospital of Colorado, Section of Allergy and Immunology, University of Colorado School of Medicine, Aurora, Colo
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Carine Blanchard
- Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé, Vevey, Switzerland
| | - Antonella Cianferoni
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Constanza Ciriza de Los Rios
- Department of Gastroenterology, Hospital Clínico San Carlos, Universidad Complutense, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Frederic Clayton
- Department of Pathology, The University of Utah, Huntsman Cancer Hospital, Salt Lake City, Utah
| | - Carla M Davis
- Immunology, Allergy, and Retrovirology Section of the Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - Nicola de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Jorge A Dias
- Pediatric Gastroenterology, Centro Hospitalar S. João, Porto, Portugal
| | - Gary W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Robert M Genta
- Inform Diagnostics, Irving, Tex; Department of Pathology, Baylor College of Medicine, Houston, Tex
| | - Gisoo Ghaffari
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Pennsylvania State College of Medicine, Hershey, Pa
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Russell Hopp
- University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, Neb
| | - Karen S Hsu Blatman
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Elizabeth T Jensen
- Wake Forest University School of Medicine, Department of Epidemiology and Prevention, Winston-Salem, NC
| | | | - Amir F Kagalwalla
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Division of Gastroenterology, Department of Pediatrics, John H. Stroger Jr Hospital of Cook County, Chicago, Ill
| | - Helen M Larsson
- Department of ENT, Head, and Neck Surgery, NÄL Medical Centre, Trollhättan, Sweden
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, Mass
| | - Hubert Louis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Calies Menard-Katcher
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Colorado School of Medicine, Aurora, Colo
| | - Paul A Menard-Katcher
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Fouad J Moawad
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, Calif
| | - Amanda B Muir
- Center for Pediatric Eosinophilic Diseases, Division of Gastroenterology and Hepatology & Nutrition, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Robert D Pesek
- Division of Allergy and Immunology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Kathryn Peterson
- Division of Gastroenterology, The University of Utah, Salt Lake City, Utah
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alberto Ravelli
- University Department of Pediatrics, Children's Hospital-Spedali Civili, Brescia, Italy
| | - Edoardo V Savarino
- Department of Surgery, Oncology, and Gastroenterology, DiSCOG, University of Padua, Padua, Italy
| | - Christoph Schlag
- II. Medizinische Klinik, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Philipp Schreiner
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Jonathan M Spergel
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Tiffany H Taft
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Ingrid Terreehorst
- Department of ENT, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Tim Vanuytsel
- Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Translational Research in Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Carina Venter
- Gastrointestinal Eosinophilic Diseases Program, Children's Hospital of Colorado, Section of Allergy and Immunology, University of Colorado School of Medicine, Aurora, Colo
| | - Mario C Vieira
- Department of Pediatrics, Pontifical Catholic University of Paraná and Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Michael Vieth
- Institute for Pathology, Klinikum Bayreuth, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | | | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology, and Infectious Diseases, University Hospital, Magdeburg, Germany
| | - Marjorie M Walker
- Centre of Research Excellence in Digestive Health, University of Newcastle, Newcastle, Australia
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Barts, and the London School of Medicine and Dentistry, Queen Mary University of London, London, England, United Kingdom
| | - John T Woosley
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Guang-Yu Yang
- Division of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
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Wechsler JB, Ackerman SJ, Chehade M, Amsden K, Riffle ME, Wang M, Du J, Kleinjan ML, Alumkal P, Gray E, Kim KA, Wershil BK, Kagalwalla AF. Noninvasive biomarkers identify eosinophilic esophagitis: A prospective longitudinal study in children. Allergy 2021; 76:3755-3765. [PMID: 33905577 DOI: 10.1111/all.14874] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/14/2021] [Accepted: 03/31/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Esophageal histology is critical for diagnosis and surveillance of disease activity in eosinophilic esophagitis (EoE). A validated noninvasive biomarker has not been identified. We aimed to determine the utility of blood and urine eosinophil-associated proteins to diagnose EoE and predict esophageal eosinophilia. METHODS Blood and urine were collected from children undergoing endoscopy with biopsy. Absolute eosinophil count (AEC), plasma eosinophil-derived neurotoxin (EDN), eosinophil cationic protein (ECP), major basic protein-1 (MBP-1), galectin-10 (CLC/GAL-10), Eotaxin-2 and Eotaxin-3, and urine osteopontin (OPN) and matrix metalloproteinase-9 (MMP-9) were determined. Differences were assessed between EoE and control, and with treatment response. The capacity to predict EoE diagnosis and esophageal eosinophil counts was assessed. RESULTS Of 183 specimens were collected from 56 EoE patients and 15 non-EoE controls with symptoms of esophageal dysfunction; 33 EoE patients had paired pre- and post-treatment specimens. Plasma (CLC/GAL-10, ECP, EDN, Eotaxin-3, MBP-1) and urine (OPN) biomarkers were increased in EoE compared to control. A panel comprising CLC/GAL-10, Eotaxin-3, ECP, EDN, MBP-1, and AEC was superior to AEC alone in distinguishing EoE from control. AEC, CLC/GAL-10, ECP, and MBP-1 were significantly decreased in patients with esophageal eosinophil counts <15/hpf in response to treatment. AEC, CLC/GAL-10, ECP, EDN, OPN, and MBP-1 each predicted esophageal eosinophil counts utilizing mixed models controlled for age, gender, treatment, and atopy; AEC combined with MBP-1 best predicted the counts. CONCLUSIONS We identified novel panels of eosinophil-associated proteins that along with AEC are superior to AEC alone in distinguishing EoE from controls and predicting esophageal eosinophil counts.
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Affiliation(s)
- Joshua B. Wechsler
- Northwestern University Feinberg School of Medicine Chicago IL USA
- Department of Pediatrics Division of Gastroenterology, Hepatology, and Nutrition Eosinophilic Gastrointestinal Diseases ProgramAnn & Robert H. Lurie Children's Hospital of Chicago Chicago IL USA
| | - Steven J. Ackerman
- Department of Biochemistry and Molecular Genetics University of Illinois‐Chicago Chicago IL USA
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders Icahn School of Medicine at Mount Sinai New York NY USA
| | - Katie Amsden
- Department of Pediatrics Division of Gastroenterology, Hepatology, and Nutrition Eosinophilic Gastrointestinal Diseases ProgramAnn & Robert H. Lurie Children's Hospital of Chicago Chicago IL USA
| | - Mary E. Riffle
- Mount Sinai Center for Eosinophilic Disorders Icahn School of Medicine at Mount Sinai New York NY USA
| | - Ming‐Yu Wang
- Department of Pediatrics Division of Gastroenterology, Hepatology, and Nutrition Eosinophilic Gastrointestinal Diseases ProgramAnn & Robert H. Lurie Children's Hospital of Chicago Chicago IL USA
| | - Jian Du
- Department of Biochemistry and Molecular Genetics University of Illinois‐Chicago Chicago IL USA
| | - Matt L. Kleinjan
- Department of Biochemistry and Molecular Genetics University of Illinois‐Chicago Chicago IL USA
| | - Preeth Alumkal
- Department of Biochemistry and Molecular Genetics University of Illinois‐Chicago Chicago IL USA
| | - Elizabeth Gray
- Northwestern University Feinberg School of Medicine Chicago IL USA
- Department of Preventive Medicine Feinberg School of Medicine Chicago IL USA
| | - Kwang‐Youn A. Kim
- Northwestern University Feinberg School of Medicine Chicago IL USA
- Department of Preventive Medicine Feinberg School of Medicine Chicago IL USA
| | - Barry K. Wershil
- Northwestern University Feinberg School of Medicine Chicago IL USA
- Department of Pediatrics Division of Gastroenterology, Hepatology, and Nutrition Eosinophilic Gastrointestinal Diseases ProgramAnn & Robert H. Lurie Children's Hospital of Chicago Chicago IL USA
| | - Amir F. Kagalwalla
- Northwestern University Feinberg School of Medicine Chicago IL USA
- Department of Pediatrics Division of Gastroenterology, Hepatology, and Nutrition Eosinophilic Gastrointestinal Diseases ProgramAnn & Robert H. Lurie Children's Hospital of Chicago Chicago IL USA
- John H. Stroger Hospital of Cook County Chicago IL USA
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Bashaw H, Schwartz S, Kagalwalla AF, Wechsler JB. Tutorial: Nutrition Therapy in Eosinophilic Esophagitis—Outcomes and Deficiencies. JPEN J Parenter Enteral Nutr 2019; 44:600-609. [DOI: 10.1002/jpen.1738] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/07/2019] [Accepted: 10/16/2019] [Indexed: 01/02/2023]
Affiliation(s)
- Hillary Bashaw
- Division of Gastroenterology Hepatology & Nutrition Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
| | - Sally Schwartz
- Division of Gastroenterology Hepatology & Nutrition Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
| | - Amir F. Kagalwalla
- Division of Gastroenterology Hepatology & Nutrition Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
- Department of Pediatrics John H. Stroger Hospital of Cook County Chicago Illinois USA
- Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Joshua B. Wechsler
- Division of Gastroenterology Hepatology & Nutrition Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
- Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago Illinois USA
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8
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Ackerman SJ, Kagalwalla AF, Hirano I, Gonsalves N, Menard-Katcher P, Gupta S, Wechsler JB, Grozdanovic MM, Pan Z, Masterson JC, Du J, Fantus RJ, Ochkur SI, Ahmed F, Capocelli KE, Melin-Aldana H, Hammer J, Dubner A, Amsden K, Keeley K, Sulkowski M, Zalewski A, Atkins F(D, Furuta GT. The 1-Hour Esophageal String Test: A Non-Endoscopic Minimally Invasive Test to Accurately Detect Disease Activity in Eosinophilic Esophagitis. J Allergy Clin Immunol 2019. [DOI: 10.1016/j.jaci.2018.12.940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wechsler JB, Bolton S, Amsden K, Wershil BK, Hirano I, Kagalwalla AF. Eosinophilic Esophagitis Reference Score Accurately Identifies Disease Activity and Treatment Effects in Children. Clin Gastroenterol Hepatol 2018; 16:1056-1063. [PMID: 29248734 PMCID: PMC6003847 DOI: 10.1016/j.cgh.2017.12.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/01/2017] [Accepted: 12/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The endoscopic reference score (EREFS) is used to determine severity of 5 endoscopic findings: edema, rings, exudates, furrows, and strictures. Little is known about the relationship between EREFSs and histologic markers of disease activity in children with eosinophilic esophagitis (EoE). We aimed to determine whether the EREFS can be used to identify children with EoE and how it changes with treatment. METHODS We performed a prospective study of consecutive children (ages 2-17 years) undergoing diagnostic or post-treatment endoscopy scored real-time with EREFS from December 2012 through 2016. Findings from 192 diagnostic endoscopies and 229 post-treatment endoscopies were evaluated, from 371 children. Incident EoE cases were diagnosed based on 2011 consensus guidelines. Patients were treated with either elimination diet or topical steroids. Subjects who underwent endoscopy for symptoms of esophageal dysfunction but had normal esophageal findings from histology analysis were used as controls. EREFS and receiver operating characteristic curves were determined for incident EoE cases (n = 77) vs controls (n = 115), patients with active EoE (n = 101) vs inactive EoE after treatment (n = 128), and paired pre- and post-treatment cases of EoE (n = 85). Component and composite scores were correlated with eosinophilia. RESULTS Visual detection of more than 1 esophageal abnormality during the diagnostic endoscopy identified children with EoE with 89.6% sensitivity and 87.9% specificity. EREFS correlated with peak level of eosinophilia (P < .001) at all esophageal levels. Children who responded to therapy had mean EREFSs of 0.5 compared to 2.4 in non-responders. In comparing pre-treatment vs post-treatment data from 85 patients, we found a significant reduction in the composite EREFS (from 2.4 to 0.7) (P < .001) among patients who responded to treatment; 92% of responders had a reduced EREFSs after treatment. EREFSs identified children with EoE with an area under the curve value (AUC) of 0.93. EREFSs identified children with active EoE following treatment with an AUC of 0.81 before treatment and an AUC of 0.79 after treatment. CONCLUSIONS In a prospective study of children undergoing diagnostic or post-treatment endoscopy, we found the EREFS to accurately identify those with EoE. Children who responded to therapy had lower EREFS scores than non-responders. EREFSs can be used to measure outcomes of pediatric patients, in conjunction with histology findings, and assess treatments for children with EoE.
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Affiliation(s)
- Josh B. Wechsler
- Northwestern University Feinberg School of Medicine, Chicago, Illinois,Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - S. Bolton
- Northwestern University Feinberg School of Medicine, Chicago, Illinois,Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - K. Amsden
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - B. K. Wershil
- Northwestern University Feinberg School of Medicine, Chicago, Illinois,Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - I. Hirano
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amir F. Kagalwalla
- Northwestern University Feinberg School of Medicine, Chicago, Illinois,Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,John H. Stroger Hospital of Cook County, Chicago, Illinois
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10
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Abstract
PURPOSE OF REVIEW The goal of this review is to present and summarize studies on endoscopic findings in eosinophilic esophagitis (EoE), at diagnosis and in response to treatment, utilizing rigorous peer-reviewed literature in children wherever possible and to introduce a recently proposed standardized endoscopic evaluation system. RECENT FINDINGS Gold standard of diagnosis and assessment of response to therapy in EoE requires multiple endoscopies with biopsies for histology, which allows for observation of the esophageal mucosa. Typical endoscopic findings in patients with EoE include edema, exudate, furrowing, concentric rings, and strictures. Endoscopic findings have been broadly characterized into inflammatory features (edema, exudate, furrowing) and fibro-stenotic features (rings, stricture), in order to better reflect their underlying pathophysiology. Recent studies suggest strong correlations between endoscopic findings, through composite scoring systems, and histology, and therefore may be helpful as part of disease surveillance. The EoE Endoscopic Reference Score (EREFS) classification system was proposed in 2013 as an outcome metric for standardization in reporting endoscopic signs of EoE. Subsequent studies support utility of composite scoring, which utility has similarly been seen in pediatric treatment trials. Endoscopy in children provides insight into the natural history of EoE, with progressively more fibro-stenotic features occurring over time, giving an additional perspective into esophageal remodeling and response to treatment. Recognition of typical endoscopic findings at diagnosis and upon repeat endoscopy has allowed a clinician to monitor visual changes in esophageal mucosal health. Further studies to assess the role of composite scoring in disease management are needed.
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Affiliation(s)
- S M Bolton
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - A F Kagalwalla
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
- John H. Stroger Hospital of Cook County, Chicago, IL, USA
| | - J B Wechsler
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA.
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11
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Kagalwalla AF, Wechsler JB, Amsden K, Schwartz S, Makhija M, Olive A, Davis CM, Manuel-Rubio M, Marcus S, Shaykin R, Sulkowski M, Johnson K, Ross JN, Riffle ME, Groetch M, Melin-Aldana H, Schady D, Palac H, Kim KYA, Wershil BK, Collins MH, Chehade M. Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2017; 15:1698-1707.e7. [PMID: 28603055 PMCID: PMC6448398 DOI: 10.1016/j.cgh.2017.05.048] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/26/2017] [Accepted: 05/30/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS A 6-food elimination diet induces remission in most children and adults with eosinophilic esophagitis (EoE). The effectiveness of empiric elimination of only 4 foods has not been studied in children. We performed a prospective observational outcome study in children with EoE treated with dietary exclusion of cow's milk, wheat, egg, and soy. The objective was to assess the clinical, endoscopic, and histologic efficacy of this treatment in EoE. METHODS We recruited children (1-18 years old, diagnosed per consensus guidelines) from 4 medical centers. Study participants (n = 78) were given a proton pump inhibitor twice daily and underwent a baseline esophagogastroduodenoscopy. Subjects were instructed on dietary exclusion of cow's milk, wheat, egg, and soy. Clinical, endoscopic, and histologic assessments were made after 8 weeks. Responders had single foods reintroduced for 8 weeks, with repeat endoscopy to assess for recurrence of active disease. The primary endpoint was histologic remission (fewer than 15 eosinophils per high-powered field). Secondary endpoints included symptom and endoscopic improvements and identification of foods associated with active histologic disease. RESULTS After 8 weeks on 4-food elimination diet, 50 subjects were in histologic remission (64%). The subjects' mean baseline clinical symptoms score was 4.5, which decreased to 2.3 after 8 weeks of 4-food elimination diet (P < .001). The mean endoscopic baseline score was 2.1, which decreased to 1.3 (P < .001). After food reintroduction, the most common food triggers that induced histologic inflammation were cow's milk (85%), egg (35%), wheat (33%), and soy (19%). One food trigger that induced recurrence of esophageal inflammation was identified in 62% of patients and cow's milk-induced EoE was present in 88% of these patients. CONCLUSIONS In a prospective study of children with EoE, 8 weeks of 4-food elimination diet induced clinical, endoscopic, and histologic remission in more than 60% of children with EoE. Although less restrictive than 6-food elimination diet, 4-food elimination diet was nearly as effective, and can be recommended as a treatment for children with EoE.
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Affiliation(s)
- Amir F. Kagalwalla
- Northwestern University Feinberg School of Medicine, Chicago, Illinois,Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,John H Stroger Hospital of Cook County, Chicago, Illinois
| | - Joshua B. Wechsler
- Northwestern University Feinberg School of Medicine, Chicago, Illinois,Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Katie Amsden
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Sally Schwartz
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Melanie Makhija
- Northwestern University Feinberg School of Medicine, Chicago, Illinois,Division of Allergy & Clinical Immunology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Anthony Olive
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Carla M. Davis
- Section of Immunology, Allergy and Rheumatology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Maria Manuel-Rubio
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | - Ronda Shaykin
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Maureen Sulkowski
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Kristen Johnson
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Jessica N. Ross
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Mary Ellen Riffle
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Marion Groetch
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Hector Melin-Aldana
- Northwestern University Feinberg School of Medicine, Chicago, Illinois,Department of Pathology and Laboratory Medicine, Ann & Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Deborah Schady
- Department of Pathology, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Hannah Palac
- Department of Preventive Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Kwan-Youn A. Kim
- Department of Preventive Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Barry K. Wershil
- Northwestern University Feinberg School of Medicine, Chicago, Illinois,Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Margaret H. Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York City, New York
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12
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Dellon ES, Collins MH, Bonis PA, Capocelli KE, Dohil R, Falk GW, Furuta GT, Gupta SK, Hirano I, Hiremath GS, Kagalwalla AF, Leung J, Liacouras CA, Menard-Katcher C, Muir AB, Mukkada VA, Putnam PE, Schoepfer AM, Straumann A, Wershil BK, Wo JM, Yang GY, Rothenberg ME, Gonsalves N. Substantial Variability in Biopsy Practice Patterns Among Gastroenterologists for Suspected Eosinophilic Gastrointestinal Disorders. Clin Gastroenterol Hepatol 2016; 14:1842-1844. [PMID: 27112108 PMCID: PMC5075280 DOI: 10.1016/j.cgh.2016.04.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 04/14/2016] [Accepted: 04/18/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Margaret H. Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Peter A. Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, MA
| | - Kelley E. Capocelli
- Division of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Aurora, CO
| | - Ranjan Dohil
- Division of Pediatric Gastroenterology, Rady Children’s Hospital, San Diego, CA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Glenn T. Furuta
- Digestive Health Institute, Children’s Hospital Colorado; and Section of Pediatric Gastroenterology, University of Colorado School of Medicine; Aurora, CO
| | - Sandeep K. Gupta
- Division of Pediatric Gastroenterology, Riley Hospital for Children, Indianapolis, IN
| | - Ikuo Hirano
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Girish S. Hiremath
- Division of Pediatric Gastroenterology, Vanderbilt University, Nashville, TN
| | - Amir F. Kagalwalla
- Division of Pediatric Gastroenterology, Lurie Children’s Hospital, Chicago, IL
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, MA
| | - Chris A. Liacouras
- Division of Pediatric Gastroenterology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Calies Menard-Katcher
- Digestive Health Institute, Children’s Hospital Colorado; and Section of Pediatric Gastroenterology, University of Colorado School of Medicine; Aurora, CO
| | - Amanda B. Muir
- Division of Pediatric Gastroenterology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Vincent A. Mukkada
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Philip E. Putnam
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Alain M. Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Barry K. Wershil
- Division of Pediatric Gastroenterology, Lurie Children’s Hospital, Chicago, IL
| | - John M. Wo
- Division of Gastroenterology, Indiana University, Indianapolis, IN
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Marc E. Rothenberg
- Division of Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
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13
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Pelz BJ, Wechsler JB, Amsden K, Johnson K, Singh AM, Wershil BK, Kagalwalla AF, Bryce PJ. IgE-associated food allergy alters the presentation of paediatric eosinophilic esophagitis. Clin Exp Allergy 2016; 46:1431-1440. [PMID: 27388929 DOI: 10.1111/cea.12776] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/23/2016] [Accepted: 06/28/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Links between food allergens and eosinophilic esophagitis (EoE) have been established, but the interplay between EoE- and IgE-associated immediate hypersensitivity to foods remains unclear. OBJECTIVE We sought to determine the prevalence of IgE-associated food allergy at the time of diagnosis of EoE in children and to determine whether differences existed in presentation and disease compared to subjects with EoE alone. METHODS Eosinophilic esophagitis patients were stratified based on the diagnosis of IgE-associated immediate hypersensitivity (EoE + IH vs. EoE-IH). Clinical, histologic, pathologic, and endoscopic differences were investigated using a retrospective database. RESULTS We found that 29% of the 198 EoE patients in our cohort had EoE + IH. These subjects presented at a younger age than those without IH (6.05 vs. 8.09 years, P = 0.013) and were more likely to have comorbid allergic disease. Surprisingly, the EoE + IH group presented with significantly different clinical symptoms, with increased dysphagia, gagging, cough, and poor appetite compared to their counterparts in the EoE-IH group. Male gender, allergic rhinitis, the presence of dysphagia, and younger age were independently associated with having EoE + IH. Specific IgE levels to common EoE-associated foods were higher in EoE + IH, regardless of eliciting immediate hypersensitivity symptoms. In contrast, IgE levels for specific foods triggering EoE were relatively lower in both the groups than IgE levels for immediate reactions. CONCLUSIONS AND CLINICAL RELEVANCE Immediate hypersensitivity is common in children with EoE and identifies a population of EoE patients with distinct clinical characteristics. Our study describes a subtype of EoE in which IgE-mediated food allergy may impact the presentation of paediatric EoE.
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Affiliation(s)
- B J Pelz
- Division of Allergy & Immunology, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Northwestern University Food Allergy Research Consortium, Chicago, IL, USA
| | - J B Wechsler
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - K Amsden
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A M Singh
- Division of Allergy & Immunology, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Northwestern University Food Allergy Research Consortium, Chicago, IL, USA
| | - B K Wershil
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A F Kagalwalla
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P J Bryce
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Northwestern University Food Allergy Research Consortium, Chicago, IL, USA.
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Bush JW, Mohammad S, Melin-Aldana H, Kagalwalla AF, Arva NC. Eosinophilic density in graft biopsies positive for rejection and blood eosinophil count can predict development of post-transplant digestive tract eosinophilia. Pediatr Transplant 2016; 20:540-51. [PMID: 26917244 DOI: 10.1111/petr.12693] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2016] [Indexed: 01/07/2023]
Abstract
EGID is a known post-transplant complication. Its etiology has been related to antirejection medication, but other factors may also play a role as only few transplant recipients develop EGID despite standardized treatment. This study aimed to determine whether EGID is associated with rejection events and with a specific phenotype of the rejection-positive graft biopsies in children with solid organ transplant. All patients with liver, heart, and kidney transplant followed at our institution were included in the study. Digestive tract eosinophilia was more common in heart and liver recipients and was a rare event after renal transplantation. Subjects with EGID had higher incidence of rejection and elevated peripheral blood AEC. The first rejection event and high AEC values preceded EGID diagnosis in the majority of patients. Histologically, the initial rejection-positive graft biopsy revealed accentuated eosinophilia in EGID patients compared with non-EGID cohort, which correlated with higher blood eosinophil counts at the time of first rejection episode. Prominent graft tissue and peripheral blood eosinophilia prior to EGID diagnosis suggests a predisposition for eosinophil activation in patients with post-transplant digestive eosinophilic disorder. These parameters can be used as markers for subsequent development of EGID.
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Affiliation(s)
- Jonathan W Bush
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Saeed Mohammad
- Department of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Hector Melin-Aldana
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Amir F Kagalwalla
- Department of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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15
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Harris JK, Fang R, Wagner BD, Choe HN, Kelly CJ, Schroeder S, Moore W, Stevens MJ, Yeckes A, Amsden K, Kagalwalla AF, Zalewski A, Hirano I, Gonsalves N, Henry LN, Masterson JC, Robertson CE, Leung DY, Pace NR, Ackerman SJ, Furuta GT, Fillon SA. Esophageal microbiome in eosinophilic esophagitis. PLoS One 2015; 10:e0128346. [PMID: 26020633 PMCID: PMC4447451 DOI: 10.1371/journal.pone.0128346] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/26/2015] [Indexed: 01/07/2023] Open
Abstract
Objective The microbiome has been implicated in the pathogenesis of a number of allergic and inflammatory diseases. The mucosa affected by eosinophilic esophagitis (EoE) is composed of a stratified squamous epithelia and contains intraepithelial eosinophils. To date, no studies have identified the esophageal microbiome in patients with EoE or the impact of treatment on these organisms. The aim of this study was to identify the esophageal microbiome in EoE and determine whether treatments change this profile. We hypothesized that clinically relevant alterations in bacterial populations are present in different forms of esophagitis. Design In this prospective study, secretions from the esophageal mucosa were collected from children and adults with EoE, Gastroesophageal Reflux Disease (GERD) and normal mucosa using the Esophageal String Test (EST). Bacterial load was determined using quantitative PCR. Bacterial communities, determined by 16S rRNA gene amplification and 454 pyrosequencing, were compared between health and disease. Results Samples from a total of 70 children and adult subjects were examined. Bacterial load was increased in both EoE and GERD relative to normal subjects. In subjects with EoE, load was increased regardless of treatment status or degree of mucosal eosinophilia compared with normal. Haemophilus was significantly increased in untreated EoE subjects as compared with normal subjects. Streptococcus was decreased in GERD subjects on proton pump inhibition as compared with normal subjects. Conclusions Diseases associated with mucosal eosinophilia are characterized by a different microbiome from that found in the normal mucosa. Microbiota may contribute to esophageal inflammation in EoE and GERD.
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Affiliation(s)
- J. Kirk Harris
- Division of Pulmonology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Rui Fang
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, United States of America
| | - Brandie D. Wagner
- Division of Pulmonology, University of Colorado School of Medicine, Aurora, CO, United States of America
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, United States of America
| | - Ha Na Choe
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Caleb J. Kelly
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Shauna Schroeder
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Wendy Moore
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Mark J. Stevens
- Division of Pulmonology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Alyson Yeckes
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Katie Amsden
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, IL, United States of America
- Department of Pediatrics, John H. Stroger Hospital of Cook County, Chicago, IL, United States of America
| | - Amir F. Kagalwalla
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, IL, United States of America
- Department of Pediatrics, John H. Stroger Hospital of Cook County, Chicago, IL, United States of America
| | - Angelika Zalewski
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States of America
| | - Ikuo Hirano
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States of America
| | - Nirmala Gonsalves
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States of America
| | - Lauren N. Henry
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Joanne C. Masterson
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Charles E. Robertson
- Molecular Cellular and Developmental Biology, University of Colorado Boulder, Boulder, CO, United States of America
| | - Donald Y. Leung
- Department of Pediatrics, National Jewish Health, Denver, CO, United States of America
| | - Norman R. Pace
- Molecular Cellular and Developmental Biology, University of Colorado Boulder, Boulder, CO, United States of America
| | - Steven J. Ackerman
- Department of Biochemistry and Molecular Genetics, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Glenn T. Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Sophie A. Fillon
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO, United States of America
- * E-mail:
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Pelz BJ, Wechsler JB, Krier-Burris R, Wershil B, Kagalwalla AF, Bryce P. The Relationship of Eosinophilic Esophagitis and Food Allergy: Evaluating the Spectrum of Eosinophilic Esophagitis. J Allergy Clin Immunol 2015. [DOI: 10.1016/j.jaci.2014.12.1068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Emerging evidence supports impaired epithelial barrier function as the key initial event in the development of eosinophilic esophagitis (EoE) and other allergic diseases. Symptom resolution, histologic remission, and prevention of both disease and treatment-related complications are the goals of treatment. Successful dietary treatments include elemental, empirical elimination and allergy test directed diets. Dietary therapy with exclusive elemental diet offers the best response. Cow's milk, wheat, egg, soy, peanut/tree nut, and fish/shellfish are the 6 food antigens most likely to induce esophageal inflammation.
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Affiliation(s)
- Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University-Feinberg School of Medicine, 676 North Saint Claire, Suite 1400, Chicago, IL 60611, USA
| | - Amir F Kagalwalla
- Division of Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University-Feinberg School of Medicine, 225 East Chicago Avenue, Chicago, IL 60611, USA.
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Abstract
Eosinophilic esophagitis, an increasingly recognized chronic inflammatory disorder isolated to the esophagus, is triggered by an abnormal allergic response to dietary antigens. Current treatment includes swallowed topical steroids and dietary modification, which aim to resolve symptoms and prevent long-term complications such as formation of strictures. The dietary approach has become more widely accepted because long-term steroid therapy is associated with potential risks. Dietary treatment includes elemental and elimination diets. An exclusive elemental diet, which requires replacement of all intact protein with amino acid-based formula, offers the best response of all available therapies, with remission in up to 96% of subjects proving it to be superior to all other available therapies including topical steroids. However, compliance with this approach is challenging because of poor taste and monotony. The high cost of formula and the associated psychosocial problems are additional drawbacks of this approach. Empiric and allergy test-directed elimination diets have gained popularity given that elimination of a limited number of foods is much easier and as such is more readily acceptable. There is a growing body of literature supporting this type of therapy in both children and adults. This paper reviews the evidence for all types of dietary therapy in eosinophilic esophagitis.
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Affiliation(s)
- Joshua B Wechsler
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Sally Schwartz
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Katie Amsden
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Amir F Kagalwalla
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
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19
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Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder of the esophagus that, in a genetically susceptible host, is triggered by a food antigen. Emerging evidence supports impaired epithelia barrier function as the key initial event in the development of EoE and other allergic diseases. Symptom resolution, histologic remission, and prevention of both disease and treatment-related complications are the goals of treatment. Successful dietary treatments include elemental and elimination diets, both empiric and allergy test directed. These treatments are dietary approaches to inducing clinical and histologic remission. Dietary therapy with an exclusive elemental diet offers the best response with a remission rate of more than 96%. Empiric elimination diets and allergy-directed diets offer similar response with remission induced in 3 of 4 subjects (75%). Cow's milk, wheat, egg and soy are the four common food antigens most likely to induce esophageal inflammation.
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Affiliation(s)
- Amir F Kagalwalla
- Department of Pediatrics - Gastroenterology, Hepatology and Nutrition, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, and John H. Stroger Hospital of Cook County, Chicago, Ill., USA
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20
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Furuta GT, Kagalwalla AF, Lee JJ, Alumkal P, Maybruck BT, Fillon S, Masterson JC, Ochkur S, Protheroe C, Moore W, Pan Z, Amsden K, Robinson Z, Capocelli K, Mukkada V, Atkins D, Fleischer D, Hosford L, Kwatia MA, Schroeder S, Kelly C, Lovell M, Melin-Aldana H, Ackerman SJ. The oesophageal string test: a novel, minimally invasive method measures mucosal inflammation in eosinophilic oesophagitis. Gut 2013; 62:1395-405. [PMID: 22895393 PMCID: PMC3786608 DOI: 10.1136/gutjnl-2012-303171] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Eosinophil predominant inflammation characterises histological features of eosinophilic oesophagitis (EoE). Endoscopy with biopsy is currently the only method to assess oesophageal mucosal inflammation in EoE. We hypothesised that measurements of luminal eosinophil-derived proteins would correlate with oesophageal mucosal inflammation in children with EoE. DESIGN The Enterotest diagnostic device was used to develop an oesophageal string test (EST) as a minimally invasive clinical device. EST samples and oesophageal mucosal biopsies were obtained from children undergoing upper endoscopy for clinically defined indications. Eosinophil-derived proteins including eosinophil secondary granule proteins (major basic protein-1, eosinophil-derived neurotoxin, eosinophil cationic protein, eosinophil peroxidase) and Charcot-Leyden crystal protein/galectin-10 were measured by ELISA in luminal effluents eluted from ESTs and extracts of mucosal biopsies. RESULTS ESTs were performed in 41 children with active EoE (n=14), EoE in remission (n=8), gastro-oesophageal reflux disease (n=4) and controls with normal oesophagus (n=15). EST measurement of eosinophil-derived protein biomarkers significantly distinguished between children with active EoE, treated EoE in remission, gastro-oesophageal reflux disease and normal oesophagus. Levels of luminal eosinophil-derived proteins in EST samples significantly correlated with peak and mean oesophageal eosinophils/high power field (HPF), eosinophil peroxidase indices and levels of the same eosinophil-derived proteins in extracts of oesophageal biopsies. CONCLUSIONS The presence of eosinophil-derived proteins in luminal secretions is reflective of mucosal inflammation in children with EoE. The EST is a novel, minimally invasive device for measuring oesophageal eosinophilic inflammation in children with EoE.
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Affiliation(s)
- Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
- Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - Amir F Kagalwalla
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago and Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pediatrics, John H. Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - James J Lee
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Preeth Alumkal
- Departments of Biochemistry and Molecular Genetics, and Medicine, College of Medicine, University of Illinois at Chicago, Illinois, USA
| | - Brian T Maybruck
- Departments of Biochemistry and Molecular Genetics, and Medicine, College of Medicine, University of Illinois at Chicago, Illinois, USA
| | - Sophie Fillon
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Joanne C Masterson
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Sergei Ochkur
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Cheryl Protheroe
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Wendy Moore
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
- Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - Zhaoxing Pan
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Katie Amsden
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago and Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Zachary Robinson
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Kelley Capocelli
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Department of Pathology, University of Colorado Denver School of Medicine, Colorado, USA
| | - Vince Mukkada
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Dan Atkins
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - David Fleischer
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - Lindsay Hosford
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Mark A Kwatia
- Departments of Biochemistry and Molecular Genetics, and Medicine, College of Medicine, University of Illinois at Chicago, Illinois, USA
| | - Shauna Schroeder
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Caleb Kelly
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Mark Lovell
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Department of Pathology, University of Colorado Denver School of Medicine, Colorado, USA
| | - Hector Melin-Aldana
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago and Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pathology, Ann and Robert H Lurie Children's Hospital of Chicago and Northwestern University, Chicago, Illinois, USA
| | - Steven J Ackerman
- Departments of Biochemistry and Molecular Genetics, and Medicine, College of Medicine, University of Illinois at Chicago, Illinois, USA
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Kagalwalla AF, Akhtar N, Woodruff SA, Rea BA, Masterson JC, Mukkada V, Parashette KR, Du J, Fillon S, Protheroe CA, Lee JJ, Amsden K, Melin-Aldana H, Capocelli KE, Furuta GT, Ackerman SJ. Eosinophilic esophagitis: epithelial mesenchymal transition contributes to esophageal remodeling and reverses with treatment. J Allergy Clin Immunol 2012; 129:1387-1396.e7. [PMID: 22465212 DOI: 10.1016/j.jaci.2012.03.005] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 03/07/2012] [Accepted: 03/08/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND Mechanisms underlying esophageal remodeling with subepithelial fibrosis in subjects with eosinophilic esophagitis (EoE) have not been delineated. OBJECTIVES We sought to explore a role for epithelial mesenchymal transition (EMT) in subjects with EoE and determine whether EMT resolves with treatment. METHODS Esophageal biopsy specimens from 60 children were immunostained for epithelial (cytokeratin) and mesenchymal (vimentin) EMT biomarkers, and EMT was quantified. Subjects studied had EoE (n = 17), indeterminate EoE (n = 15), gastroesophageal reflux disease (n = 7), or normal esophagus (n = 21). EMT was analyzed for relationships to diagnosis, eosinophil counts, and indices of subepithelial fibrosis, eosinophil peroxidase, and TGF-β immunostaining. EMT was assessed in pretreatment and posttreatment biopsy specimens from 18 subjects with EoE treated with an elemental diet, 6-food elimination diet, or topical corticosteroids (n = 6 per group). RESULTS TGF-β1 treatment of esophageal epithelial cells in vitro for 24 hours induced upregulation of mesenchymal genes characteristic of EMT, including N-cadherin (3.3-fold), vimentin (2.1-fold), and fibronectin (7.5-fold). EMT in esophageal biopsy specimens was associated with EoE (or indeterminate EoE) but not gastroesophageal reflux disease or normal esophagus and was correlated to eosinophil counts (r = 0.691), eosinophil peroxidase (r = 0.738), and TGF-β (r = 0.520) immunostaining and fibrosis (r = 0.644) indices. EMT resolved with EoE treatments that induced clinicopathologic remission with reduced eosinophil counts. EMT decreased significantly after treatment by 74.1% overall in the 18 treated subjects with EoE; pretreatment versus posttreatment EMT scores were 3.17 ± 0.82 versus 0.82 ± 0.39 (P < .001), with similar decreases within treatment groups. Pretreatment/posttreatment EMT was strongly correlated with eosinophil counts for combined (r = 0.804, P < .001) and individual treatment groups. CONCLUSIONS EMT likely contributes to subepithelial fibrosis in subjects with EoE and resolves with treatments that decrease esophageal inflammation, and its resolution correlates with decreased numbers of esophageal eosinophils.
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Affiliation(s)
- Amir F Kagalwalla
- Department of Pediatrics, Children's Memorial Hospital and Northwestern University, Chicago, IL, USA
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22
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Affiliation(s)
- Amir F Kagalwalla
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Kagalwalla AF, Sentongo TA, Ritz S, Hess T, Nelson SP, Emerick KM, Melin-Aldana H, Li BUK. Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis. Clin Gastroenterol Hepatol 2006; 4:1097-102. [PMID: 16860614 DOI: 10.1016/j.cgh.2006.05.026] [Citation(s) in RCA: 472] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In children, eosinophilic esophagitis (EE) is predominantly, but not exclusively, a food-hypersensitivity disorder. A crystalline amino acid-based elemental diet (ELED) formula currently remains the most effective nutritional treatment in inducing clinical and histologic remission. However, compliance with an exclusive, poor-tasting liquid formulation is difficult. METHODS This retrospective observational study assessed the short-term clinical and histologic responses of 2 cohorts of children with EE evaluated during 2 different time periods: one was treated with the standard 6-food elimination diet (SFED) and the other was treated with ELED. Of the 60 children who met the inclusion criteria and were compliant with the dietary protocol, 35 were treated with a diet excluding cow-milk protein, soy, wheat, egg, peanut, and seafood while allowing all other table foods and 25 were treated exclusively with ELED. Repeat esophageal biopsy specimens were obtained at least 6 weeks later. RESULTS Twenty-six of 35 (74%) in the SFED group and 22 of 25 (88%) in the ELED group achieved significant improvement of esophageal inflammation (</=10 eosinophils/high-power field). The pretreatment and posttreatment peak eosinophil counts for the SFED were 80.2 +/- 44.0 and 13.6 +/- 23.8 (P < .0001) and 58.8 +/- 31.9 and 3.7 +/- 6.5 (P < .001) for the ELED group, respectively. CONCLUSIONS SFED treatment was associated with clinical and histologic improvement in EE in an observational study. It offers advantages of better acceptance, cost, and compliance than ELED and should be considered as an option in the initial management of children with EE.
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Affiliation(s)
- Amir F Kagalwalla
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
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24
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Strautnieks SS, Bull LN, Knisely AS, Kocoshis SA, Dahl N, Arnell H, Sokal E, Dahan K, Childs S, Ling V, Tanner MS, Kagalwalla AF, Németh A, Pawlowska J, Baker A, Mieli-Vergani G, Freimer NB, Gardiner RM, Thompson RJ. A gene encoding a liver-specific ABC transporter is mutated in progressive familial intrahepatic cholestasis. Nat Genet 1998; 20:233-8. [PMID: 9806540 DOI: 10.1038/3034] [Citation(s) in RCA: 663] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The progressive familial intrahepatic cholestases (PFIC) are a group of inherited disorders with severe cholestatic liver disease from early infancy. A subgroup characterized by normal serum cholesterol and gamma-glutamyltranspeptidase (gammaGT) levels is genetically heterogeneous with loci on chromosomes 2q (PFIC2) and 18q. The phenotype of the PFIC2-linked group is consistent with defective bile acid transport at the hepatocyte canalicular membrane. The PFIC2 gene has now been identified by mutations in a positional candidate, BSEP, which encodes a liver-specific ATP-binding cassette (ABC) transporter, sister of p-glycoprotein (SPGP). The product of the orthologous rat gene has been shown to be an effective bile acid transporter in vitro. These data provide evidence that SPGP is the human bile salt export pump (BSEP).
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Affiliation(s)
- S S Strautnieks
- Department of Paediatrics, University College London Medical School, UK
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Strautnieks SS, Kagalwalla AF, Tanner MS, Knisely AS, Bull L, Freimer N, Kocoshis SA, Gardiner RM, Thompson RJ. Identification of a locus for progressive familial intrahepatic cholestasis PFIC2 on chromosome 2q24. Am J Hum Genet 1997; 61:630-3. [PMID: 9326328 PMCID: PMC1715942 DOI: 10.1086/515501] [Citation(s) in RCA: 146] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Progressive familial intrahepatic cholestasis (PFIC; OMIM 211600) is the second most common familial cholestatic syndrome presenting in infancy. A locus has previously been mapped to chromosome 18q21-22 in the original Byler pedigree. This chromosomal region also harbors the locus for benign recurrent intrahepatic cholestasis (BRIC) a related phenotype. Linkage analysis in six consanguineous PFIC pedigrees from the Middle East has previously excluded linkage to chromosome 18q21-22, indicating the existence of locus heterogeneity within the PFIC phenotype. By use of homozygosity mapping and a genome scan in these pedigrees, a locus designated "PFIC2" has been mapped to chromosome 2q24. A maximum LOD score of 8.5 was obtained in the interval between marker loci D2S306 and D2S124, with all families linked.
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Affiliation(s)
- S S Strautnieks
- Department of Pediatrics, University College London Medical School, Rayne Institute, United Kingdom
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Kagalwalla AF, Altraif I, Shamsan L, Omojola M, Khan H, Kagalwalla YA. Primary sclerosing cholangitis in Arab children: report of four cases and literature review. J Pediatr Gastroenterol Nutr 1997; 24:146-52. [PMID: 9106100 DOI: 10.1097/00005176-199702000-00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The prevalence of primary sclerosing cholangitis, a rare progressive liver disorder, is increasing with the advent of endoscopic retrograde cholangiography in the investigation of children with obscure liver disease. The etiology of primary sclerosing cholangitis is not known, clinical presentation is variable, treatment is only of limited success and long-term studies on prognosis in children are incomplete. Primary sclerosing cholangitis has not been described in Arab children. METHODS To describe detailed clinical, laboratory, histologic and radiological features in 4 children with primary sclerosing cholangitis identified over a 2-year period at a tertiary referral center in Riyadh Saudi Arabia. RESULTS Four children, all females, between the ages of 4 and 11 years with primary sclerosing cholangitis are identified. The diagnosis was suggested by the histology and confirmed by the characteristic cholangiographic findings. Clinical findings were itching in all 4 children, hepatomegaly in 3 and splenomegaly in 4 patients. Three of 4 patients had portal hypertension and 2 of these three variceal hemorrhage. Antinuclear and smooth muscle antibodies were negative in all four patients. None had clinical manifestations of chronic inflammatory bowel disease but microscopic colitis was documented in all 4 patients. CONCLUSIONS Primary sclerosing cholangitis is present in Arab children with a prevalence rate of 5% in our study population.
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Affiliation(s)
- A F Kagalwalla
- Department of Pediatrics, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia
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Abstract
Progressive familial intrahepatic cholestasis (PFIC or Byler disease) is a rare autosomal recessive form of severe and fatal cholestatic liver disease. A locus for PFIC has recently been mapped to chromosome 18q21-q22 in the original Byler pedigree. This region harbours the locus for a related phenotype, benign recurrent intrahepatic cholestasis (BRIC), suggesting that these traits are allelic. Linkage analysis was undertaken in five consanguineous PFIC pedigrees from Saudi Arabia using marker loci (D18S69, D18S41, D18S64, D18S38, D18S42, D18S55, D18S68, and D18S61) which span the Byler disease/BRIC region on 18q21-q22. In this family set the disease locus was excluded from this region, showing that locus heterogeneity exists for the PFIC phenotype.
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Affiliation(s)
- S S Strautnieks
- Department of Paediatrics, University College London Medical School, Rayne Institute, UK
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Kagalwalla AF, Al Amir AR, Khalifa A, Sylven M, Al Ajaji S, Kagalwalla YA. Progressive familial intrahepatic cholestasis (Byler's disease) in Arab children. Ann Trop Paediatr 1995; 15:321-7. [PMID: 8687210 DOI: 10.1080/02724936.1995.11747792] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The clinical, biochemical and histological characteristics in six Arab children with progressive familial intrahepatic cholestasis (PFIC) (Byler's disease) are described. The autosomal recessive mode of inheritance is established. Jaundice and pruritus were early symptoms, with onset in the 1st 3 months in all patients. Other features included growth failure, developmental delay, ataxia, areflexia, gall-stones and epistaxis. Gamma-glutamyl-transpeptidase and cholesterol were normal, but total bile acid levels were uniformly elevated in all patients. Histology showed features of hepato-canalicular cholestasis, lack of bile duct proliferation and fibrosis or cirrhosis in all patients. Five patients who were followed up were alive at a mean age of 75.8 months.
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Affiliation(s)
- A F Kagalwalla
- Department of Pediatrics, King Fahad National Guard Hospital, Riyadh, Saudi Arabia
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Abstract
We describe an Arab girl with complete absence of phosphorylase b kinase activity in the liver, symptomatic hypoglycemia, and persistently elevated serum aminotransferase values whose symptoms did not lessen with age; sequential liver biopsies showed progression to cirrhosis. Cirrhosis could not be ascribed to any other known cause. We conclude that type IX glycogenosis is not always associated with a benign outcome.
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Affiliation(s)
- A F Kagalwalla
- Department of Pediatrics, King Fahad National Guard Hospital, Riyadh, Saudi Arabia
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Affiliation(s)
- A F Kagalwalla
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, King Fahad National Guard Hospital, and Division of Pediatrics Gastroenterology, Department of Pediatrics, King Khalid University Hospital, Riyadh, Saudi Arabia
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Abstract
Congenital chloride diarrhea (CCD) is a common metabolic disorder in Saudi children with an incidence of 1 in 5,500. The present retrospective study from Saudi Arabia, over 7.5 years, presents the clinical, biochemical, and treatment details in 10 children with CCD. The perinatal characteristics of maternal polyhydramnios, prematurity, abdominal distention, and diarrhea were seen in 100% and hyperbilirubinemia in 90% of patients. Hypokalemic hypochloremic metabolic alkalosis was a feature in 50% of the children and acidosis in both neonates. Fecal chloride greater than 100 mmol/L in 100% and fecal chloride greater than the sum of fecal sodium and potassium were found in 55% of patients. The mean age at the time of diagnosis was 10 months and the mean duration of follow-up for the group was 38 months (range 2-89 months). Eight of the nine patients treated with continuous oral electrolyte solution demonstrated "catch-up" physical growth. Mental subnormality, growth retardation, and renal impairment were seen in one patient who failed to comply with the treatment. Cerebral palsy in another child was due to neonatal intraventricular hemorrhage.
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Affiliation(s)
- A F Kagalwalla
- Department of Pediatrics, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia
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Abstract
Extrahepatic manifestations have been reported in a majority of patients with ACAH. We describe an 11-year-old girl with CAH who developed life-threatening AH and was successfully managed with mechanical ventilation and high-dose steroids. Although a number of pulmonary manifestations have been described in association with AICAH, this article is the first showing its association with AH.
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Affiliation(s)
- A F Kagalwalla
- Department of Pediatrics, King Fahad National Guard Hospital, Riyadh, Saudi Arabia
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Abstract
In this study 234 children with shigellosis were evaluated during a 6-year period. The ages ranged from 2 days to 13 years (mean, 3.4 years). Sixty percent of the children were in the 1- to 4-year age group. One hundred four children were hospitalized and 130 were outpatients. Most cases of shigellosis presented during the months of April-May and September-November. Shigella flexneri accounted for 44% and Shigella sonnei for 43% of the isolates. Susceptibility testing showed that 54% were resistant to ampicillin, 72% to trimethoprim-sulfamethoxazole and 77% to tetracycline. Eighty percent were resistant to two or more antimicrobial agents. Morbidity and mortality was higher in children who were initially treated with antimicrobials to which the organism was resistant than in those treated with antimicrobial agent to which the organism was susceptible.
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Affiliation(s)
- A F Kagalwalla
- Department of Pediatrics, King Fahad National Guard Hospital, Riyadh, Saudi Arabia
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