Reducing Eosinophil Counts in Eosinophilic Esophagitis in Children Is Associated With Reduction in Later Stricture Development

INTRODUCTION

There are limited longitudinal data on the impact of chronic therapy on the natural history of eosinophilic esophagitis (EoE), a chronic allergic disease of the esophagus. The purpose of this study was to evaluate if patients with well-controlled EoE were less likely to develop fibrostenotic complications.

METHODS

Subjects were identified from a database of pediatric patients with EoE at the Children's Hospital of Philadelphia started in 2000. Patients were then searched in adult medical records to identify patients who transitioned care. All office visits, emergency department visits, and endoscopic, histologic, and imaging reports were reviewed for the primary outcome of strictures and the secondary outcomes of food impactions and dysphagia. Cox proportional hazard regression was performed for outcomes.

RESULTS

One hundred five patients were identified with the mean follow-up of 11.4 ± 4.9 years. 52.3% (n = 55) had a period of histologic disease control defined as ≥2 consecutive endoscopies with histologic remission. These patients were less likely to develop strictures compared with patients who did not have a period of histologic control (HR 0.232; 95% CI 0.084-0.64, P = 0.005). Patients who were diagnosed at younger ages were less likely to develop strictures. Presentation with dysphagia or impaction was associated with higher rate of stricture development.

DISCUSSION

In this cohort study with > 10 years of follow-up, children with EoE with a period of histologic disease control and diagnosed at younger ages were less likely to develop esophageal strictures. While this suggests histologic remission is associated with reduction of remodeling complications, additional prospective data with long-term follow-up are needed.

Clinical Evaluation of the Child with Eosinophilic Esophagitis

The diagnosis of eosinophilic esophagitis (EoE) is based on clinical symptoms of esophageal dysfunction and eosinophil predominant esophageal inflammation. Clinical symptoms in children with EoE vary based on age and may be nonspecific. EoE has a male predominance with the majority having comorbid atopic disorders. At present, treatment options include medications (proton pump inhibition, swallowed topical steroids), dietary therapy or biologic therapy (dupilumab, approved for those ≥12 years of age). Outside of EoE in the context of oral immunotherapy, EoE is typically chronic requiring lifelong therapy. Long-term complications including feeding difficulties, malnutrition, and fibrostenotic disease.

Clinical guidance for the use of dupilumab in eosinophilic esophagitis: A yardstick

The Joint Task Force for the American Academy of Allergy Asthma Immunology and American College of Allergy Asthma Immunology and the American Gastroenterology Association recently published guidelines for the management of eosinophilic esophagitis (EoE). Because the guideline was published, dupilumab became the first and only medication to gain regulatory approval for the treatment of EoE. This expert opinion document provides a framework for how the clinician can consider using dupilumab in the treatment strategy for patients with EoE.

International Consensus Recommendations for Eosinophilic Gastrointestinal Disease Nomenclature

BACKGROUND & AIMS

Substantial heterogeneity in terminology used for eosinophilic gastrointestinal diseases (EGIDs), particularly the catchall term "eosinophilic gastroenteritis," limits clinical and research advances. We aimed to achieve an international consensus for standardized EGID nomenclature.

METHODS

This consensus process utilized Delphi methodology. An initial naming framework was proposed and refined in iterative fashion, then assessed in a first round of Delphi voting. Results were discussed in 2 consensus meetings, and the framework was updated and reassessed in a second Delphi vote, with a 70% threshold set for agreement.

RESULTS

Of 91 experts participating, 85 (93%) completed the first and 82 (90%) completed the second Delphi surveys. Consensus was reached on all but 2 statements. "EGID" was the preferred umbrella term for disorders of gastrointestinal (GI) tract eosinophilic inflammation in the absence of secondary causes (100% agreement). Involved GI tract segments will be named specifically and use an "Eo" abbreviation convention: eosinophilic gastritis (now abbreviated EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC). The term "eosinophilic gastroenteritis" is no longer preferred as the overall name (96% agreement). When >2 GI tract areas are involved, the name should reflect all of the involved areas.

CONCLUSIONS

This international process resulted in consensus for updated EGID nomenclature for both clinical and research use. EGID will be the umbrella term, rather than "eosinophilic gastroenteritis," and specific naming conventions by location of GI tract involvement are recommended. As more data are developed, this framework can be updated to reflect best practices and the underlying science.

A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions

BACKGROUND & AIMS

Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE.

METHODS

A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity.

RESULTS

Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE.

CONCLUSIONS

A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.

A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions

BACKGROUND & AIMS

Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE.

METHODS

A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity.

RESULTS

Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE.

CONCLUSIONS

A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.

Improvement in eosinophilic esophagitis when using dupilumab for other indications or compassionate use

BACKGROUND

Dupilumab has been approved to treat atopic dermatitis, asthma, and nasal polyps and is in active clinical trials for the treatment of eosinophilic esophagitis (EoE). Given its shared immunopathology, we hypothesized that EoE symptoms and inflammation would improve when dupilumab therapy was used for other allergic indications.

OBJECTIVE

To measure the clinical and histologic response in EoE to dupilumab when treating other atopic diseases.

METHODS

We completed a retrospective chart review of all patients at Children's Hospital of Philadelphia and Rady Children Hospital who were prescribed dupilumab for atopic dermatitis, asthma, or nasal polyps and had a concomitant clinical diagnosis of EoE. Demographic information along with histology, symptom scores, medications, and diet information were collected. Response to dupilumab was evaluated.

RESULTS

A total of 45 patients were identified. Of which, 11 patients were prescribed dupilumab for asthma, 27 for atopic dermatitis, 3 for nasal polyps, and 4 for compassionate use for EoE. There was no follow-up data for 8 patients. Follow-up histology was available for 26 patients: 22 of 26 had less than 6 eosinophils per high power field after the initiation of dupilumab with significant improvement (pre: 52.9 + 35.1 to post: 4.5 + 10.9 eosinophils/high power field, P < .005). A total of 28 patients had improvement of symptoms, with 24 patients reporting complete resolution of symptoms after dupilumab initiation. Reductions in EoE treatment medications (swallowed steroids, proton pump inhibitors) or expansion of diet occurred in 29 patients treated with dupilumab.

CONCLUSION

Dupilumab therapy initiated for atopic disease effectively induces symptomatic and histologic remission of esophageal disease and reduces the need for EoE-directed therapy in patients with concomitant EoE.

Persistent Basal Cell Hyperplasia Is Associated With Clinical and Endoscopic Findings in Patients With Histologically Inactive Eosinophilic Esophagitis

BACKGROUND & AIMS

Although eosinophil count is the standard used to monitor disease activity in patients with eosinophilic esophagitis (EoE), there are often disparities between patient-reported symptoms and eosinophil counts. We examined the prevalence of epithelial alterations, namely basal cell hyperplasia (BCH) and spongiosis, among patients with inactive EoE (eosinophil counts below 15 following therapy) and aimed to determine whether maintenance of these changes in epithelial morphology are associated with persistent clinical findings.

METHODS

Esophageal biopsies of 243 patients (mean age, 16.9 years) undergoing routine endoscopy at the University of Pennsylvania were evaluated for epithelial BCH and spongiosis. Univariable analysis was used to calculate the association between epithelial changes and symptoms as well as endoscopic findings and peak eosinophil count. We validated our findings using data from a cohort of patients at the University of North Carolina.

RESULTS

The discovery and validation cohorts each included patients with inactive EoE, based on histologic factors, but ongoing BCH and spongiosis. Ongoing BCH, but not spongiosis, in patients with inactive EoE was associated with symptoms (odds ratio, 2.14; 95% CI, 1.03-4.42; P = .041) and endoscopic findings (odds ratio, 7.10; 95% CI, 3.12-16.18; P < .001).

CONCLUSIONS

In patients with EoE, the presence of BCH might indicate ongoing disease activity, independent of eosinophil count. This might account for the persistent symptoms in patients who are considered to be in remission based on histologic factors.

Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference

BACKGROUND & AIMS

Over the last decade, clinical experiences and research studies raised concerns regarding use of proton pump inhibitors (PPIs) as part of the diagnostic strategy for eosinophilic esophagitis (EoE). We aimed to clarify the use of PPIs in the evaluation and treatment of children and adults with suspected EoE to develop updated international consensus criteria for EoE diagnosis.

METHODS

A consensus conference was convened to address the issue of PPI use for esophageal eosinophilia using a process consistent with standards described in the Appraisal of Guidelines for Research and Evaluation II. Pediatric and adult physicians and researchers from gastroenterology, allergy, and pathology subspecialties representing 14 countries used online communications, teleconferences, and a face-to-face meeting to review the literature and clinical experiences.

RESULTS

Substantial evidence documented that PPIs reduce esophageal eosinophilia in children, adolescents, and adults, with several mechanisms potentially explaining the treatment effect. Based on these findings, an updated diagnostic algorithm for EoE was developed, with removal of the PPI trial requirement.

CONCLUSIONS

EoE should be diagnosed when there are symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (or approximately 60 eosinophils per mm²) on esophageal biopsy and after a comprehensive assessment of non-EoE disorders that could cause or potentially contribute to esophageal eosinophilia. The evidence suggests that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criterion, and we have developed updated consensus criteria for EoE that reflect this change.

New developments in patients with eosinophilic gastrointestinal diseases presented at the CEGIR/TIGERS Symposium at the 2018 American Academy of Allergy, Asthma & Immunology Meeting

The Consortium of Eosinophilic Gastrointestinal Diseases and the International Gastrointestinal Eosinophil Researchers organized a day-long symposium at the recent 2018 Annual Meeting of the American Academy of Allergy, Asthma & Immunology, which was coupled for the first time with the World Allergy Organization meeting to create an international platform. The symposium featured experts in many facets of eosinophilic gastrointestinal diseases, including allergy, immunology, gastroenterology, pathology, and nutrition, and was a well-attended event. The basic science, genetics, cellular immunology, and clinical features of the diseases, with a focus on epithelial, eosinophil, and mast cell responses, as well as current and emerging treatment options, were reviewed. Here we briefly review some of the highlights of the material presented at the meeting.

Eosinophilic Gastrointestinal Disorders

Eosinophilic esophagitis (EoE) is an atopic disease that is characterized by an isolated infiltration of eosinophils into the epithelium of the esophagus and is triggered by specific allergens. Patients should undergo an upper endoscopy with biopsy after 6 to 8 weeks of treatment with a proton pump inhibitor in order to make the diagnosis of EoE. Eosinophilic gastroenteritis is a pathologic eosinophilic infiltration of any portion of the gastrointestinal tract, and eosinophilic proctocolitis is an eosinophilic infiltration in the colon alone.

Eosinophilic esophagitis phenotypes: Ready for prime time?

Eosinophilic esophagitis (EoE) is one of the most common causes of reflux-like symptoms and feeding problems in children and food impaction and dysphagia in adults with a prevalence of 1:2500. Therapeutic options include diet, use of swallowed corticosteroids, or dilation. In the last several years, recent clinical and translational researches have identified some common and distinctive features, for example, the varying response to diet and medications. As EoE shares some characteristics with both asthma and inflammatory bowel disease, the advances in these fields suggest that various phenotypes may also exist in patients with EoE. Here, we provide a rationale for EoE phenotypes and provide some suggestions for potential phenotypes based on histology, molecular signature, response to therapy or dietary therapy.

Seasonal exacerbation of esophageal eosinophilia in children with eosinophilic esophagitis and allergic rhinitis

BACKGROUND

Evidence supports a possible link between eosinophilic esophagitis (EoE) and environmental aeroallergens, which can manifest as seasonal exacerbation of esophageal eosinophilia. Few studies have examined this link in pediatric patients with EoE.

OBJECTIVE

To identify the proportion of patients with seasonal induced esophageal eosinophilia.

METHODS

A retrospective chart review was conducted of all patients diagnosed with EoE at the authors' institution. Demographic data were collected by chart review. Seasonal variation or flare was defined as a change from fewer than to at least 15 eosinophils per high-power field and a minimum of a 2-fold increase in eosinophil count between 2 consecutive biopsy specimens in different seasons without dietary or medication modifications.

RESULTS

Of the 1,180 patients with EoE, 160 (14%) were suspected of having aeroallergen-associated triggers by history. Of these 160 patients, 32 (20%) had biopsy examination-confirmed variation of EoE triggered by aeroallergens. Most of these patients were boys (84%), all had a history or examination consistent with allergic rhinitis, and most had a history of asthma (75%). Thirty-two subjects had obvious seasonal variation, 22 of whom also had known food-induced symptoms.

CONCLUSION

Children with EoE and allergic rhinitis might have exacerbations in their esophageal eosinophilia during certain seasons depending on the specific aeroallergens to which they are sensitized. Identification of environmental allergens to sensitized patients is important and can guide therapy.

Advances in clinical management of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated clinicopathologic condition that has become an increasingly important cause of upper gastrointestinal morbidity in adults and children over the past 2 decades. It is diagnosed based on symptoms of esophageal dysfunction, the presence of at least 15 eosinophils/high-power field in esophageal biopsy specimens, and exclusion of competing causes of esophageal eosinophilia, including proton pump inhibitor-responsive esophageal eosinophilia. We review what we have recently learned about the clinical aspects of EoE, discussing the clinical, endoscopic, and histological features of EoE in adults and children. We explain the current diagnostic criteria and challenges to diagnosis, including the role of gastroesophageal reflux disease and proton pump inhibitor-responsive esophageal eosinophilia. It is also important to consider the epidemiology of EoE (with a current incidence of 1 new case per 10,000 per year and prevalence of 0.5 to 1 case per 1000 per year) and disease progression. We review the main treatment approaches and new treatment options; EoE can be treated with topical corticosteroids, such as fluticasone and budesonide, or dietary strategies, such as amino acid-based formulas, allergy test-directed elimination diets, and nondirected empiric elimination diets. Endoscopic dilation has also become an important tool for treatment of fibrostenotic complications of EoE. There are a number of unresolved issues in EoE, including phenotypes, optimal treatment end points, the role of maintenance therapy, and treatment of refractory EoE. The care of patients with EoE and the study of the disease span many disciplines; EoE is ideally managed by a multidisciplinary team of gastroenterologists, allergists, pathologists, and dieticians.

Eosinophilic esophagitis: clinical presentation in children

Eosinophilic esophagitis (EoE) is increasing in western nations. Symptoms in infants and young children include feeding difficulties, failure to thrive, and gastroesophageal reflux. School-aged children may present with vomiting, abdominal pain, and regurgitation; adolescents and adults with dysphagia and food impaction. Delayed diagnosis increases risk of stricture formation. Children with untreated EoE have tissue changes resembling airway remodeling. Endoscopy does not always correlate. Management centers on food elimination. Approaches include skin prick and patch testing, removal of foods, or an amino acid formula diet. Long-term elimination diets can produce nutritional deficiencies and have poor adherence.

The natural history of eosinophilic oesophagitis in the transition from childhood to adulthood

BACKGROUND

Eosinophilic oesophagitis (EoE) is a chronic inflammatory condition affecting both children and adults. Little is known about the natural history of EoE in the transition from childhood into adulthood.

AIM

To determine the prevalence of EoE symptoms and impact of EoE on quality of life among adults diagnosed with EoE during childhood.

METHODS

This is a cross-sectional study of EoE patients from the Children's Hospital of Philadelphia EoE registry. Patients ≥18 years diagnosed with EoE during childhood were administered validated dysphagia [Mayo Dysphagia Questionnaire (MDQ)-30] and Quality of Life (PAGI-QOL) questionnaires. Ongoing EoE treatments were ascertained.

RESULTS

A total of 140 EoE patients ≥18 years were identified; 53 completed all questions. Only 6 (11%) subjects had positive (n = 2) or indeterminate (n = 4) dysphagia scores. However, of 47 patients with negative scores, 18 (37%) reported ongoing difficulty swallowing. The mean PAGI-QOL score was 4.58/5. The dietary dimension score was 3.73/5. Current pharmacological EoE treatments were topical steroids (3/53) and interleukin-5 antagonists (3/53). Additionally, 26/53 (49%) were on PPI therapy and 40/53 (76%) were following allergy directed diets.

CONCLUSIONS

The majority of young adults diagnosed with EoE during childhood continue to require pharmacological treatment and/or dietary modification for EoE. A substantial proportion of this population experiences ongoing swallowing difficulties that a standard dysphagia questionnaire fails to capture. Dietary quality of life, but not total quality of life, appears to be adversely affected. These data suggest that EoE diagnosed during childhood remains a significant medical issue during early adulthood, and that better EoE symptom measurement instruments are needed.

Reslizumab in children and adolescents with eosinophilic esophagitis: results of a double-blind, randomized, placebo-controlled trial

BACKGROUND

Eosinophilic esophagitis is a chronic allergic disease with insufficient treatment options. Results from animal studies suggest that IL-5 induces eosinophil trafficking in the esophagus.

OBJECTIVE

We sought to evaluate the effect of reslizumab, a neutralizing antibody against IL-5, in children and adolescents with eosinophilic esophagitis.

METHODS

Patients with symptom severity scores of moderate or worse and an esophageal biopsy specimen with 24 or more intraepithelial eosinophils per high-power field were randomly assigned to receive infusions of 1, 2, or 3 mg/kg reslizumab or placebo at weeks 0, 4, 8, and 12. The coprimary efficacy measures were changes in peak esophageal eosinophil count and the physician's global assessment score at week 15 (end of therapy).

RESULTS

Two-hundred twenty-six patients received study medication. Median reductions from baseline to the end of therapy in peak esophageal eosinophil counts were 59%, 67%, 64%, and 24% in the 1, 2, and 3 mg/kg reslizumab (all P < .001) and placebo groups, respectively. All treatment groups, including the placebo group, showed improvements in physician's global assessment scores; the differences between the reslizumab and placebo groups were not statistically significant. The most common adverse events in the reslizumab groups were headache, cough, nasal congestion, and upper respiratory tract infection. One patient in each reslizumab group and 2 in the placebo group had serious adverse events; none were considered related to the study medication.

CONCLUSION

Reslizumab significantly reduced intraepithelial esophageal eosinophil counts in children and adolescents with eosinophilic esophagitis. However, improvements in symptoms were observed in all treatment groups and were not associated with changes in esophageal eosinophil counts.

Eosinophilic esophagitis: updated consensus recommendations for children and adults

Eosinophilic esophagitis (EoE) is a clinicopathologic condition of increasing recognition and prevalence. In 2007, a consensus recommendation provided clinical and histopathologic guidance for the diagnosis and treatment of EoE; however, only a minority of physicians use the 2007 guidelines, which require fulfillment of both histologic and clinical features. Since 2007, the number of EoE publications has doubled, providing new disease insight. Accordingly, a panel of 33 physicians with expertise in pediatric and adult allergy/immunology, gastroenterology, and pathology conducted a systematic review of the EoE literature (since September 2006) using electronic databases. Based on the literature review and expertise of the panel, information and recommendations were provided in each of the following areas of EoE: diagnostics, genetics, allergy testing, therapeutics, and disease complications. Because accumulating animal and human data have provided evidence that EoE appears to be an antigen-driven immunologic process that involves multiple pathogenic pathways, a new conceptual definition is proposed highlighting that EoE represents a chronic, immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. The diagnostic guidelines continue to define EoE as an isolated chronic disorder of the esophagus diagnosed by the need of both clinical and pathologic features. Patients commonly have high rates of concurrent allergic diatheses, especially food sensitization, compared with the general population. Proved therapeutic options include chronic dietary elimination, topical corticosteroids, and esophageal dilation. Important additions since 2007 include genetic underpinnings that implicate EoE susceptibility caused by polymorphisms in the thymic stromal lymphopoietin protein gene and the description of a new potential disease phenotype, proton pump inhibitor-responsive esophageal eosinophila. Further advances and controversies regarding diagnostic methods, surrogate disease markers, allergy testing, and treatment approaches are discussed.

A descriptive study of complications of gastrostomy tubes in children

OBJECTIVES

The purpose of this study was to determine the number and types of complications experienced by children with gastrostomy tubes.

METHODS

This is a prospective study of children with gastrostomy tube complications. Enrollment occurred on the first 24 months of the study. Data were collected for 4 years, beginning at the enrollment of the first participant. Demographic data and information on infections, granulation tissue formation, and major complications were recorded.

RESULTS

Infections occurred in 37% of patients, with most experiencing a single infection that occurred within the first 15 days after tube placement. Granulation tissue developed in 68% of patients, with 17% experiencing recurrent granulation tissue despite treatment. There was no difference in infection rates or granulation tissue formation between subgroups based on gender, ethnicity, or parents' education level. Major complications occurred in 4% of the patients.

CONCLUSION

Complications of infection and granulation tissue occur frequently and likely are a cause of stress and increased burden of care for these children and families. Improved strategies for care are needed.

Eosinophilic esophagitis

Eosinophilic esophagitis is specific disease that involves an isolated esophageal eosinophilic inflammation and clinical symptoms that do not respond to acid-suppression therapy or are associated with normal esophageal pH monitoring. To establish the diagnosis, upper endoscopy with esophageal biopsies is required. Referral to an allergist and food allergen testing is recommended. Dietary and topical corticosteroid therapies are commonly used and are effective in the majority of patients.

A case-control study of sociodemographic and geographic characteristics of 335 children with eosinophilic esophagitis

BACKGROUND & AIMS

The epidemiology of pediatric eosinophilic esophagitis (EE) is poorly characterized. In this study, we aimed to determine demographic, socioeconomic, and geographic characteristics of our cohort of EE children.

METHODS

A case-control design was used to compare 335 EE subjects with control subjects from gastroenterology (GI) and allergy clinics as well as 2000 U.S. census data.

RESULTS

EE subjects were significantly different than the greater Philadelphia population as well as control subjects from our gastroenterology and allergy clinics. EE subjects were 83.6% Caucasian, compared with 70.9% of GI control subjects (odds ratio [OR], 2.17; P < .001; confidence interval [CI], 1.52-3.11), 64.9% of allergy control subjects (OR, 2.83; P < .001; CI, 1.99-4.04), and 73.0% of the greater Philadelphia population. EE subjects were 75.8% male, compared with 48.0% of GI control subjects (OR, 3.39; P < .001; CI, 2.47-4.65), 60.4% of allergy control subjects (OR, 1.62; P < .001; CI, 1.19-2.19), and 48.0% of the greater Philadelphia population. We initially demonstrated that EE subjects are more affluent, more educated, and reside more often in suburban areas. However, Caucasian race was a significant confounding variable and accounted for socioeconomic or geographic differences among EE subjects and our control populations with one exception. A significant difference remained between suburban and urban residence in EE and allergy control populations.

CONCLUSIONS

EE subjects are significantly different than control groups in their demographic characteristics of Caucasian race and male sex. EE subject socioeconomic and geographic characteristics are not different than our typical referral patterns to GI clinic when adjusted for race as a confounding factor.

Eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a disease based on a clinicopathologic diagnosis that involves a localized eosinophilic inflammation of the esophagus. A significant increase in the diagnosis of pediatric EoE has occurred over the past 10 years not only due to a greater recognition of the disease among gastroenterologists, allergists, and pathologists but also secondary to an increased incidence of the disease. EoE is defined by the presence of 15 or more esophageal eosinophils per high-power field isolated to the esophagus associated with clinical symptoms that do not respond to acid suppression therapy. Although the exact mechanism of EoE is unknown, food allergens are thought to have an important role. Effective treatment options include dietary restrictions and various steroid formulations.

New visions for food allergy: an iPAC summary and future trends

The spectrum of food allergy consists of a variety of different clinical pictures including immunoglobulin (Ig)E, and non-IgE food allergy as well as mixed, IgE and non-IgE disorders. In addition, eosinophilic diseases of the gastrointestinal (GI) tract with occasional IgE-type sensitization are increasingly recognized. As a consequence, the clinical picture of food allergy is pleomorphic and can range from chronic GI symptoms to severe anaphylaxis. The diagnosis of food allergy is mostly hampered by the lack of reliable in vitro tests for non-IgE-mediated diseases, and in most cases relies on a reoccurrence of symptoms upon re-exposure to the antigen; in general during a standardized food challenge. Currently, there is no safe and efficient treatment for food allergy and the treatment relies on avoidance diets. Priorities for research have been identified by iPAC (international Pediatric Allergy and Asthma Consortium) and outlined in this review. They include studies to better identify the pathogenesis of food allergy, including genetic aspects; studies to develop diagnostic and follow-up tests; studies for standardization of food challenges; as well as studies addressing a safe and efficient treatment of food allergy.

Eosinophilic esophagitis

PURPOSE OF REVIEW

Eosinophilic esophagitis is a disorder increasing in frequency that typically causes symptoms similar to those seen with gastroesophageal reflux, and is characterized by increased eosinophils isolated to the esophagus despite the use of antireflux medications. We present a review of the literature including basic science research, prevalence, clinical presentation, diagnosis, and management of eosinophilic esophagitis.

RECENT FINDINGS

Over the past few years, there has been a dramatic increase in the number of publications relating to eosinophilic esophagitis in terms of case reports, cohorts of patients, familial occurrences, pathogenesis, and treatment options. Recent work confirms the role of food allergy in many patients with eosinophilic esophagitis. Several medications, including corticosteroids [topical (swallowed) or systemic], leukotriene receptor antagonists and, most recently, biologic molecules (such as anti-IL5), have been utilized. Although eosinophilic esophagitis is treatable, it is thought to be a chronic illness that requires dietary restriction or chronic medical therapy.

SUMMARY

Eosinophilic esophagitis is being diagnosed in both children and adults with increasing frequency. Allergists, gastroenterologists, pathologists, internists, pediatricians, and otolaryngologists must not only be educated to be able to properly identify patients with eosinophilic esophagitis but also be informed about the current treatment and management of these patients.

Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment

During the last decade, clinical practice saw a rapid increase of patients with esophageal eosinophilia who were thought to have gastroesophageal reflux disease (GERD) but who did not respond to medical and/or surgical GERD management. Subsequent studies demonstrated that these patients had a "new" disease termed eosinophilic esophagitis (EE). As recognition of EE grew, so did confusion surrounding diagnostic criteria and treatment. To address these issues, a multidisciplinary task force of 31 physicians assembled with the goal of determining diagnostic criteria and making recommendations for evaluation and treatment of children and adults with suspected EE. Consensus recommendations were based upon a systematic review of the literature and expert opinion. EE is a clinicopathological disease characterized by (1) Symptoms including but not restricted to food impaction and dysphagia in adults, and feeding intolerance and GERD symptoms in children; (2) > or = 15 eosinophils/HPF; (3) Exclusion of other disorders associated with similar clinical, histological, or endoscopic features, especially GERD. (Use of high dose proton pump inhibitor treatment or normal pH monitoring). Appropriate treatments include dietary approaches based upon eliminating exposure to food allergens, or topical corticosteroids. Since EE is a relatively new disease, the intent of this report is to provide current recommendations for care of affected patients and defining gaps in knowledge for future research studies.

Safety of intravenous midazolam and fentanyl for pediatric GI endoscopy: prospective study of 1578 endoscopies

BACKGROUND

Data on safety of intravenous sedation in pediatric GI endoscopy are sparse.

OBJECTIVE

To evaluate safety of intravenous sedation for GI endoscopy.

DESIGN/SETTING

Single-center prospective series of outpatient GI endoscopies performed from February 2003 to February 2004 at The Children's Hospital of Philadelphia. The recorded information included demographic, medication, and adverse event data.

PATIENTS

A total of 1226 patients were studied.

MAIN OUTCOME MEASUREMENTS

Description of adverse events relating to intravenous sedation.

RESULTS

A total of 2635 endoscopies were performed, of which 1717 were outpatient procedures with the patient under intravenous sedation. Sedation data were available on 1578 procedures (92%, M/F 674/552): 758 esophagogastroduodenoscopies (EGD) alone, 116 colonoscopies (COL) alone, and 352 combined EGD and COL. The median dose of fentanyl was 2.77 microg/kg (SD 0.97, range 0-6.73), and of midazolam was 0.11 mg/kg (SD 0.06, range 0-0.39). The mean recovery time was 118 minutes (SD 47.3, range 31-375). Ten patients (0.8%) failed intravenous sedation. Serious adverse events (apnea) were noted in 2 patients (0.2%). Mild or moderate adverse events included desaturation below 92% for less than 20 seconds (100 patients, 9%), vomiting (64 patients, 5%), agitation (15 patients, 1%), desaturation below 92% for greater than 20 seconds (12 patients, 0.7%), and rash (8 patients, 0.7%). No cardiopulmonary resuscitation or sedation reversal was necessary. No patients required hospitalization. Patients younger than 6 years were more likely to develop respiratory adverse event (P < .01).

CONCLUSIONS

Intravenous sedation with midazolam and fentanyl is safe for pediatric GI endoscopy. Serious adverse events are rare and no patient required hospitalization.

Interventional upper endoscopy: the pediatric perspective

Pediatric endoscopy has evolved from a purely observational modality into one with the potential for many therapeutic applications. Common therapeutic uses of endoscopy in children now include treatment of variceal bleeds and foreign body retrieval and newer procedures such as endoluminal gastroplication and endoscopic pyloromyotomy. Continuing research in pediatric endoscopy will allow pediatric gastroenterologists to perfect existing interventional endoscopic techniques and to learn to perform new ones.

Eosinophilic esophagitis: treatment in 2005

PURPOSE OF REVIEW

Eosinophilic esophagitis is an isolated, eosinophilic inflammation of the esophagus. The symptoms are often confused for those of gastroesophageal reflux. Over the past few years, there has been a significant increase in the literature surrounding eosinophilic esophagitis as more than two-thirds of the articles written on the subject have been published within the past 3 years. Because the incidence is rising and the condition is easily diagnosed by endoscopy with biopsy, it is important for physicians to understand the pathophysiology, clinical presentation, and treatment options available for patients.

RECENT FINDINGS

The etiology of eosinophilic esophagitis in children is reported to be associated with an allergic response to food antigens. Because allergy tests are often unable to determine the causative foods, complete elimination of all foods is often required. The diagnosis requires a biopsy of the esophagus, stomach and duodenum. The condition is diagnosed if the patient's esophageal biopsy depicts over 20 eosinophils per high-powered field despite the use of aggressive acid blockade, biopsies of the stomach antrum and duodenum are normal, and the tissue inflammation resolves when dietary antigens are removed from the diet. While the most commonly involved foods causing eosinophilic esophagitis include milk, eggs, nuts, beef, wheat, fish, shellfish, corn and soy, almost all foods have been implicated. Alternative treatments include esophageal dilatation and medical therapy.

SUMMARY

This article reviews the past year's literature, concentrating on the pathophysiology, and treatment of eosinophilic esophagitis in both children and adults.

Treatment of eosinophilic esophagitis with specific food elimination diet directed by a combination of skin prick and patch tests

BACKGROUND

Eosinophilic esophagitis (EE) is a recently described disorder identified in patients with symptoms suggestive of gastroesophageal reflux disease (GERD) but unresponsive to conventional reflux therapies. Therapies have included corticosteroids, elemental diet, and diet restriction. We report our experience with skin prick and atopy patch testing and food elimination diets in patients diagnosed as having EE.

OBJECTIVE

To identify food antigens that cause EE and the characteristics of patients who respond to food elimination vs those who are unresponsive.

METHODS

Patients diagnosed as having EE had restricted diets based on skin prick and atopy patch testing results. Additional biopsies were performed after 4 to 8 weeks of restricted diet. Demographics, atopic tendencies, and food antigens were identified retrospectively in our food allergy database.

RESULTS

A total of 146 patients diagnosed as having EE were evaluated with skin prick and atopy patch testing. Thirty-nine patients had unequivocal demonstration of food causing EE, with normalization of biopsy results on elimination and reoccurrence on reintroduction. An additional 73 patients, for a total 112 (77%) of 146 patients, had resolution of their EE as demonstrated by biopsy results. Fifteen (10%) of 146 patients were nonresponders manifested by no significant reduction in esophageal eosinophils despite restricted diet based on skin prick and atopy patch testing. Egg, milk, and soy were identified most frequently with skin prick testing, whereas corn, soy, and wheat were identified most frequently with atopy patch testing.

CONCLUSION

In more than 75% of patients with EE, both symptoms and esophageal inflammation can be significantly improved with dietary elimination of foods. Skin prick and atopy patch testing can help identify foods in most patients.

Eosinophilic esophagitis: a 10-year experience in 381 children

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) is a disorder characterized by a severe, isolated eosinophilic infiltration of the esophagus unresponsive to aggressive acid blockade but responsive to the removal of dietary antigens. We present information relating to our 10-year experience in children diagnosed with EoE.

METHODS

We conducted a retrospective study between January 1, 1994, and January 1, 2004, to evaluate all patients diagnosed with EoE. Clinical symptoms, demographic data, endoscopic findings, and the results of various treatment regimens were collected and evaluated.

RESULTS

A total of 381 patients (66% male, age 9.1 +/- 3.1 years) were diagnosed with EoE: 312 presented with symptoms of gastroesophageal reflux; 69 presented with dysphagia. Endoscopically, 68% of patients had a visually abnormal esophagus; 32% had a normal-appearing esophagus despite a severe histologic esophageal eosinophilia. The average number of esophageal eosinophils (per 400 x high power field) proximally and distally were 23.3 +/- 10.5 and 38.7 +/- 13.3, respectively. Corticosteroids significantly improved clinical symptoms and esophageal histology; however, upon their withdrawal, the symptoms and esophageal eosinophilia recurred. Dietary restriction or complete dietary elimination using an amino acid-based formula significantly improved both the clinical symptoms and esophageal histology in 75 and 172 patients, respectively.

CONCLUSIONS

Medications such as corticosteroids are effective; however, upon withdrawal, EoE recurs. The removal of dietary antigens significantly improved clinical symptoms and esophageal histology in 98% of patients.

Success rate and duration of paediatric outpatient colonoscopy

BACKGROUND

The paediatric colonoscopy completion rates have rarely been reported.

AIMS

We sought to evaluate colonoscopy completion rate and compare the rates using colonoscope versus enteroscope.

METHODS

We prospectively investigated 60 patients who underwent colonoscopy between July 1999 and June 2001. The following data were collected: demographics, type of endoscope used, extent of colonoscopy, indication for procedure, histology, adverse events and time to reach the caecum and the terminal ileum.

RESULTS

Sixty colonoscopies were performed during the study period, 30 with an enteroscope and 30 with a colonoscope. The caecum was reached in 56/60 (93%) and the terminal ileum in 50/60 (83%). An average time of 12.61 min (S.D. 7.3) was necessary to advance the instrument from the anus to the caecum, and additional 3.67 min (S.D. 3.62) to terminal ileum. There was no difference in the success rate between enteroscope and colonoscope. Six patients (10%) had definitive diagnosis established because a full colonoscopy was performed. No serious adverse events occurred.

CONCLUSION

Paediatric colonoscopy to the caecum can be completed safely and expeditiously in more than 90% of procedures. Various types of instruments do not appear to influence completion rate. Full colonoscopy contributes to the establishment of a definitive diagnosis.