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Pokrzywinski RM, Goodwin B, Dellon ES, Kodroff E, Brooks A, Bailey A, Williams J, Desai NK. Qualitative assessment of the suitability of the Dysphagia Symptom Questionnaire to monitor dysphagia in children aged 7-10 years with eosinophilic esophagitis. J Patient Rep Outcomes 2023; 7:110. [PMID: 37906323 PMCID: PMC10618132 DOI: 10.1186/s41687-023-00646-z] [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] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 10/10/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND The Dysphagia Symptom Questionnaire (DSQ) is a patient-reported outcome measure that assesses the frequency and severity of dysphagia in patients with eosinophilic esophagitis (EoE); however, it has only been validated for use in patients with EoE aged 11-40 years. This study examined the content validity of the DSQ and its usability on an electronic handheld device in children aged 7-10 years with EoE. METHODS In this qualitative, observational cohort study, participants were recruited to partake in two rounds of interviews. During visit 1, a cognitive interview examined EoE-associated concepts and the appropriateness of the DSQ for assessing dysphagia. Participants completed the DSQ daily for 2 weeks, and DSQ scores were calculated. After 2 weeks, a second interview assessed the usability of the DSQ on the electronic device and the burden associated with completing it daily. RESULTS Overall, 16 participants were included (aged 7-8 years: n = 8; aged 9-10 years: n = 8); most were male (75%) and white (81%), and the mean (standard deviation [SD]) age was 8.4 (1.3) years. The most commonly reported EoE-associated concept was 'trouble with swallowing' (63% [10/16]). Most participants reported that the questions were 'easy to complete' and 'relevant to someone with EoE and dysphagia'. Overall, participants reported understanding the questions and associated responses; however, further probing demonstrated inconsistent comprehension. Key challenging concepts included 'solid food', 'trouble swallowing', 'vomit', and 'relief'; some participants also reported difficulty differentiating between pain levels (31% [4/13]). Most caregivers reported that their child had experienced dysphagia (94% [15/16]); however, mean (SD) DSQ scores over the study period were low (7.3 [7.4]), suggesting infrequent and mild dysphagia, or a lack of comprehension of the questions. Most participants reported that completing the DSQ on the electronic device was easy (93% [14/15]) and they would be willing to complete it for longer than 2 weeks (73% [11/15]). CONCLUSIONS Difficulties with comprehension and comprehensiveness suggest that the DSQ may not be sufficiently comprehensive for use in all patients in this population, and wording/phrasing changes are required before use in a clinical trial setting.
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Grants
- This study was funded by Shire Human Genetic Therapies Inc., a member of the Takeda Group of companies
- Medical writing support was provided by Iona MacKillop, MSc, Natasha Molle, MSc, and Tsvetana Stoilova, PhD, of PharmaGenesis London, London, UK, and funded by Takeda Pharmaceuticals USA, Inc.
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Affiliation(s)
| | | | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ellyn Kodroff
- Campaign Urging Research for Eosinophilic Disease, Lincolnshire, IL, USA
| | - Anne Brooks
- Evidera, 7101 Wisconsin Ave #1400, Bethesda, MD, 20814, USA
| | - Adam Bailey
- Evidera, 7101 Wisconsin Ave #1400, Bethesda, MD, 20814, USA
| | - James Williams
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Nirav K Desai
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
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Hida E, Muroi K, Kakushima N, Furune S, Ishikawa E, Mizutani Y, Sawada T, Keiko M, Yamamura T, Ishikawa T, Furukawa K, Ohno E, Nakamura M, Nishida K, Fujishiro M, Kawashima H. Diagnostic Performance of Endocytoscopy for Esophageal Eosinophilia. Digestion 2023:1-10. [PMID: 36603569 DOI: 10.1159/000528174] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/11/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Eosinophils in the esophageal epithelium are unevenly distributed in eosinophilic esophagitis (EoE). Esophageal eosinophilia (EE) may be observable by endocytoscopy (EC). This study aimed to evaluate the diagnostic performance of EC for the diagnosis of EE. METHODS A total of 33 EoE patients underwent EC with methylene blue staining from March 2020 to April 2021. A total of 194 EC images with corresponding biopsies were obtained. Three findings of EC, increased squamous cells (item I), increased inflammatory cells (item II), and cells with bilobed nuclei (item III), were established. These findings were reviewed by two endoscopists to diagnose EE. Another four endoscopists reviewed the images for interobserver agreement. RESULTS When all three items were met by EC, the sensitivity and the accuracy for the diagnosis of EE were 88% and 76%, respectively. The integrated diagnostic odds ratios (ORs) for the diagnosis of EE of the four endoscopists were significant (OR: 3.98, 95% CI: 2.94-5.40, p < 0.001). The results were similar when only item III was met. Interobserver agreement was good for item III to diagnose EE (kappa value = 0.653). DISCUSSION/CONCLUSION The diagnostic performance of EC for EE is acceptable and has good interobserver agreement. It may be useful for targeted biopsy in EoE patients.
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Affiliation(s)
- Emiko Hida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan,
| | - Koichi Muroi
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoshi Furune
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsunaki Sawada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Maeda Keiko
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuki Nishida
- Biostatistics and Bioinformatics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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3
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Abstract
The prevalence of eosinophilic esophagitis (EoE) has been increasing in Japan. Although the diagnosis of EoE is based on simple criteria that include the presence of esophageal symptoms and esophageal eosinophilia on biopsies, there are several important issues associated with the diagnostic approach. Following an extensive literature search, the symptoms of 886 EoE cases in Japanese adults were analyzed and divided into three categories as follows: (1) typical symptoms, such as dysphagia (53%); (2) other upper GI symptoms (40%); and (3) no symptoms found during screening or medical examination, i.e., "asymptomatic esophageal eosinophilia" (19%). The diagnostic approach was reviewed according to these categories as well as according to the presence or absence of esophageal eosinophilia. The present manuscript describes the current therapeutic strategy of EoE and ultimately proposes a symptom-based diagnostic approach for EoE.
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Affiliation(s)
- Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan.
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4
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Tambucci R, Rea F, Angelino G, Malamisura M, Mennini M, Riccardi C, Farello G, Valfré L, Dall’Oglio L, Markowitz JE, Fiocchi AG, De Angelis P. Eosinophilic esophagitis in esophageal atresia: Tertiary care experience of a "selective" approach for biopsy sampling. World Allergy Organ J 2020; 13:100116. [PMID: 32256942 PMCID: PMC7132091 DOI: 10.1016/j.waojou.2020.100116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND A high prevalence (9.5-30%) of eosinophilic esophagitis (EoE) in patients with esophageal atresia (EA) has been reported. The application of the EoE criteria to EA patients might be problematic. To date, only studies using a "routine" biopsy approach, even in asymptomatic patients, have been performed. The aim of the study was to establish the prevalence of EoE among symptomatic EA patients (EA/EoE group) without anastomotic stricture (AS) and to compare their characteristics with those of EoE patients from general population (EoE group). METHODS From 2005 to 2018, we reviewed charts of children with EA and EoE. "Selective" biopsy approach only in EA children without AS and/or endoscopic feature of EoE was performed. Characteristics of EA/EoE and EoE groups were compared. RESULTS Among 370 EA and 118 EoE, 15 EA/EoE patients were detected (4.0% of EA patients). Male predominance and a high prevalence of allergy without differences between EA/EoE and EoE groups was observed. EA/EoE children were significantly younger (p < 0.0001). PPI-responder patients were significantly more prevalent in EA/EoE group (p = 0.045). CONCLUSION Our data confirm that EA patients are at high risk for developing EoE. High incidence, early onset, and high prevalence of PPI-responders might suggest that esophageal motility disorders interact to increase propensity to EoE in EA patients. However, our study also suggests that overdiagnosis of EoE may occur in EA and that adapted criteria for EoE diagnosis should be developed for EA patients. TRIAL REGISTRATION Not applicable for this retrospective study.
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Affiliation(s)
- Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Corresponding author. Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant’Onofrio 4, 00165, Rome, Italy.
| | - Francesca Rea
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Giulia Angelino
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Monica Malamisura
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Maurizio Mennini
- Pediatric Allergology Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Carla Riccardi
- Pediatric Allergology Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Giovanni Farello
- Pediatric Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Laura Valfré
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Luigi Dall’Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Jonathan E. Markowitz
- Pediatric Gastroenterology, Greenville Health System, University of South Carolina School of Medicine-Greenville, Clemson University School of Health Research, Greenville, SC, USA
| | | | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
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5
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Ferreira CT, Vieira MC, Furuta GT, Barros FCLFD, Chehade M. Eosinophilic esophagitis-Where are we today? J Pediatr (Rio J) 2019; 95:275-281. [PMID: 30075121 DOI: 10.1016/j.jped.2018.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 06/04/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The objective of this review is to provide an overview of the practical diagnostic and therapeutic approaches to eosinophilic esophagitis and to increase the visibility of the disease among pediatricians. SOURCES A search of the MEDLINE, Embase, and CINAHL databases and recent consensus statements and guidelines were performed. SUMMARY OF THE FINDINGS The definition of eosinophilic esophagitis is based on symptoms and histology. It is important to rule out other diseases associated with esophageal eosinophil-predominant inflammation. It is not yet clear whether the increased prevalence is due to a real increase in incidence or a result of increased awareness of the disease. Various options for management have been used in pediatric patients, including proton pump inhibitors, dietary restriction therapies, swallowed topical steroids, and endoscopic dilations. More recently, proton pump inhibitor-responsive esophageal eosinophilia and eosinophilic esophagitis have been contemplated on the same spectrum, and proton pump inhibitors should be considered the initial step in the treatment of these patients. CONCLUSIONS Eosinophilic esophagitis is a relatively new disease with a remarkable progression of its incidence and prevalence in the past two to three decades, and diagnostic criteria that are constantly evolving. It is important to better understand the pathogenesis of the disease, the predisposing factors, the natural history, and the categorization of varying phenotypes to develop diagnostic and therapeutic strategies that meet the clinical needs of patients.
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Affiliation(s)
- Cristina Targa Ferreira
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Pediatria, Porto Alegre, RS, Brazil; Hospital Santo Antonio, Porto Alegre, RS, Brazil.
| | - Mario Cesar Vieira
- Pontifícia Universidade Católica do Paraná (PUC-PR), Departamento de Pediatria, Curitiba, PR, Brazil; Hospital Pequeno Príncipe, Centro de Gastroenterologia Pediátrica, Curitiba, PR, Brazil
| | - Glenn T Furuta
- Children's Hospital Colorado, Hepatology and Nutrition, Digestive Health Institute, Aurora, United States; University of Colorado School of Medicine, Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Aurora, United States
| | | | - Mirna Chehade
- Icahn School of Medicine at Mount Sinai, Mount Sinai Center for Eosinophilic Disorders, New York, United States
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6
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García-Compeán D, González-González JA, González-Moreno EI, Maldonado-Garza HJ. Eosinophilic esophagitis. The North against the South? A bio-economic-social mechanistic approach and clinical implications. Rev Gastroenterol Mex 2017; 82:328-336. [PMID: 28676192 DOI: 10.1016/j.rgmx.2017.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 01/17/2017] [Accepted: 02/09/2017] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis is a chronic antigen-mediated disease characterized by esophageal symptoms, esophageal eosinophilia, and the absence of response to proton pump inhibitors. It is the most frequent cause of dysphagia and food impaction in adults. Its incidence and prevalence is very high in the developed countries (USA, Europe, Australia), where its connotation is that of an emerging epidemic. While studies have been published with large case series in the developed countries, those published in Latin America are small or consist of isolated case reports. The differences in the prevalence of the disease between the developed and developing regions are unknown. Genetic or racial causes have been cited. Nevertheless, the epidemic nature of the disease suggests that environmental causes are the most powerful. Based on the published hypotheses, as well as on epidemiologic studies, the present review discusses some of the possible causes of the disparity in the prevalence of eosinophilic esophagitis between the two types of countries. The 'hygiene hypothesis' is reviewed, together with the possible relation of Helicobacter pylori, intestinal parasites, and modifications of the esophageal microbiota in patients with eosinophilic esophagitis. In reference to studies conducted in the United States, the clinical behavior and progression of eosinophilic esophagitis in Hispanics is reviewed and a possible predominant phenotype in Mexican and other Latin American patients is discussed. Finally, based on the above, an algorithm for studying the disease in the Latin American countries is proposed.
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Affiliation(s)
- D García-Compeán
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario y Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, México.
| | - J A González-González
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario y Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, México
| | - E I González-Moreno
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario y Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, México
| | - H J Maldonado-Garza
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario y Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, México
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7
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Abstract
Eosinophilic esophagitis is a worldwide chronic allergic disease of the esophagus. In the last decade, there is an epidemic of this entity in the western world. Mostly seen in children and young adults, patients present with dysphagia or food impaction in the emergency room. Characteristic endoscopic findings, esophageal eosinophilia and non-responsiveness to proton pump inhibitors help make the diagnosis. Avoidance of food allergens, administration of steroidal anti-inflammatory medications and dilation of the esophagus are the mainstays of treatment. Investigations are ongoing for mucosal healing and optimum maintenance treatment.
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8
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Abstract
Eosinophilic esophagitis (EoE) is an increasingly recognized immune antigen-mediated esophageal disease found in both children and adults. It is defined as a clinicopathologic disease characterized by symptoms of esophageal dysfunction accompanied by an eosinophil-predominant esophageal inflammation that occurs in the absence of other causes of esophageal eosinophilia. Classic symptoms in adults include dysphagia to solids and food bolus impaction but a variety of other symptoms are also encountered. Despite the increasing awareness of EoE among practicing physicians, a long delay from onset of symptoms to diagnosis remains a problem in this disease.
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9
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Müller M, Eckardt AJ, Fisseler-Eckhoff A, Haas S, Gockel I, Wehrmann T. Endoscopic findings in patients with Schatzki rings: Evidence for an association with eosinophilic esophagitis. World J Gastroenterol 2012; 18:6960-6. [PMID: 23322994 PMCID: PMC3531680 DOI: 10.3748/wjg.v18.i47.6960] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 09/28/2012] [Accepted: 10/22/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate endoscopic findings in patients with Schatzki rings (SRs) with a focus on evidence for eosinophilic esophagitis (EoE).
METHODS: We consecutively approached all adult patients scheduled for elective outpatient upper endoscopy for a variety of indications at the German Diagnostic Clinic, Wiesbaden, Germany between July 2007 and July 2010. All patients with endoscopically diagnosed SRs, defined as thin, symmetrical, mucosal structures located at the esophagogastric junction, were prospectively registered. Additional endoscopic findings, clinical information and histopathological findings with a focus on esophageal eosinophilia (≥ 20 eosinophils/high power field) were recorded. The criteria for active EoE were defined as: (1) eosinophilic tissue infiltration ≥ 20 eosinophils/hpf; (2) symptoms of esophageal dysfunction; and (3) exclusion of other causes of esophageal eosinophilia. Gastroesophageal reflux disease was excluded by proton pump inhibitor treatment prior to endoscopy. The presence of ≥ 20 eosinophils/hpf in esophageal biopsies in patients that did not fulfil the criteria of EoE was defined as esophageal hypereosinophilia.
RESULTS: A SR was diagnosed in 171 (3.3%; 128 males, 43 females, mean age 66 ± 12.9 years) of the 5163 patients that underwent upper gastrointestinal-endoscopy. Twenty of the 116 patients (17%) from whom esophageal biopsies were obtained showed histological hypereosinophilia (≥ 20 eosinophils/hpf). Nine of these patients (8 males, 1 female, mean age 49 ± 10 years) did not fulfill all diagnostic criteria of EoE, whereas in 11 (9%) patients with ≥ 20 eosinophils/hpf, a definite diagnosis of EoE was made. Three of the 11 patients (27%) with definite EoE had no suspicious endoscopic features of EoE. In contrast, in the 25 patients in whom EoE was suspected by endoscopic features, EoE was only confirmed in 7 (28%) patients. Patients with EoE were younger (mean age 41.5 ± 6.5 vs 50.5 ± 11.5 years, P = 0.012), were more likely to have a history of allergies (73% vs 29%, P = 0.007) and complained more often of dysphagia (91% vs 34%, P = 0.004) and food impaction (36% vs 6%, P = 0.007) than patients without EoE. Endoscopically, additional webs were found significantly more often in patients with EoE than in patients without EoE (36% vs 11%, P = 0.04). Furthermore, the SR had a tendency to be narrower in patients with EoE than in those without EoE (36% vs 18%, P = 0.22). The percentage of males (73% vs 72%, P = 1.0) and frequency of heartburn (27% vs 27%, P = 1.0) were not significantly different in both groups. The 9 patients with esophageal hypereosinophilia that did not fulfil the diagnostic criteria of EoE were younger (mean age 49 ± 10 years vs 58 ± 6 years, P = 0.0008) and were more likely to have a history of allergies (78% vs 24%, P = 0.003) than patients with < 20 eosinophils/hpf. Predictors of EoE were younger age, presence of dysphagia or food impaction and a history of allergies.
CONCLUSION: A significant proportion of patients with SRs also have EoE, which may not always be suspected according to other endoscopic features.
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10
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Abstract
The presence of esophageal eosinophilia encompasses a broad differential diagnosis, and at times a specific histologic diagnosis is not possible. This content provides a systematic approach to esophageal squamous eosinophilia with emphasis on specific, distinguishing features within this expansive differential.
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Affiliation(s)
- Rebecca Wilcox
- Department of Pathology, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - John Hart
- Department of Pathology, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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