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Shaheen NJ, Mukkada V, Eichinger CS, Schofield H, Todorova L, Falk GW. Natural history of eosinophilic esophagitis: a systematic review of epidemiology and disease course. Dis Esophagus 2018; 31:4958126. [PMID: 29617744 PMCID: PMC6102800 DOI: 10.1093/dote/doy015] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/03/2018] [Indexed: 12/14/2022]
Abstract
Eosinophilic esophagitis is a chronic immune-mediated esophageal disorder. For its timely diagnosis, clinicians must recognize common symptoms, and understand differences in symptoms across patient groups. The aim of this study is to systematically review the epidemiology and natural history of eosinophilic esophagitis. The MEDLINE, Embase, and Cochrane databases were searched from 1974 to February 2017 for studies describing the epidemiology and natural history of eosinophilic esophagitis. Congress abstracts from 2014 to 2016 were also searched. Search results were screened against predetermined inclusion/exclusion criteria by two independent reviewers, and data extraction was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 1376 articles identified, 47 met the inclusion criteria: 20 on epidemiology and 27 on natural history. Incidence and prevalence of eosinophilic esophagitis varied widely across North America and Europe, and increased over time. Incidence increased 131-fold in the Netherlands (1996-2010), 20-fold in Denmark (1997-2006), and 5.1-fold in Calgary, Canada (2004-2008). The most commonly reported symptoms were emesis and abdominal pain in children, and dysphagia and food impaction in adults. Age at diagnosis was 5.9-12.0 years in children, and approximately 30 years in adults. Time between symptom onset and diagnosis was 1.2-3.5 years in children and 3.0-8.0 years in adults. Diagnostic delay was associated with an increased risk of endoscopic features of fibrostenosis. Symptoms of eosinophilic esophagitis differed significantly by age and race. In conclusion, there is an increasing incidence and prevalence of eosinophilic esophagitis. The considerable delay between symptom onset and diagnosis suggests that clinicians do not readily recognize the disease, which may have important clinical ramifications.
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Affiliation(s)
- N J Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina,Address correspondence to: Nicholas J. Shaheen, MD, MPH, Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, CB#7080, 130 Mason Farm Road, Suite 4150, Chapel Hill, NC 27599-7080, USA.
| | - V Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | | | - G W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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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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Protheroe C, Woodruff SA, DePetris G, Mukkada V, Ochkur SI, Janarthanan S, Lewis JC, Pasha S, Lunsford T, Harris L, Sharma VK, McGarry MP, Lee NA, Furuta GT, Lee JJ. A novel histologic scoring system to evaluate mucosal biopsies from patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2009; 7:749-755.e11. [PMID: 19345285 PMCID: PMC2706311 DOI: 10.1016/j.cgh.2009.03.022] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [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: 10/31/2008] [Revised: 03/02/2009] [Accepted: 03/22/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) is characterized by medically/surgically-resistant gastroesophageal reflux symptoms and dense squamous eosinophilia. Studies suggest that histologic assessment of esophageal eosinophilia alone cannot reliably separate patients with EoE from those with gastroesophageal reflux disease (GERD). Our goal was to develop an assay to identify EoE patients and perhaps differentiate EoE from other causes of esophageal eosinophilia. METHODS A monoclonal antibody specific for an eosinophil secondary granule protein (eosinophil peroxidase [EPX]) was developed and shown to specifically identify intact eosinophils and detect eosinophil degranulation in formalin-fixed specimens. A histopathologic scoring algorithm was developed to analyze data from patient evaluations; the utility of this algorithm was assessed by using archived esophageal tissues from patients with known diagnoses of EoE and GERD as well as controls from 2 tertiary care centers. RESULTS Intraobserver/interobserver blinded evaluations demonstrated a significant difference (P < .001) between scores of samples taken from control subjects, from patients with esophageal eosinophilia who had a diagnosis of EoE, and from patients with GERD (P < .001). This algorithm also was able to identify patients whose clinical course was suggestive of a diagnosis of EoE, but that nonetheless failed to reach the critical threshold number of > or =15 eosinophils in a high-power (40x) microscopy field. CONCLUSIONS A novel immunohistochemical scoring system was developed to address an unmet medical need to differentiate histologic specimens from patients with EoE relative to those with GERD. The availability of a unique anti-EPX-specific monoclonal antibody, combined with the ease/rapidity of this staining method and scoring system, will provide a valuable strategy for the assessment of esophageal eosinophilia.
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Affiliation(s)
- Cheryl Protheroe
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ 85259, Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Samantha A. Woodruff
- Section of Pediatric Gastroenterology, Hepatology and Nutrition; Gastrointestinal Eosinophilic Diseases Program, The Children’s Hospital, Denver, University of Colorado Denver, School of Medicine, Aurora, CO 80045
| | - Giovanni DePetris
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Vince Mukkada
- Section of Pediatric Gastroenterology, Hepatology and Nutrition; Gastrointestinal Eosinophilic Diseases Program, The Children’s Hospital, Denver, University of Colorado Denver, School of Medicine, Aurora, CO 80045
| | - Sergei I Ochkur
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Sailajah Janarthanan
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - John C. Lewis
- Division of Allergy, Department of Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Shabana Pasha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Tisha Lunsford
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Lucinda Harris
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Virender K. Sharma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Michael P. McGarry
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Nancy A. Lee
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ 85259
| | - Glenn T. Furuta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition; Gastrointestinal Eosinophilic Diseases Program, The Children’s Hospital, Denver, University of Colorado Denver, School of Medicine, Aurora, CO 80045
| | - James J. Lee
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ 85259,Corresponding Author: James J. Lee, Ph.D., Consultant, Associate Professor, Department of Biochemistry and Molecular Biology, Director of Special Animal Services Laboratory, Postal Address: Division of Pulmonary Medicine, SCJMRB-RESEARCH, Mayo Clinic Arizona, 13400 E. Shea Blvd., Scottsdale, AZ 85259, Telephone number: (480) 301-7183, FAX Number: (480) 301-7017, Email Address:
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