Budesonide Oral Suspension Improves Symptomatic, Endoscopic, and Histologic Parameters Compared With Placebo in Patients With Eosinophilic Esophagitis

BACKGROUND & AIMS

Pharmacologic treatment of eosinophilic esophagitis (EoE) is limited to off-label use of corticosteroids not optimized for esophageal delivery. We performed a randomized, controlled phase 2 trial to assess the ability of budesonide oral suspension (BOS), a novel muco-adherent topical steroid formulation, to reduce symptoms and esophageal eosinophilia in adolescents and adults with EoE.

METHODS

In this multicenter, randomized, double-blind, placebo-controlled, parallel-group trial, 93 EoE patients between the ages of 11 and 40 years with dysphagia and active esophageal eosinophilia were randomized to receive either BOS 2 mg or placebo twice daily for 12 weeks. Co-primary outcomes were change in Dysphagia Symptom Questionnaire (DSQ) score from baseline, and proportion of patients with a histologic response (≤6 eosinophils/high-power field) after treatment. Endoscopic severity scores and safety parameters were assessed.

RESULTS

At baseline, mean DSQ scores were 29.3 and 29.0, and mean peak eosinophil counts were 156 and 130 per hpf in the BOS and placebo groups, respectively. After treatment, DSQ scores were 15.0 and 21.5, and mean peak eosinophil counts were 39 and 113 per high-power field, respectively (P < .05 for all). For BOS vs placebo, change in DSQ score was -14.3 vs -7.5 (P = .0096), histologic response rates were 39% vs 3% (P < .0001), and change in endoscopic severity score was -3.8 vs 0.4 (P < .0001). Adverse events were similar between groups.

CONCLUSIONS

Treatment with BOS was well tolerated in adolescent and young adult patients with EoE and resulted in improvement in symptomatic, endoscopic, and histologic parameters using validated outcome instruments. ClinicalTrials.gov ID NCT01642212.

Esophageal perforation: An uncommon initial manifestation of eosinophilic esophagitis

EoE-Perforation: Eosinophilic esophagitis (EoE) is commonly observed in children and young adults. Common manifestations of EoE include dysphagia and food impaction in adolescents and adults, whereas children present with failure to thrive, regurgitation, or heartburn and abdominal pain. We describe two patients presenting with esophageal perforation and EoE. Diagnosing perforation promptly is critical to minimize and/or to avoid the multitude of complications resulting from esophageal perforation and to treat EoE because if left untreated, this condition may result in the recurrence of perforation, major morbidity, or rarely death.

Prevalence of gastroesophageal reflux symptoms in adolescents: is there a difference in different racial and ethnic groups?

The study aims to determine if differences exist among racial/ethnic groups in the prevalence of gastroesophageal reflux symptoms in adolescents. A cross-sectional questionnaire was administered to a sample of students in four racially and ethnically diverse high schools in suburban Chicago. A total of 2561 questionnaires were analyzed: 33% Hispanics, 30% Caucasians, 22% African Americans, 15% Asians, 54% female, mean age 15.8 (±1.3) years. Thirty-two percent had at least one esophageal and/or respiratory symptom ≥once a week. Caucasians and African Americans had more dysphagia than Hispanics and Asians (7% vs. 4%; P= 0.04). Hispanics had more heartburn (13% vs. 9-11%; P= 0.06) but this was not statistically significant. There was no difference for regurgitation. Hispanic females had more dysphagia (6% vs. 3%; P= 0.02) and heartburn (17% vs. 9%; P= 0.0003) than Hispanic males. African Americans and Caucasians had more respiratory symptoms than Hispanics and Asians (29%, 24% vs. 18%; P= 0.000004). Students with esophageal symptoms were more likely to have respiratory symptoms (46% vs. 17%; P < 0.0005). African Americans and Caucasians with esophageal symptoms had more respiratory symptoms than Hispanics and Asians with esophageal symptoms (55%, 49% vs. 42%, 34%; P= 0.0003). Asians and Hispanics were less likely to treat symptoms than African Americans and Caucasians (26%, 33% vs. 47%, 49%; P= 0.001). We found that differences exist among the racial/ethnic groups with esophageal and respiratory symptoms; esophageal symptoms are a risk factor for respiratory symptoms, and Asians and Hispanics seek less medical help. Future research should focus on whether the differences found continue and reasons for them.

Prescribing proton-pump inhibitors to irritable infants: where is the evidence?

Infants with gastroesophageal reflux present with multiple symptoms, including irritability. When a physician is evaluating such an irritable infant, she/he would often prescribe a histamine 2 receptor antagonist blocker. When this fails, proton-pump inhibitors (PPIs) are often prescribed. Evidence demonstrates that there has been a fourfold increase in the use of PPIs, which may be prescribed in children as young as 2 weeks of age. This article addresses multiple issues: variable pharmacokinetics, risk of infection, absence of an adequate oral preparation, and lack of clear evidence to support the efficacy of PPIs in irritable infants. Extreme caution should be used in prescribing PPIs to this vulnerable age group, particularly those less than 6 months of age. Until more data are available, we suggest that PPIs should be used only in infants with well-documented gastroesophageal reflux disease or as part of a clinical trial.

Bannayan-Riley-Ruvalcaba syndrome: spectrum of intestinal pathology including juvenile polyps

Bannayan-Riley-Ruvalcaba syndrome (BRRS) is a disorder that includes juvenile polyposis as part of its pathologic spectrum, and it recently has been shown to share phenotypic and genotypic features with Cowden's disease. In existing literature, descriptions of intestinal pathology in patients with BRRS are relatively sparse and occasionally erroneous. We describe the intestinal pathology in multiple specimens from three children with BRRS. Examination of gastrointestinal biopsies from these children revealed predominantly colonic and rectal polyps with the histology of juvenile polyps. Additionally, two cases with clusters of ectopic ganglion cells within the lamina propria, one in a colonic polyp and one in a duodenal biopsy, and an atypical polyp were observed. Bannayan-Riley-Ruvalcaba syndrome should be included in the list of differential diagnostic considerations when a child or young adult presents with a juvenile polyp, particularly if unusual histologic features such as atypical polyps or ectopic ganglion cells are encountered.

Duodenojejunitis: is it idiopathic or is it Henoch-Schönlein purpura without the purpura?

BACKGROUND

Henoch-Schönlein purpura is a small-vessel vasculitic disease that most often affects the skin. Gastrointestinal manifestations have been well described, including duodenojejunal inflammation (DJI).

METHODS

Four children with DJI and clinical features of HSP are described, in whom the rash was either not present or appeared atypically late in the illness.

RESULTS

The characteristic rash did not develop in three children, and it developed much later in one. The patients (three boys and one girl) were aged between 7 and 9 years (mean, 7.5 years). Growth characteristics were normal. In all patients, pain occurred acutely with colicky abdominal pain in the spring or fall of the year, and all stools were positive for occult blood. No infectious cause was identified. Upper gastrointestinal endoscopic examinations demonstrated significant visual and histologic duodenitis in a pattern consistent with previous reports in children with known HSP. Factor XIII activity was absent. Immunoglobulin A levels were increased in three of four children. All children made a prompt recovery with the administration of intravenous glucocorticoids. In one child, the characteristic rash of HSP developed 18 weeks after the initial examination.

CONCLUSION

Duodenojejunal inflammation may be the primary manifestation of HSP, even in the absence of the characteristic rash.

Recurrent gastrointestinal Henoch-Schönlein purpura

A 7-year-old boy was seen for severe abdominal pain, vomiting, and a 2.0-kg weight loss of 2 weeks duration. Stools were Hemoccult positive. Upper gastrointestinal (UGI) endoscopy showed multiple, raised red lesions in the duodenal bulb and descending duodenum. Although the patient did not have the typical cutaneous eruption, other findings such as acute onset of abdominal pain in a previously healthy boy, absence of infectious or surgical lesions, and more importantly endoscopic changes seen typically in the descending duodenum, led to the likely diagnosis of Henoch-Schönlein purpura (HSP). The patient was treated with prednisone and the duodenal lesions resolved. The diagnosis of HSP was confirmed 24 weeks after the initial symptom when he developed a palpable purpuric rash over both legs. Thirteen months following the initial symptoms and 6 months after the onset of rash, severe abdominal pain with epigastric tenderness recurred and stools were Hemoccult positive. UGI endoscopy showed multiple, raised red lesions in the descending duodenum as seen earlier. The patient was diagnosed with recurrent HSP. This presentation is atypical because of the abnormally long interval between the onset of abdominal pain and the appearance of the skin rash, and unique because of the endoscopically demonstrated recurrent gastrointestinal lesions.

Henoch-Schönlein purpura: what does the "rash" look like in the gastrointestinal mucosa?

Two patients are reported with Henoch-Schönlein purpura, one with the typical presenting sign of purpuric skin lesions, the other whose diagnosis was made on the basis of endoscopic examination in the absence of an initial cutaneous eruption.

Henoch-Schönlein purpura: a diagnosis not to be forgotten

Henoch-Schönlein purpura (HSP) is a systemic, generalized vasculitis of unknown etiology thought to be related to an IgA-mediated autoimmune phenomenon. Diagnosis is based on a constellation of physical findings that include the characteristic nonthrombocytopenic petechial or purpuric rash, migratory polyarthralgias, abdominal pain, and renal complications. We report the case of a 19-year-old man with a diagnosis of HSP who had severe abdominal pain and endoscopic documentation of duodenal involvement. Though not clear at presentation, the diagnosis became obvious when the characteristic rash emerged.

Efficacy and safety of omeprazole for severe gastroesophageal reflux in children

Omeprazole, a potent inhibitor of acid secretion, is effective in adults with severe gastroesophageal reflux, but no such data are available on children. We studied 15 children in whom treatment with histamine (type 2) blockers and prokinetic agents had failed; 4 had also had one or more fundoplications. Their ages were 0.8 to 17 years (mean, 8.1 years) and weights were 7.5 to 30.7 kg (mean, 18.6 kg). Of the 15 children, 8 were neurologically handicapped. All patients had endoscopic and histologic evidence of esophagitis; most had esophagitis grade 3 to 4. Patients were initially given omeprazole at 10 to 20 mg; the dose was titrated upward until results of a subsequent 24-hour intraesophageal pH study was normal. Symptoms and signs abated and evidence of esophagitis diminished in all patients. Omeprazole was given for periods of 5.5 to 26 months (mean, 12.2 months). The effective total dose was 20 to 40 mg (0.7 to 3.3 mg/kg) in 11 patients, 10 mg (0.7 mg/kg) in 1 patient, and 60 mg (1.9 to 2.4 mg/kg) in 3 patients. The dosage range was 0.7 to 3.3 to mg/kg per day (mean, 1.9 mg/kg). Mildly elevated transaminase values in 7 patients and elevated fasting gastrin levels in 11 patients were present; in 6 of the 11, gastrin levels were 3 to 5.5 times the upper limit of normal. We found omeprazole to be highly effective in this group of patients with severe esophagitis refractory to other measures. We recommend a starting dose of 0.7 mg/kg as a single morning dose; the adequacy of reflux control is then determined by follow-up 24-hour intraesophageal pH studies. Omeprazole appears to be safe for short-term use, but further studies are needed to assess long-term safety because the significance of chronically elevated gastrin levels in children is unknown.

Magnetic resonance imaging of the brain in Wilson's disease

Eight patients with Wilson's disease (WD) were studied by magnetic resonance imaging (MRI) of the brain; seven also underwent X-ray computed tomography (CT) of the brain. We describe the changes in the brain and try to correlate them with the clinical manifestations and progress of the disease. Six patients were symptomatic, with predominantly neurological problems. Two were asymptomatic, diagnosed upon screening siblings of index cases. Of the six symptomatic patients, five had basal ganglia lesions, combined in four with brain stem changes; in one with only brain stem abnormalities, clinical findings were minimal despite pronounced MRI changes. In three patients MRI abnormalities regressed following chelating therapy. MRI can contribute to documentation of early neurological involvement in WD, especially in patients with no abnormalities on CT. However, MRI changes may not correlate with clinical presentation or response to therapy.

Recurrence of extrahepatic biliary atresia in two half sibs

Extrahepatic biliary atresia (EHBA) usually is a sporadic disorder. Familial cases, including occurrence in sibs and twins, have been reported. We report the first recurrence of EHBA in two half sibs born to a common father and unrelated mothers and suggest the possibility of gonadal mosaicism for a new dominant mutation.

Giardiasis mimicking inflammatory bowel disease

An adolescent had marked systemic features suggestive of inflammatory bowel disease. Giardia lamblia trophozoites were present in endoscopic biopsy specimens from the terminal ileum and from the duodenum. His illness rapidly and completely resolved after metronidazole therapy. Giardiasis must be included in the differential diagnosis of inflammatory bowel disease in children.

Concurrence of Robinow syndrome and Crigler-Najar syndrome in two offspring of first cousins

Robinow syndrome and Crigler-Najar syndrome were encountered in 2 Saudi offspring of first cousins. Both died at age 4 months. The parents lost 2 previous children at age 2 months with progressive jaundice but without fetal facial characteristics.