51
|
Safroneeva E, Balsiger L, Hafner D, Kuehni CE, Zwahlen M, Trelle S, Godat S, Biedermann L, Greuter T, Vavricka S, Straumann A, Schoepfer AM. Adults with eosinophilic oesophagitis identify symptoms and quality of life as the most important outcomes. Aliment Pharmacol Ther 2018; 48:1082-1090. [PMID: 30375682 DOI: 10.1111/apt.15000] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/11/2018] [Accepted: 09/05/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Well informed patients who are in cohesive partnership with physicians and who have realistic expectations towards therapy are more likely to be adherent, which results in better disease control. AIM To assess which therapy goals adults with eosinophilic oesophagitis consider relevant. METHODS Following refinement during three focus groups, a study brochure and questionnaire were sent to 148 patients. Patients ranked the importance (five levels) of short-term (in the next 3 months) and long-term (≥1 year) treatment effect on symptoms, quality of life (QoL), histologically-detected inflammation and fibrosis, endoscopically-detected inflammation, and stricture formation as well as achieving histological remission while asymptomatic. Patients' characteristics associated with treatment goals were identified using logistic regression. RESULTS Of 109 respondents (mean age 43 years), 85 were men. Over 90% chose symptoms and QoL improvement as important short- and long-term therapy goals. A greater proportion attributed more importance to long-term reduction in endoscopic (90% vs 73%, P < 0.001) and histological (81% vs 62%, P = 0.002) inflammation, and histologically-detected fibrosis (79% vs 64%, P = 0.018) when compared to short-term reduction in these features. Patients (88%) ranked achieving histological remission while being asymptomatic as important. Gender, therapy use, education level, QoL, symptom severity, and history of dilation were associated with patients' choice of treatment goals. CONCLUSIONS Patients attributed most importance to improvement in symptoms and QoL. Reduction in biological activity was judged less important, but more relevant in the long- compared to the short-term.
Collapse
Affiliation(s)
- Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Lukas Balsiger
- Division of Internal Medicine, Kantonsspital Langenthal, Solothurn, Switzerland
| | - David Hafner
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sven Trelle
- Institute of Social and Preventive Medicine, Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Sébastien Godat
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Luc Biedermann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Alex Straumann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| |
Collapse
|
52
|
Inage E, Furuta GT, Menard-Katcher C, Masterson JC. Eosinophilic esophagitis: pathophysiology and its clinical implications. Am J Physiol Gastrointest Liver Physiol 2018; 315:G879-G886. [PMID: 30212252 PMCID: PMC6293259 DOI: 10.1152/ajpgi.00174.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Classically, eosinophilic esophagitis is an antigen-mediated chronic disease distinct from gastroesophageal reflux disease. Eosinophilic esophagitis is an emerging clinical problem that is growing in recognition. It is characterized clinically by feeding dysfunction, dysphagia, and reflux-like symptoms. Histologically, eosinophilic esophagitis is identifiable by a dense epithelial eosinophilic infiltrate. Experimental modeling and clinical studies over the last decade have greatly improved mechanistic insights and led to improvements in clinical understanding and the assessment of therapeutic options for patients and their clinicians who manage this disease. Here, we review the clinicopathologic diagnostic criteria and our understanding of eosinophilic esophagitis as an allergic disease with genetic and immunological components. We present studies defining the importance of the epithelial barrier and the concept of barrier dysfunction as an initiating or perpetuating factor for this disease. We discuss the relationship between the symptoms of dysphagia and feeding dysfunction, our current knowledge of the underlying pathophysiologic mechanisms, and advances in clinical assessment of esophageal distensibility and narrowing in eosinophilic esophagitis patients. Finally, therapeutic implications relating to the advances that have led to our current understanding of the pathophysiology of eosinophilic esophagitis are explored.
Collapse
Affiliation(s)
- Eisuke Inage
- 1Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan,2Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Glenn T. Furuta
- 2Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Calies Menard-Katcher
- 2Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Joanne C. Masterson
- 2Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado,3Department of Biology, Maynooth University, Kildare, Ireland
| |
Collapse
|
53
|
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus associated with an atopic predisposition which appears to be increasing in prevalence over the last few decades. Symptoms stem from fibrosis, swelling, and smooth muscle dysfunction. In the past two decades, the etiology of EoE has been and is continuing to be revealed. This review provides an overview of the effects of genetics, environment, and immune function including discussions that touch on microbiome, the role of diet, food allergy, and aeroallergy. The review further concentrates on the pathophysiology of the disease with particular focus on the important concepts of the molecular etiology of EoE including barrier dysfunction and allergic hypersensitivity.
Collapse
Affiliation(s)
- Benjamin P Davis
- Department of Internal Medicine, Division of Immunology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52246, USA.
| |
Collapse
|
54
|
Steinbach EC, Hernandez M, Dellon ES. Eosinophilic Esophagitis and the Eosinophilic Gastrointestinal Diseases: Approach to Diagnosis and Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:1483-1495. [PMID: 30201096 PMCID: PMC6134874 DOI: 10.1016/j.jaip.2018.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/06/2018] [Accepted: 06/21/2018] [Indexed: 12/12/2022]
Abstract
The eosinophilic gastrointestinal diseases (EGIDs) represent disorders of the gastrointestinal (GI) tract that result from the local infiltration and aberrant activity of eosinophils and other immune cells. Eosinophilic esophagitis (EoE) is the most well-characterized EGID and is defined by the presence of intraepithelial eosinophils in the esophagus (≥15 eosinophils per high-powered field) and clinical symptoms associated with esophageal dysfunction. The other EGIDs are rare and lack strong data regarding pathogenesis and management. The incidence and prevalence of EoE are increasing, and EoE is now a major cause of upper GI morbidity. Management is multidisciplinary, with collaboration between gastroenterologists, allergists, pathologists, and dieticians, and is aimed at amelioration of symptoms and prevention of long-term complications such as esophageal stricture. Treatment options for EoE include proton pump inhibitors, swallowed topical corticosteroids, and elimination diets. Esophageal dilation is used when esophageal strictures or fibrostenotic changes are present. Additional therapies targeting eosinophils and other mediators of Th2 inflammation are under development and are promising. Treatment options for other EGIDs typically involve corticosteroids or dietary elimination.
Collapse
Affiliation(s)
- Erin C Steinbach
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Michelle Hernandez
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC.
| |
Collapse
|
55
|
Pediatric Eosinophilic Esophagitis Is Associated With Increased Lamina Propria Immunoglobulin G4-Positive Plasma Cells. J Pediatr Gastroenterol Nutr 2018; 67:204-209. [PMID: 29509633 DOI: 10.1097/mpg.0000000000001949] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Eosinophilic esophagitis (EoE) is considered a TH2-mediated food allergy disease that leads to submucosal esophageal fibrosis and strictures. Recent studies focused on adults with EoE identified a strong association with elevated esophageal IgG4 immunostaining. Our study aimed to determine the association of IgG4 with EoE in pediatric patients. METHODS Using our local EoE research registry, we identified 41 adequate biopsies from EoE patients. We used 10 age- and sex-matched patients with no diagnostic abnormalities at endoscopy or on biopsy. Using a monoclonal antibody to Immunoglobulin G4 (IgG4), we determined the maximum density of IgG4-positive plasma cells (IgG4-PC) per high-power field (hpf). Using a semi-quantitative assessment, we also graded the noncellular staining of the lamina propria and epithelium. RESULTS Our EoE cohort consisted predominantly of boys with an average age of 5.9 years and 63% had a documented IgE-based food allergy. Median peak eosinophilia was 40 eosinophils/hpf and the median IgG4-PC density was 39/hpf in the active esophagitis patients, compared with a median of 0 IgG4-PC/hpf in the non-EoE patients (P = 0.0001). EoE patients with a food allergy showed a significantly higher IgG4-PC density (44.5/hpf) than those without a food allergy (8/hpf; P = 0.0385). There was no significant association between IgG4-PC density and peak eosinophilia (r = 0.0011). CONCLUSIONS We demonstrate that active esophagitis in pediatric EoE patients is associated with elevated levels of IgG4-positive plasma cells, which was more significant in EoE patients with a documented food allergy. Our study also adds to the growing literature that EoE may involve more than just an exaggerated TH2 immune response.
Collapse
|
56
|
Tomono T, Machida T, Kamioka H, Shibasaki Y, Yano K, Ogihara T. Entinostat reverses P-glycoprotein activation in snail-overexpressing adenocarcinoma HCC827 cells. PLoS One 2018; 13:e0200015. [PMID: 29979729 PMCID: PMC6034804 DOI: 10.1371/journal.pone.0200015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/18/2018] [Indexed: 12/16/2022] Open
Abstract
Epithelial-to-mesenchymal transition (EMT) in cancer cells facilitates tumor progression by promoting invasion and metastasis. Snail is a transcriptional factor that induces EMT, while P-glycoprotein (P-gp) is an efflux transporter involved in anticancer drug resistance, and P-gp efflux activity is stimulated in Snail-overexpressing lung cancer cells with EMT characteristics. Since the histone deacetylase (HDAC) inhibitor entinostat (Ent) reverses EMT features, our aim in this study was to determine whether Ent also suppresses P-gp activation in Snail-induced cells. First, we confirmed that Ent treatment reduced migration activity, downregulated E-cadherin and upregulated vimentin at the mRNA level in Snail-overexpressing cells, thus inhibiting EMT. Efflux and uptake assays using rhodamine123 (Rho123), a fluorescent P-gp substrate, showed that Ent also inhibited Snail-induced activation of P-gp. Moreover, P-gp activity was more strongly inhibited by Ent in Snail-overexpressing cells than in Mock cells. When we evaluated the uptakes of Rho123 by LLC-PK1 cells and P-gp-overexpressing LLC-GA5COL150 cells, Rho123 accumulation in LLC-GA5COL150 cells was significantly decreased compared with that in LLC-PK1 cells. Coincubation with Ent had no effect on Rho123 accumulation in either of the cell lines. Thus, Ent appears to be an inhibitor, but not a substrate, of P-gp at low concentration. Our results suggest that Ent treatment might suppress not only Snail-induced cancer malignant alteration, but also P-gp-mediated multidrug resistance.
Collapse
Affiliation(s)
- Takumi Tomono
- Laboratory of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Takasaki University of Health and Welfare, Takasaki-shi, Gunma, Japan
| | - Tatsuya Machida
- Laboratory of Biopharmaceutics, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki-shi, Gunma, Japan
| | - Hiroki Kamioka
- Laboratory of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Takasaki University of Health and Welfare, Takasaki-shi, Gunma, Japan
| | - Yumi Shibasaki
- Laboratory of Biopharmaceutics, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki-shi, Gunma, Japan
| | - Kentaro Yano
- Laboratory of Biopharmaceutics, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki-shi, Gunma, Japan
| | - Takuo Ogihara
- Laboratory of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Takasaki University of Health and Welfare, Takasaki-shi, Gunma, Japan
- Laboratory of Biopharmaceutics, Faculty of Pharmacy, Takasaki University of Health and Welfare, Takasaki-shi, Gunma, Japan
- * E-mail:
| |
Collapse
|
57
|
Abstract
PURPOSE OF REVIEW For patients with eosinophilic esophagitis (EoE), endoscopic dilation has been used primarily to provide immediate symptomatic relief of dysphagia. This report reviews the current position of esophageal dilation in the therapeutic algorithm for EoE, including effectiveness and safety issues. RECENT FINDINGS Esophageal strictures in EoE develop as a consequence of long-lasting esophageal eosinophilia, with patient age and diagnostic delay as well established risk factors. Endoscopic dilation leads to immediate symptomatic improvement in 95% of EoE patients who have strictures or narrow caliber esophagus. As dilation has no effect on the underlying eosinophil inflammation, repeated procedures are usually needed to maintain symptoms in remission. Adding an effective drug or dietary-based EoE therapy reduces the need of further dilation. The high rate of severe complications from dilation reported in early literature has not been reproduced in most recent series, with mild postprocedural chest pain as the most common side effect. Current data suggest that the risk of esophageal perforation is less than 1%. Mucosal tears after dilation should no longer be considered a complication, but rather a marker of procedural success. SUMMARY Esophageal dilation should be considered in EoE patients with esophageal strictures or narrow caliber esophagus who have persistent dysphagia/food impaction despite an effective anti-inflammatory treatment.
Collapse
|
58
|
Eke R, Li T, White A, Tariq T, Markowitz J, Lenov A. Systematic review of histological remission criteria in eosinophilic esophagitis. JGH OPEN 2018; 2:158-165. [PMID: 30483582 PMCID: PMC6207047 DOI: 10.1002/jgh3.12059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/03/2018] [Accepted: 05/07/2018] [Indexed: 12/15/2022]
Abstract
Elemental diets, dietary elimination, and steroid therapies are the most common therapies in the clinical trials for eosinophilic esophagitis (EoE). Histological findings (usually reported as eosinophils per microscopic high‐powered field [hpf]) remain the most common end‐point used to define response. Yet, the threshold for defining “response” and “remission” are ill‐defined among consensus guidelines and may vary from study to study. We conducted a systematic literature review of articles on eosinophilic esophagitis, published between January 2007 and November 2017, considering histological remission as the primary outcome. We abstracted treatment information and definitions of histological remission or response. A comparison of definitions of histological remission across and within institutions was performed. A total of 61 articles were included in this review, with approximately 60% of the studies published from centers in the United States. Histological definitions of remission of EoE ranged from 0 to ≤20 eosinophils/hpf. The most stringent criteria, ranging from 0 to ≤5 eosinophils/hpf, were commonly used in interventional trial studies that examined the effects of new treatments. We found remarkable variability in definitions between studies, treatment types, and regions. Age or epidemiological distribution of study subjects did not influence the criteria for histological remission. Clinical and histological improvements are important measures of the effects of treatment. Histological findings, the most objective measure of treatment, should provide an optimal method for comparing the effectiveness of various treatments. Yet, our findings suggest a lack of consistent remission criteria in published studies. Considering these inconsistencies, it is difficult to compare the effectiveness of various treatments.
Collapse
Affiliation(s)
- Ransome Eke
- Division of Epidemiology and Biostatistics Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
| | - Tong Li
- Division of Epidemiology and Biostatistics Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
| | - Anna White
- Medical Library Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
| | - Tooba Tariq
- Department of Internal Medicine Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
| | - Jonathan Markowitz
- Division of Pediatric Gastroenterology Greenville Children's Hospital Greenville South Carolina US
| | - Andrey Lenov
- Allergy-Asthma-Immunology Clinic, Department of Pediatric and Adolescent Medicine Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
| |
Collapse
|
59
|
Schoepfer A, Blanchard C, Dawson H, Lucendo A, Mauro A, Ribi C, Safroneeva E, Savarino EV, Penagini R. Eosinophilic esophagitis: latest insights from diagnosis to therapy. Ann N Y Acad Sci 2018; 1434:84-93. [DOI: 10.1111/nyas.13731] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/06/2018] [Accepted: 03/21/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Alain Schoepfer
- Division of Gastroenterology and HepatologyCentre Hospitalier Universitaire Vaudois/CHUV and University of Lausanne (UNIL) Lausanne Switzerland
| | | | - Heather Dawson
- Institute of PathologyUniversity of Bern Bern Switzerland
| | - Alfredo Lucendo
- Department of GastoenterologyHospital General de Tomelloso Tomelloso Ciudad Real Spain
| | - Aurelio Mauro
- Division of Gastroenterology, Dipartimento di Fisiopatologia Medico‐Chirurgica e dei TrapiantiUniversità degli Studi of Milan, Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico Milan Italy
| | - Camillo Ribi
- Division of Allergy and Clinical ImmunologyCentre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | | | - Edoardo V. Savarino
- Division of Gastroenterology, Department of SurgeryOncology and Gastroenterology – DiSCOG Azienza Ospedaliera di Padova Padova Italy
| | - Roberto Penagini
- Division of Gastroenterology, Dipartimento di Fisiopatologia Medico‐Chirurgica e dei TrapiantiUniversità degli Studi of Milan, Fondazione IRCCS Cà Granda – Ospedale Maggiore Policlinico Milan Italy
| |
Collapse
|
60
|
Shoda T, Wen T, Aceves SS, Abonia JP, Atkins D, Bonis PA, Caldwell JM, Capocelli KE, Carpenter CL, Collins MH, Dellon ES, Eby MD, Gonsalves N, Gupta SK, Falk GW, Hirano I, Menard-Katcher P, Kuhl JT, Krischer JP, Leung J, Mukkada VA, Spergel JM, Trimarchi MP, Yang GY, Zimmermann N, Furuta GT, Rothenberg ME. Eosinophilic oesophagitis endotype classification by molecular, clinical, and histopathological analyses: a cross-sectional study. Lancet Gastroenterol Hepatol 2018; 3:477-488. [PMID: 29730081 DOI: 10.1016/s2468-1253(18)30096-7] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/15/2018] [Accepted: 03/15/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis is understood in terms of quantifiable histological, endoscopic, and molecular features. Data are scant for inter-relations of these features and their potential to identify distinct disease endotypes. We aimed to identify clinical-pathological correlations between endoscopic and histological disease variables by transcription profiling of the oesophagus of patients with eosinophilic oesophagitis of varying severity and disease activity states. METHODS We did a cross-sectional study across ten hospital sites in the USA associated with the Consortium of Eosinophilic Gastrointestinal Disease Researchers. We analysed oesophageal biopsy specimens taken from paediatric and adult patients with eosinophilic oesophagitis (discovery cohort), using the eosinophilic oesophagitis diagnostic panel (EDP), a set of 96 informative transcripts. Histological and endoscopic features were assessed by quantification of oesophageal eosinophils and use of the eosinophilic oesophagitis histology scoring system (HSS) and the eosinophilic oesophagitis endoscopic reference score (EREFS). Associations among the various histological, endoscopic, and molecular features were analysed by Spearman correlation. Results were replicated in a biologically independent, single-centre, validation cohort of patients with active eosinophilic oesophagitis. FINDINGS The discovery cohort contained 185 samples and the validation cohort comprised 100 specimens. In the discovery cohort, EDP showed intersite consistency, significant correlation with oesophageal eosinophils (p<0·0001), and similar findings between paediatric and adult patients. Of eight HSS domains, basal zone hyperplasia correlated with the EDP (median Spearman ρ 0·47 [IQR 0·36-0·60]). Of five EREFS features, distal furrows correlated with the EDP (median Spearman ρ 0·42 [0·32-0·50]). By analysing active eosinophilic oesophagitis in the discovery cohort, the EDP identified three clusters associated with distinct endotypes (termed EoEe1-3) despite similar eosinophil levels. EoEe1 was associated with a normal-appearing oesophagus (risk ratio [RR] 3·27, 95% CI 1·04-10·27; p=0·0443), an inverse association with a history of oesophageal dilation (0·27, 0·09-0·82; p=0·0105) and showed relatively mild histological, endoscopic, and molecular changes. EoEe2 showed an inflammatory and steroid-refractory phenotype (RR 2·77, 95% CI 1·11-6·95; p=0·0376) and had the highest expression of inflammatory cytokines and steroid-responding genes. EoEe3 was associated with a narrow-calibre oesophagus (RR 7·98, 95% CI 1·84-34·64; p=0·0013) and adult onset (2·22, 1·19-4·12; p=0·0155), and showed the highest degree of endoscopic and histological severity and the lowest expression of epithelial differentiation genes. These endotypes were replicated in the validation cohort by clustering and with an eosinophilic oesophagitis endotype-prediction algorithm. INTERPRETATION Our new disease classification stratifies patients with eosinophilic oesophagitis into subgroups with potential clinical and therapeutic significance and provides a framework for a precision medicine approach to eosinophilic oesophagitis. FUNDING National Institutes of Health.
Collapse
Affiliation(s)
- Tetsuo Shoda
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ting Wen
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Seema S Aceves
- Division of Allergy Immunology, University of California at San Diego, Rady Children's Hospital, San Diego, CA, USA
| | - J Pablo Abonia
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Dan Atkins
- Division of Pediatric Allergy and Immunology, Children's Hospital Colorado, Denver, CO, USA
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Julie M Caldwell
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Christina L Carpenter
- Health Informatics Institute, Departments of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Margaret H Collins
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Michael D Eby
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandeep K Gupta
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine, Peoria, IL, USA
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jonathan T Kuhl
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey P Krischer
- Health Informatics Institute, Departments of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Michael P Trimarchi
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nives Zimmermann
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Glenn T Furuta
- Division Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | | |
Collapse
|
61
|
Abdala-Valencia H, Coden ME, Chiarella SE, Jacobsen EA, Bochner BS, Lee JJ, Berdnikovs S. Shaping eosinophil identity in the tissue contexts of development, homeostasis, and disease. J Leukoc Biol 2018; 104:95-108. [PMID: 29656559 DOI: 10.1002/jlb.1mr1117-442rr] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 02/16/2018] [Accepted: 02/17/2018] [Indexed: 12/20/2022] Open
Abstract
Eosinophils play homeostatic roles in different tissues and are found in several organs at a homeostatic baseline, though their tissue numbers increase significantly in development and disease. The morphological, phenotypical, and functional plasticity of recruited eosinophils are influenced by the dynamic tissue microenvironment changes between homeostatic, morphogenetic, and disease states. Activity of the epithelial-mesenchymal interface, extracellular matrix, hormonal inputs, metabolic state of the environment, as well as epithelial and mesenchymal-derived innate cytokines and growth factors all have the potential to regulate the attraction, retention, in situ hematopoiesis, phenotype, and function of eosinophils. This review examines the reciprocal relationship between eosinophils and such tissue factors, specifically addressing: (1) tissue microenvironments associated with the presence and activity of eosinophils; (2) non-immune tissue ligands regulatory for eosinophil accumulation, hematopoiesis, phenotype, and function (with an emphasis on the extracellular matrix and epithelial-mesenchymal interface); (3) the contribution of eosinophils to regulating tissue biology; (4) eosinophil phenotypic heterogeneity in different tissue microenvironments, classifying eosinophils as progenitors, steady state eosinophils, and Type 1 and 2 activated phenotypes. An appreciation of eosinophil regulation by non-immune tissue factors is necessary for completing the picture of eosinophil immune activation and understanding the functional contribution of these cells to development, homeostasis, and disease.
Collapse
Affiliation(s)
- Hiam Abdala-Valencia
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mackenzie E Coden
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sergio E Chiarella
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elizabeth A Jacobsen
- Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Bruce S Bochner
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - James J Lee
- Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Sergejs Berdnikovs
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
62
|
Peinhaupt M, Roula D, Theiler A, Sedej M, Schicho R, Marsche G, Sturm EM, Sabroe I, Rothenberg ME, Heinemann A. DP1 receptor signaling prevents the onset of intrinsic apoptosis in eosinophils and functions as a transcriptional modulator. J Leukoc Biol 2018; 104:159-171. [PMID: 29607536 PMCID: PMC6032830 DOI: 10.1002/jlb.3ma1017-404r] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/15/2018] [Accepted: 03/10/2018] [Indexed: 02/06/2023] Open
Abstract
Prostaglandin (PG) D2 is the ligand for the G-protein coupled receptors DP1 (D-type prostanoid receptor 1) and DP2 (also known as chemoattractant receptor homologous molecule, expressed on Th2 cells; CRTH2). Both, DP1 and DP2 are expressed on the cellular surface of eosinophils; although it has become quite clear that PGD2 induces eosinophil migration mainly via DP2 receptors, the role of DP1 in eosinophil responses has remained elusive. In this study, we addressed how DP1 receptor signaling complements the pro-inflammatory effects of DP2. We found that PGD2 prolongs the survival of eosinophils via a DP1 receptor-mediated mechanism that inhibits the onset of the intrinsic apoptotic cascade. The DP1 agonist BW245c prevented the activation of effector caspases in eosinophils and protected mitochondrial membranes from depolarization which-as a consequence-sustained viability of eosinophils. DP1 activation in eosinophils enhanced the expression of the anti-apoptotic gene BCL-XL , but also induced pro-inflammatory genes, such as VLA-4 and CCR3. In HEK293 cells that overexpress recombinant DP1 and/or DP2 receptors, activation of DP1, but not DP2, delayed cell death and stimulated proliferation, along with induction of serum response element (SRE), a regulator of anti-apoptotic, early-response genes. We conclude that DP1 receptors promote the survival via SRE induction and induction of pro-inflammatory genes. Therefore, targeting DP1 receptors, along with DP2, may contribute to anti-inflammatory therapy in eosinophilic diseases.
Collapse
Affiliation(s)
- Miriam Peinhaupt
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - David Roula
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - Anna Theiler
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - Miriam Sedej
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - Rudolf Schicho
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria
| | - Gunther Marsche
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria
| | - Eva M Sturm
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - Ian Sabroe
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, England
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Akos Heinemann
- Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Division of Pharmacology, Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria
| |
Collapse
|
63
|
Schoepfer AM, Simko A, Bussmann C, Safroneeva E, Zwahlen M, Greuter T, Biedermann L, Vavricka S, Godat S, Reinhard A, Saner C, Maye H, Sempoux C, Brunel C, Blanchard C, Simon D, Simon HU, Straumann A. Eosinophilic Esophagitis: Relationship of Subepithelial Eosinophilic Inflammation With Epithelial Histology, Endoscopy, Blood Eosinophils, and Symptoms. Am J Gastroenterol 2018; 113:348-357. [PMID: 29336433 DOI: 10.1038/ajg.2017.493] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 11/12/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVES For technical reasons, the histologic characterization of eosinophilic esophagitis (EoE)-specific alterations is almost exclusively based on those found in the esophageal epithelium, whereas little is known about subepithelial abnormalities. In this study, we aimed to systematically assess the nature of subepithelial histologic alterations, and analyze their relationship with epithelial histologic findings, endoscopic features, and symptoms. METHODS Adult patients with established EoE diagnosis were prospectively included during a yearly follow-up visit. Patients underwent assessment of clinical, endoscopic, and histologic disease activity using EoE-specific scores. RESULTS We included 200 EoE patients (mean age 43.5±15.7 years, 74% males) with a median peak count of 36 intraepithelial eosinophils/hpf (IQR 14-84). The following histologic features were identified in the subepithelial layer: eosinophilic infiltration (median peak count of 20 eosinophils/hpf (IQR 10-51)), eosinophil degranulation (43%), fibrosis (82%), and lymphoid follicles (56%). Peak intraepithelial eosinophil counts were higher, identical, and lower when compared to the subepithelial layer in 62.5%, 7%, and 30.5% of patients, respectively. Anti-eosinophilic treatment at inclusion did not influence the relation between subepithelial and epithelial peak eosinophil counts. Subepithelial histologic activity correlated with epithelial histologic activity (rho 0.331, P<0.001), endoscopic severity (rho 0.208, P=0.003), and symptom severity (rho 0.179, P=0.011). Forty percent (21/52) of patients with <15 intraepithelial eosinophils/hpf had subepithelial peak counts of ≥15/hpf. CONCLUSIONS There is a significant but modest correlation between subepithelial histologic activity and epithelial histologic activity, endoscopic severity, and symptom severity. The long-term clinical impact of assessing subepithelial alterations in EoE needs to be further elucidated.
Collapse
Affiliation(s)
- Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Audrey Simko
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Luc Biedermann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Division of Gastroenterology and Hepatology, Triemlispital, Zurich, Switzerland
| | - Sébastien Godat
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Antoine Reinhard
- Division of Otorhinolaryngology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Catherine Saner
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Hugo Maye
- Division of Internal Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Christine Sempoux
- Institute of Pathology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Christophe Brunel
- Institute of Pathology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | - Dagmar Simon
- Division of Dermatology and Allergy, Inselspital/University Hospital Bern, Bern, Switzerland
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Alex Straumann
- Swiss EoE Clinic, Praxis Römerhof, Olten, Switzerland.,Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
64
|
TGF-β1 alters esophageal epithelial barrier function by attenuation of claudin-7 in eosinophilic esophagitis. Mucosal Immunol 2018; 11:415-426. [PMID: 28832026 PMCID: PMC5825237 DOI: 10.1038/mi.2017.72] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 07/12/2017] [Indexed: 02/04/2023]
Abstract
Barrier dysfunction has been implicated in the pathophysiology of eosinophilic esophagitis (EoE). Transforming growth factor-β1 (TGF-β1), a potent pleiotropic molecule, is increased in EoE; however, no study has evaluated its influence on esophageal epithelial barrier. We hypothesized that TGF-β1 regulates barrier dysfunction in EoE. We aimed to determine the role of TGF-β1 in the epithelial barrier in models of EoE. To examine the impact of TGF-β1 on esophageal barrier, immortalized human esophageal epithelial (EPC2-hTERT) cells were exposed to TGF-β1 during the three-dimensional air-liquid interface (3D-ALI) model in vitro. TGF-β1 exposure diminished EPC2-hTERT barrier function as measured by transepithelial electrical resistance (TEER) and 3 kDa Fluorescein isothiocyanate dextran paracellular flux (FITC Flux), and hematoxylin and eosin (H&E) assessment revealed prominent cellular separation. In analysis of epithelial barrier molecules, TGF-β1 led to the specific reduction in expression of the tight-junction molecule, claudin-7 (CLDN7), and this was prevented by TGF-β-receptor I inhibitor. Short hairpin ribonucleic acid (shRNA)-mediated CLDN7 knockdown diminished epithelial barrier function, whereas CLDN7 overexpression resulted in protection from TGF-β1-mediated barrier dysfunction. In pediatric EoE biopsies CLDN7 expression was decreased and altered localization was observed with immunofluorescence analysis, and the TGF-β1 downstream transcription factor, phosphorylated SMAD2/3 (pSMAD2/3), was increased. Our data suggest that TGF-β1 participates in esophageal epithelial barrier dysfunction through CLDN7 dysregulation.
Collapse
|
65
|
Safroneeva E, Saner C, Rossel JB, Golay D, Pittet V, Godat S, Diem S, Aepli P, Sawatzki M, Borovicka J, Burgmann K, Juillerat P, Netzer P, Sendensky A, Hruz P, Girardin M, Biedermann L, Greuter T, Vavricka S, Michetti P, Mueller C, Straumann A, Schoepfer AM. Cohort Profile: The Swiss Eosinophilic Esophagitis Cohort Study (SEECS). Inflamm Intest Dis 2018; 2:163-170. [PMID: 30018966 DOI: 10.1159/000486131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/07/2017] [Indexed: 12/19/2022] Open
Abstract
Background and Aims The prospective, observational Swiss Eosinophilic Esophagitis Cohort Study (SEECS) was set up in 2015 with the following goals in mind: (1) to provide up-to-date epidemiologic data; (2) to assess the appropriateness of care; (3) to evaluate the psychosocial impact; and (4) to foster translational research projects. Data capture relies on validated instruments to assess disease activity and focuses on epidemiologic variables and biosamples (esophageal biopsies and blood specimens). An annual inclusion of 70 new patients with eosinophilic esophagitis (EoE) or proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE) is intended. We herein describe the SEECS cohort profile. Methods The SEECS includes adult patients (age ≥18 years) with EoE or PPI-REE diagnosed according to published criteria. After inclusion, the patients are typically seen once a year for a clinical and endoscopic/histologic follow-up examination. Data are captured using validated questionnaires. Biosamples from patients with gastroesophageal reflux disease (GERD) and controls with a healthy esophagus are collected as well. Results From January 2016 to July 2017, a total of 111 patients with EoE and 10 patients with PPI-REE were recruited. In addition, esophageal biopsies and blood samples from 11 patients with GERD and 20 controls with a healthy esophagus were collected. The mean age of the patients with EoE and those with PPI-REE was 39.6 ± 12.9 and 44.6 ± 15.6 years, respectively. A male predominance was found among both the patients with EoE (77.5%) and those with PPI-REE (70%). Concomitant allergic disorders were found in 79.3% of the patients with EoE and 90% of the patients with PPI-REE. At inclusion, the EoE patients were treated with the following therapeutic regimens: no therapy (0.9%), PPI (36%), swallowed topical corticosteroids (82.9%), elimination diets (15.3%), and esophageal dilation (19.8%). Conclusions The SEECS is the first national cohort study of patients with EoE or PPI-REE. The SEECS will provide up-to-date epidemiologic data and foster translational research projects.
Collapse
Affiliation(s)
- Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Catherine Saner
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Jean-Benoît Rossel
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Delphine Golay
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Valérie Pittet
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Sébastien Godat
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Stefan Diem
- Division of Gastroenterology and Hepatology, Kantonsspital Luzern, Luzern, Switzerland
| | - Patrick Aepli
- Division of Gastroenterology and Hepatology, Kantonsspital Luzern, Luzern, Switzerland
| | - Mikael Sawatzki
- Division of Gastroenterology and Hepatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Jan Borovicka
- Division of Gastroenterology and Hepatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Konstantin Burgmann
- Division of Gastroenterology and Hepatology, Kantonsspital Fribourg, Fribourg, Switzerland
| | - Pascal Juillerat
- Division of Gastroenterology and Hepatology, Inselspital and University of Bern, Bern, Switzerland
| | - Peter Netzer
- GastroZentrum Netzer AG, Lindenhofspital, Bern, Switzerland
| | | | - Petr Hruz
- Division of Gastroenterology and Hepatology, University Hospital Basel, Basel, Switzerland
| | - Marc Girardin
- Division of Gastroenterology and Hepatology, University Hospital of Geneva, Geneva, Switzerland
| | - Luc Biedermann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Stephan Vavricka
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Pierre Michetti
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,Crohn's and Colitis Center, La Source, Lausanne, Switzerland
| | - Christoph Mueller
- Division of Experimental Pathology, Institute of Pathology, University of Bern, Bern, Switzerland
| | - Alex Straumann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Swiss EoE Clinic, Olten, Switzerland
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | |
Collapse
|
66
|
Whelan KA, Muir AB, Nakagawa H. Esophageal 3D Culture Systems as Modeling Tools in Esophageal Epithelial Pathobiology and Personalized Medicine. Cell Mol Gastroenterol Hepatol 2018; 5:461-478. [PMID: 29713660 PMCID: PMC5924738 DOI: 10.1016/j.jcmgh.2018.01.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/11/2018] [Indexed: 12/13/2022]
Abstract
The stratified squamous epithelium of the esophagus shows a proliferative basal layer of keratinocytes that undergo terminal differentiation in overlying suprabasal layers. Esophageal pathologies, including eosinophilic esophagitis, gastroesophageal reflux disease, Barrett's esophagus, squamous cell carcinoma, and adenocarcinoma, cause perturbations in the esophageal epithelial proliferation-differentiation gradient. Three-dimensional (3D) culture platforms mimicking in vivo esophageal epithelial tissue architecture ex vivo have emerged as powerful experimental tools for the investigation of esophageal biology in the context of homeostasis and pathology. Herein, we describe types of 3D culture that are used to model the esophagus, including organotypic, organoid, and spheroid culture systems. We discuss the development and optimization of various esophageal 3D culture models; highlight the applications, strengths, and limitations of each method; and summarize how these models have been used to evaluate the esophagus under homeostatic conditions as well as under the duress of inflammation and precancerous/cancerous conditions. Finally, we present future perspectives regarding the use of esophageal 3D models in basic science research as well as translational studies with the potential for personalized medicine.
Collapse
Key Words
- 3D, 3-dimensional
- BE, Barrett’s esophagus
- COX, cyclooxygenase
- CSC, cancer stem cell
- EADC, esophageal adenocarcinoma
- EGF, epidermal growth factor
- EGFR, epidermal growth factor receptor
- EMT, epithelial-mesenchymal transition
- ESCC, esophageal squamous cell carcinoma
- EoE, eosinophilic esophagitis
- Esophageal Disease
- FEF3, primary human fetal esophageal fibroblast
- GERD, gastroesophageal reflux disease
- OTC, organotypic 3-dimensional culture
- Organoid
- Organotypic Culture
- STAT3, signal transducer and activator of transcription-3
- Spheroid Culture
Collapse
Affiliation(s)
- Kelly A. Whelan
- Pathology and Laboratory Medicine, Fels Institute for Cancer Research and Molecular Biology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Amanda B. Muir
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Correspondence Address correspondence to: Amanda B. Muir, MD, Children's Hospital of Philadelphia, 3615 Civic Center Boulevard, Abramson Research Center 902E, Philadelphia, Pennsylvania 19103. fax: (267) 426–7814.
| | - Hiroshi Nakagawa
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
67
|
Armbruster-Lee J, Cavender CP, Lieberman JA, Samarasinghe AE. Understanding fibrosis in eosinophilic esophagitis: Are we there yet? J Leukoc Biol 2018; 104:31-40. [DOI: 10.1002/jlb.5mr1017-395r] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Jennifer Armbruster-Lee
- Department of Pediatrics; Division of Gastroenterology, University of Tennessee Health Science Center; Memphis Tennessee USA
| | - Cary P. Cavender
- Department of Pediatrics; Division of Gastroenterology, University of Tennessee Health Science Center; Memphis Tennessee USA
| | - Jay A. Lieberman
- Department of Pediatrics; Division of Allergy/Immunology, University of Tennessee Health Science Center; Memphis Tennessee USA
| | - Amali E. Samarasinghe
- Department of Pediatrics; Division of Pulmonology; University of Tennessee Health Science Center; Memphis Tennessee USA
- Children's Foundation Research Institute; Memphis Tennessee USA
| |
Collapse
|
68
|
Kasagi Y, Chandramouleeswaran PM, Whelan KA, Tanaka K, Giroux V, Sharma M, Wang J, Benitez AJ, DeMarshall M, Tobias JW, Hamilton KE, Falk GW, Spergel JM, Klein-Szanto AJ, Rustgi AK, Muir AB, Nakagawa H. The Esophageal Organoid System Reveals Functional Interplay Between Notch and Cytokines in Reactive Epithelial Changes. Cell Mol Gastroenterol Hepatol 2018; 5:333-352. [PMID: 29552622 PMCID: PMC5852293 DOI: 10.1016/j.jcmgh.2017.12.013] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/28/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Aberrations in the esophageal proliferation-differentiation gradient are histologic hallmarks in eosinophilic esophagitis (EoE) and gastroesophageal reflux disease. A reliable protocol to grow 3-dimensional (3D) esophageal organoids is needed to study esophageal epithelial homeostasis under physiological and pathologic conditions. METHODS We modified keratinocyte-serum free medium to grow 3D organoids from endoscopic esophageal biopsies, immortalized human esophageal epithelial cells, and murine esophagi. Morphologic and functional characterization of 3D organoids was performed following genetic and pharmacologic modifications or exposure to EoE-relevant cytokines. The Notch pathway was evaluated by transfection assays and by gene expression analyses in vitro and in biopsies. RESULTS Both murine and human esophageal 3D organoids displayed an explicit proliferation-differentiation gradient. Notch inhibition accumulated undifferentiated basal keratinocytes with deregulated squamous cell differentiation in organoids. EoE patient-derived 3D organoids displayed normal epithelial structure ex vivo in the absence of the EoE inflammatory milieu. Stimulation of esophageal 3D organoids with EoE-relevant cytokines resulted in a phenocopy of Notch inhibition in organoid 3D structures with recapitulation of reactive epithelial changes in EoE biopsies, where Notch3 expression was significantly decreased in EoE compared with control subjects. CONCLUSIONS Esophageal 3D organoids serve as a novel platform to investigate regulatory mechanisms in squamous epithelial homeostasis in the context of EoE and other diseases. Notch-mediated squamous cell differentiation is suppressed by cytokines known to be involved in EoE, suggesting that this may contribute to epithelial phenotypes associated with disease. Genetic and pharmacologic manipulations establish proof of concept for the utility of organoids for future studies and personalized medicine in EoE and other esophageal diseases.
Collapse
Key Words
- 3D, 3-dimensional
- BCH, basal cell hyperplasia
- DAPI, 4′,6-Diamidino-2-Phenylindole, Dihydrochloride
- DNMAML1, dominant negative MAML1
- DOX, doxycycline
- EGF, epidermal growth factor
- EMT, epithelial-mesenchymal transition
- EoE, eosinophilic esophagitis
- Eosinophilic Esophagitis
- GERD, gastroesophageal reflux disease
- GFP, green fluorescent protein
- GSI, γ-secretase inhibitor
- H&E, hematoxylin and eosin
- IF, immunofluorescence
- IHC, immunohistochemistry
- IL, interleukin
- IVL, Involucrin
- KSFM, keratinocyte SFM
- KSFMC, KSFM containing 0.6 mM Ca2+
- Keratinocytes
- MAML1, Mastermind-like protein1
- OFR, organoid formation rate
- Squamous Cell Differentiation
- TNF-α, tumor necrosis factor-α
- Three-Dimensional
- Tslp, thymic stromal lymphopoietin
- aDMEM/F12, advanced Dulbecco's Modified Eagle Medium: Nutrient Mixture F-12
- qRT-PCR, quantitative reverse-transcription polymerase chain reaction
Collapse
Affiliation(s)
- Yuta Kasagi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Prasanna M. Chandramouleeswaran
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Kelly A. Whelan
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Koji Tanaka
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Veronique Giroux
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Medha Sharma
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Joshua Wang
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alain J. Benitez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maureen DeMarshall
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - John W. Tobias
- Penn Genomic Analysis Core, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathryn E. Hamilton
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Gary W. Falk
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jonathan M. Spergel
- Division of Allergy and Immunology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andres J. Klein-Szanto
- Histopathology Facility and Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Anil K. Rustgi
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Amanda B. Muir
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hiroshi Nakagawa
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania,Correspondence Address correspondence to: Hiroshi Nakagawa, MD, PhD, Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 956 Biomedical Research Building, 421 Curie Boulevard, Philadelphia, Pennsylvania 19104-6160. fax: (215) 573–2024.Division of GastroenterologyDepartment of MedicinePerelman School of MedicineUniversity of Pennsylvania956 Biomedical Research Building, 421 Curie BoulevardPhiladelphia19104-6160Pennsylvania
| |
Collapse
|
69
|
Abstract
Eosinophilic esophagitis advances parallel the increased prevalence. Developments include refining the diagnostic criteria, identifying risk factors, appreciating the contribution of inflammatory pathways, recognizing the importance of subepithelial remodeling, validating trial endpoints, defining a role for biological therapies, and optimizing dietary therapy. Endoscopic outcomes have emerged as endpoints in trials of novel therapeutics. Expanding efforts seek to develop less-invasive methods to assess disease activity thereby reducing the burden of repeated endoscopic procedures during elimination diets. The functional lumen imaging probe is now identified as a determinant of complications with potential utility as a therapeutic endpoint.
Collapse
|
70
|
O'Shea KM, Aceves SS, Dellon ES, Gupta SK, Spergel JM, Furuta GT, Rothenberg ME. Pathophysiology of Eosinophilic Esophagitis. Gastroenterology 2018; 154:333-345. [PMID: 28757265 PMCID: PMC5787048 DOI: 10.1053/j.gastro.2017.06.065] [Citation(s) in RCA: 272] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/09/2017] [Accepted: 06/09/2017] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis is an emerging disease that is distinguished from gastroesophageal reflux disease by the expression of a unique esophageal transcriptome and the interplay of early life environmental factors with distinct genetic susceptibility elements at 5q22 (TSLP) and 2p23 (CAPN14). Rare genetic syndromes have uncovered the contribution of barrier disruption, mediated in part by defective desmosomes and dysregulated transforming growth factor beta production and signaling, to eosinophilic esophagitis pathophysiology. Experimental modeling has defined a cooperative role of activated eosinophils, mast cells, and the cytokines IL-5 and IL-13, mediated by allergic sensitization to multiple foods. Understanding these processes is opening the way to better treatment based on disrupting allergic inflammatory and type 2 cytokine-mediated responses, including anti-cytokine therapeutics and dietary therapy.
Collapse
Affiliation(s)
- Kelly M O'Shea
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Seema S Aceves
- Division of Allergy Immunology, Center for Immunity, Infection and Inflammation, University of California San Diego and Rady Children's Hospital San Diego, California
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine at Peoria and Children's Hospital of Illinois, Peoria, Illinois
| | - Jonathan M Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Glenn T Furuta
- Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| |
Collapse
|
71
|
Schoepfer AM, Straumann A, Safroneeva E. Pharmacologic Treatment of Eosinophilic Esophagitis: An Update. Gastrointest Endosc Clin N Am 2018; 28:77-88. [PMID: 29129301 DOI: 10.1016/j.giec.2017.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Eosinophilic esophagitis (EoE) is defined as a chronic, immune-medicated or antigen-mediated, esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Food allergens are identified in most patients. Treatment strategies include elimination diets, drugs, and esophageal dilation. This article focuses on pharmacologic treatment. Currently, there is no pharmacologic treatment that has been approved by regulatory authorities. Established pharmacologic options to treat EoE include proton pump inhibitors and swallowed topical steroids. Several biologic therapies are currently under evaluation and some of them have shown promising results in improving biologic endpoints and patient-reported outcomes.
Collapse
Affiliation(s)
- Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV), Rue de Bugnon 44, 07/2409, Lausanne 1011, Switzerland.
| | - Alex Straumann
- Swiss EoE Clinic, Römerstrasse 7, 4600 Olten, Switzerland; Division of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
| |
Collapse
|
72
|
Loffredo LF, Abdala-Valencia H, Anekalla KR, Cuervo-Pardo L, Gottardi CJ, Berdnikovs S. Beyond epithelial-to-mesenchymal transition: Common suppression of differentiation programs underlies epithelial barrier dysfunction in mild, moderate, and severe asthma. Allergy 2017; 72:1988-2004. [PMID: 28599074 DOI: 10.1111/all.13222] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Epithelial barrier dysfunction is a central feature in the pathogenesis of allergic disease. Epithelial-to-mesenchymal transition (EMT) has been proposed as one mechanism afflicting barrier in asthma. However, genes and pathways involved in aberrant epithelial-mesenchymal signaling, and their relationship to asthma severity, are poorly understood. METHODS We used unbiased gene network analysis to evaluate functional convergence in epithelial gene expression signatures across multiple public access transcriptomics datasets of human asthma, followed by text mining to evaluate functional marker relevance of discovered genes. We objectively confirmed these findings in epithelial brushings and primary asthmatic epithelial cells cultured in different biological contexts. RESULTS We found a striking suppression of epithelial differentiation in asthma, overrepresented by insufficiency in insulin and Notch signaling, but with the absence of conventional EMT markers. We identified EFNB2, FGFR1, FGFR2, INSR, IRS2, NOTCH2, TLE1, and NTRK2 as novel markers central to dysregulation of epithelial-mesenchymal signaling, but surprisingly overlooked in asthma research. We found that this "core" signature of asthma is shared by mild, moderate, and severe forms of disease, progressing with severity. Loss of epithelial differentiation induced by insulin deprivation in normal human bronchial epithelial cells cultured in organotypic conditions closely approximated gene expression in asthmatic epithelial brushings. CONCLUSIONS The comparative analysis of publically available transcriptomes demonstrated that epithelial barrier dysfunction in asthma is characterized by persistent underlying de-differentiation program with complex etiology. The lasting alteration of the asthmatic epithelial cell transcriptome implicates regulation involving metabolism and epigenetics, beyond EMT driven by injury and repair in chronic inflammation.
Collapse
Affiliation(s)
- L. F. Loffredo
- Division of Allergy and Immunology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - H. Abdala-Valencia
- Division of Pulmonary and Critical Care; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - K. R. Anekalla
- Division of Pulmonary and Critical Care; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - L. Cuervo-Pardo
- Division of Allergy and Immunology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - C. J. Gottardi
- Division of Pulmonary and Critical Care; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - S. Berdnikovs
- Division of Allergy and Immunology; Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| |
Collapse
|
73
|
Carlson DA, Hirano I, Zalewski A, Gonsalves N, Lin Z, Pandolfino JE. Improvement in Esophageal Distensibility in Response to Medical and Diet Therapy in Eosinophilic Esophagitis. Clin Transl Gastroenterol 2017; 8:e119. [PMID: 28981080 PMCID: PMC5666118 DOI: 10.1038/ctg.2017.47] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/11/2017] [Indexed: 12/13/2022] Open
Abstract
Objectives: We aimed to evaluate the effect of medical and diet therapies on esophageal distensibility assessed using the functional lumen imaging probe (FLIP) and the association of changes in esophageal distensibility with clinical outcomes in eosinophilic esophagitis (EoE). Methods: Patients with EoE were evaluated with FLIP during endoscopy at baseline and following therapy without interval dilatation. Evaluation also included a validated patient-reported outcome (PRO; a positive PRO was considered at a 30% score improvement), mucosal biopsies, and scoring of endoscopic features of EoE. FLIP data were analyzed to calculate the distensibility plateau (DP). Results: In all, 18 patients (ages 19–54 years; 4 female) treated with topical steroid (8), elimination diet (6), and/or proton-pump inhibitor (4 only treated with proton-pump inhibitor) were included. Follow-up testing occurred at a mean (range) of 14.6 (8–28) weeks. Improvement was observed in DP (13.9 (12.2–19.2) to 16.8 mm (15.8–19.2), P=0.007) and peak eosinophil count (45 (29–65) to 23 per high-power field (h.p.f.) (5–53), P=0.042). Nine patients had a positive symptomatic outcome. Six of 8 (75%) patients with a DP increase ≥2 mm had a positive PRO (P=0.077), while 2 of 7 (29%) patients that achieved an eosinophil count <15/h.p.f. had a positive PRO (P=0.167). Conclusions: Improvement in esophageal body distensibility can be achieved with medical and diet therapies without dilation in EoE. Improved DP appeared to be better indicator of symptomatic improvement than eosinophil count, supporting FLIP as a valuable outcome measure in EoE.
Collapse
Affiliation(s)
- Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ikuo Hirano
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Angelika Zalewski
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nirmala Gonsalves
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zhiyue Lin
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| |
Collapse
|
74
|
Caldwell JM, Paul M, Rothenberg ME. Novel immunologic mechanisms in eosinophilic esophagitis. Curr Opin Immunol 2017; 48:114-121. [PMID: 28965008 DOI: 10.1016/j.coi.2017.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/03/2017] [Accepted: 08/16/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Julie M Caldwell
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Misu Paul
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave., Cincinnati, OH 45229, United States.
| |
Collapse
|
75
|
Lipowska AM, Kavitt RT. Current Diagnostic and Treatment Strategies for Eosinophilic Esophagitis. Gastroenterol Hepatol (N Y) 2017; 13:527-535. [PMID: 29038643 PMCID: PMC5635428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder of the esophagus diagnosed by the presence of esophageal symptoms accompanied by an esophageal eosinophilic infiltrate. EoE has an increasing worldwide prevalence and can be a cause of dysphagia and food impactions. There is an important role for the use of proton pump inhibitors in the diagnostic pathway of EoE. Treatment paradigms for EoE aim to minimize esophageal inflammation and improve symptom control. Dietary therapy targets dietary allergens and encompasses the elemental diet, the allergy testing-directed elimination diet, and the empiric elimination diet. Pharmacologic options include topical corticosteroids as the standard first-line treatment. Multiple other pharmacologic interventions are currently under investigation and are not recommended in the most recent guidelines. Endoscopic dilation is usually reserved for patients who relapse on pharmacologic or dietary regimens or who have symptomatic stricturing disease. This article provides a comprehensive discussion of existing diagnostic and management strategies for EoE.
Collapse
Affiliation(s)
- Anna M Lipowska
- Dr Lipowska is a gastroenterology fellow and Dr Kavitt is an assistant professor of medicine and director of the Center for Esophageal Diseases in the Section of Gastroenterology, Hepatology, and Nutrition at The University of Chicago Medicine in Chicago, Illinois
| | - Robert T Kavitt
- Dr Lipowska is a gastroenterology fellow and Dr Kavitt is an assistant professor of medicine and director of the Center for Esophageal Diseases in the Section of Gastroenterology, Hepatology, and Nutrition at The University of Chicago Medicine in Chicago, Illinois
| |
Collapse
|
76
|
Tavares M, Dias JA. Eosinophilic Oesophagitis in Children: Disease Modulation by Topical Steroids. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0142-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
77
|
Schleimer RP, Berdnikovs S. Etiology of epithelial barrier dysfunction in patients with type 2 inflammatory diseases. J Allergy Clin Immunol 2017; 139:1752-1761. [PMID: 28583447 DOI: 10.1016/j.jaci.2017.04.010] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/21/2017] [Accepted: 04/21/2017] [Indexed: 12/11/2022]
Abstract
Epithelial barriers of the skin, gastrointestinal tract, and airway serve common critical functions, such as maintaining a physical barrier against environmental insults and allergens and providing a tissue interface balancing the communication between the internal and external environments. We now understand that in patients with allergic disease, regardless of tissue location, the homeostatic balance of the epithelial barrier is skewed toward loss of differentiation, reduced junctional integrity, and impaired innate defense. Importantly, epithelial dysfunction characterized by these traits appears to pre-date atopy and development of allergic disease. Despite our growing appreciation of the centrality of barrier dysfunction in initiation of allergic disease, many important questions remain to be answered regarding mechanisms disrupting normal barrier function. Although our external environment (proteases, allergens, and injury) is classically thought of as a principal contributor to barrier disruption associated with allergic sensitization, there is a need to better understand contributions of the internal environment (hormones, diet, and circadian clock). Systemic drivers of disease, such as alterations of the endocrine system, metabolism, and aberrant control of developmental signaling, are emerging as new players in driving epithelial dysfunction and allergic predisposition at various barrier sites. Identifying such central mediators of epithelial dysfunction using both systems biology tools and causality-driven laboratory experimentation will be essential in building new strategic interventions to prevent or reverse the process of barrier loss in allergic patients.
Collapse
Affiliation(s)
- Robert P Schleimer
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Sergejs Berdnikovs
- Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| |
Collapse
|
78
|
Nhu QM, Aceves SS. Tissue Remodeling in Chronic Eosinophilic Esophageal Inflammation: Parallels in Asthma and Therapeutic Perspectives. Front Med (Lausanne) 2017; 4:128. [PMID: 28831387 PMCID: PMC5549614 DOI: 10.3389/fmed.2017.00128] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/21/2017] [Indexed: 12/20/2022] Open
Abstract
Chronic eosinophilic inflammation is associated with tissue remodeling and fibrosis in a number of chronic T-helper 2 (Th2)-mediated diseases including eosinophilic esophagitis (EoE) and asthma. Chronic inflammation results in dysregulated tissue healing, leading to fibrosis and end organ dysfunction, manifesting clinically as irreversible airway obstruction in asthma and as esophageal rigidity, strictures, narrowing, dysmotility, dysphagia, and food impactions in EoE. Current therapies for EoE and asthma center on reducing inflammation-driven tissue remodeling and fibrosis with corticosteroids, coupled with symptomatic control and allergen avoidance. Additional control of Th2 inflammation can be achieved in select asthma patients with biologic therapies such as anti-IL-5 and anti-IL-13 antibodies, which have also been trialed in EoE. Recent molecular analysis suggests an emerging role for structural cell dysfunction, either inherited or acquired, in the pathogenesis and progression of EoE and asthma tissue remodeling. In addition, new data suggest that inflammation-independent end organ rigidity can alter structural cell function. Herein, we review emerging data and concepts for the pathogenesis of tissue remodeling and fibrosis primarily in EoE and relevant pathogenetic parallels in asthma, focusing additionally on emerging disease-specific therapies and the ability of these therapies to reduce tissue remodeling in subsets of patients.
Collapse
Affiliation(s)
- Quan M Nhu
- Scripps Translational Science Institute, The Scripps Research Institute, La Jolla, CA, United States.,Division of Gastroenterology and Hepatology, Department of Medicine, Scripps Clinic - Scripps Green Hospital, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Medicine, Scripps Clinic-Scripps Green Hospital, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Seema S Aceves
- Division of Allergy and Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, CA, United States.,Division of Allergy and Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, United States.,Rady Children's Hospital - San Diego, San Diego, CA, United States
| |
Collapse
|
79
|
Peinhaupt M, Sturm EM, Heinemann A. Prostaglandins and Their Receptors in Eosinophil Function and As Therapeutic Targets. Front Med (Lausanne) 2017; 4:104. [PMID: 28770200 PMCID: PMC5515835 DOI: 10.3389/fmed.2017.00104] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/27/2017] [Indexed: 02/06/2023] Open
Abstract
Of the known prostanoid receptors, human eosinophils express the prostaglandin D2 (PGD2) receptors DP1 [also D-type prostanoid (DP)] and DP2 (also chemoattractant receptor homologous molecule, expressed on Th2 cells), the prostaglandin E2 receptors EP2 and EP4, and the prostacyclin (PGI2) receptor IP. Prostanoids can bind to either one or multiple receptors, characteristically have a short half-life in vivo, and are quickly degraded into metabolites with altered affinity and specificity for a given receptor subtype. Prostanoid receptors signal mainly through G proteins and naturally activate signal transduction pathways according to the G protein subtype that they preferentially interact with. This can lead to the activation of sometimes opposing signaling pathways. In addition, prostanoid signaling is often cell-type specific and also the combination of expressed receptors can influence the outcome of the prostanoid impulse. Accordingly, it is assumed that eosinophils and their (patho-)physiological functions are governed by a sensitive prostanoid signaling network. In this review, we specifically focus on the functions of PGD2, PGE2, and PGI2 and their receptors on eosinophils. We discuss their significance in allergic and non-allergic diseases and summarize potential targets for drug intervention.
Collapse
Affiliation(s)
- Miriam Peinhaupt
- Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Graz, Austria
| | - Eva M Sturm
- Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Graz, Austria
| | - Akos Heinemann
- Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Graz, Austria
| |
Collapse
|
80
|
Whelan KA, Merves JF, Giroux V, Tanaka K, Guo A, Chandramouleeswaran PM, Benitez AJ, Dods K, Que J, Masterson JC, Fernando SD, Godwin BC, Klein-Szanto AJ, Chikwava K, Ruchelli ED, Hamilton KE, Muir AB, Wang ML, Furuta GT, Falk GW, Spergel JM, Nakagawa H. Autophagy mediates epithelial cytoprotection in eosinophilic oesophagitis. Gut 2017; 66:1197-1207. [PMID: 26884425 PMCID: PMC4987278 DOI: 10.1136/gutjnl-2015-310341] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 01/05/2016] [Accepted: 01/27/2016] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The influence of eosinophilic oesophagitis (EoE)-associated inflammation upon oesophageal epithelial biology remains poorly understood. We investigated the functional role of autophagy in oesophageal epithelial cells (keratinocytes) exposed to the inflammatory EoE milieu. DESIGN Functional consequences of genetic or pharmacological autophagy inhibition were assessed in endoscopic oesophageal biopsies, human oesophageal keratinocytes, single cell-derived ex vivo murine oesophageal organoids as well as a murine model recapitulating EoE-like inflammation and basal cell hyperplasia. Gene expression, morphological and functional characterisation of autophagy and oxidative stress were performed by transmission electron microscopy, immunostaining, immunoblotting, live cell imaging and flow cytometry. RESULTS EoE-relevant inflammatory conditions promoted autophagy and basal cell hyperplasia in three independent murine EoE models and oesophageal organoids. Inhibition of autophagic flux via chloroquine treatment augmented basal cell hyperplasia in these model systems. Oesophageal keratinocytes stimulated with EoE-relevant cytokines, including tumour necrosis factor-α and interleukin-13 exhibited activation of autophagic flux in a reactive oxygen species-dependent manner. Autophagy inhibition via chloroquine treatment or depletion of Beclin-1 or ATG-7, augmented oxidative stress induced by EoE-relevant stimuli in murine EoE, oesophageal organoids and human oesophageal keratinocytes. Oesophageal epithelia of paediatric EoE patients with active inflammation displayed increased autophagic vesicle content compared with normal and EoE remission subjects. Functional flow cytometric analysis revealed autophagic flux in human oesophageal biopsies. CONCLUSIONS Our findings reveal for the first time that autophagy may function as a cytoprotective mechanism to maintain epithelial redox balance and homeostasis under EoE inflammation-associated stress, providing mechanistic insights into the role of autophagy in EoE pathogenesis.
Collapse
Affiliation(s)
- Kelly A. Whelan
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA 19104, USA
| | - Jamie F. Merves
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Veronique Giroux
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA 19104, USA
| | - Koji Tanaka
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA 19104, USA
| | - Andy Guo
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA 19104, USA
| | - Prasanna M. Chandramouleeswaran
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA 19104, USA
| | - Alain J. Benitez
- Division of Allergy and Immunology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Kara Dods
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jianwen Que
- Center for Human Development and Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA
| | - Joanne C. Masterson
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine Aurora, Colorado, USA
| | - Shahan D. Fernando
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine Aurora, Colorado, USA
| | - Bridget C. Godwin
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Andres J. Klein-Szanto
- Histopathology Facility and Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Kudakwashe Chikwava
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Perelman School of Medicine at the University of Pennsylvania, PA 19104, USA
| | - Eduardo D. Ruchelli
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Perelman School of Medicine at the University of Pennsylvania, PA 19104, USA
| | - Kathryn E. Hamilton
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA 19104, USA
| | - Amanda B. Muir
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Mei-Lun Wang
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Glenn T. Furuta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine Aurora, Colorado, USA
| | - Gary W. Falk
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Jonathan M. Spergel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Allergy and Immunology, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Hiroshi Nakagawa
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA 19104, USA
| |
Collapse
|
81
|
Runge TM, Eluri S, Woosley JT, Shaheen NJ, Dellon ES. Control of inflammation decreases the need for subsequent esophageal dilation in patients with eosinophilic esophagitis. Dis Esophagus 2017; 30:1-7. [PMID: 29206905 PMCID: PMC5906132 DOI: 10.1093/dote/dox042] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/04/2017] [Indexed: 12/11/2022]
Abstract
It is unknown if successful control of esophageal inflammation in eosinophilic esophagitis (EoE) decreases the need for subsequent esophageal dilation. We aimed to determine whether histologic response to topical steroid treatment decreases the likelihood and frequency of subsequent esophageal dilation. We conducted a retrospective cohort study. Patients with an incident diagnosis of EoE were included if they had an initial esophageal dilation, received topical steroids, and had a subsequent endoscopy with biopsies. The number of dilations performed in each group was determined, and histologic responders (<15 eos/hpf) were compared to nonresponders. The 55 EoE patients included (27 responders and 28 nonresponders) underwent a mean of 3.0 dilations over a median follow-up of 19 months. Responders required fewer dilations than nonresponders (1.6 vs. 4.6, P = 0.03), after adjusting for potential confounders. Despite undergoing significantly fewer dilations, responders achieved a similar increase in esophageal diameter with dilation (4.9 vs. 5.0 mm; P = 0.92). In EoE patients undergoing esophageal dilation at baseline, control of inflammation with topical steroids was associated with a 65% decrease in the number of subsequent dilations to maintain the same esophageal caliber. This suggests that inflammation control is an important goal in patients with fibrostenotic changes of EoE.
Collapse
Affiliation(s)
- T M Runge
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - S Eluri
- Center for Esophageal Diseases and Swallowing,U niversity of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - J T Woosley
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - N J Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - E S Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Center for Gastrointestinal Biology and Disease ,University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| |
Collapse
|
82
|
Politi E, Angelakopoulou A, Grapsa D, Zande M, Stefanaki K, Panagiotou I, Roma E, Syrigou E. Filaggrin and Periostin Expression Is Altered in Eosinophilic Esophagitis and Normalized With Treatment. J Pediatr Gastroenterol Nutr 2017. [PMID: 28644349 DOI: 10.1097/mpg.0000000000001419] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Previous data have suggested that filaggrin (FLG) and periostin (POSTN) genes may be dysregulated in eosinophilic esophagitis (EoE). We aimed to further evaluate the expression patterns of FLG and POSTN proteins in esophageal tissue samples of patients with EoE, as compared to those of patients with gastroesophageal reflux disease (GERD) and normal controls. METHODS A total of 61 prospectively collected cases, including 40 children with EoE and 21 children with GERD, and a control group of 14 sex- and age-matched healthy children were enrolled. Patients with EoE were treated with skin testing-driven elimination diet and/or corticosteroids. The immunohistochemical expression of FLG and POSTN was evaluated in esophageal biopsies obtained from patients and controls, and the results were correlated with EoE-related clinicopathological parameters. RESULTS Positive FLG and negative POSTN staining were observed in all esophageal biopsies from normal controls. In contrast, FLG and POSTN stained negative and positive, respectively, in all pretreatment biopsies obtained from patients with EoE, whereas FLG and POSTN stained positive in 57.1% and 95.2% of GERD cases, respectively (P < 0.001). A statistically significant decrease of the proportion of cases with negative FLG and positive POSTN staining was observed from the first (pretreatment) to the second (post-treatment) biopsy in the subgroup of patients with EoE (P < 0.001 in both correlations). CONCLUSIONS FLG and POSTN expression may be downregulated and upregulated, respectively, in the esophageal mucosa of patients with active EoE, and these changes may be restored with treatment in a significant percentage of cases.
Collapse
Affiliation(s)
- Ekaterini Politi
- *Cytopathology Department, Areteion Hospital †First Department of Paediatrics, University of Athens, School of Medicine ‡Allergy Department, "Sotiria" General Hospital §Pathology Department, Agia Sophia Children's Hospital, Athens, Greece
| | | | | | | | | | | | | | | |
Collapse
|
83
|
Conner JR, Kirsch R. The pathology and causes of tissue eosinophilia in the gastrointestinal tract. Histopathology 2017; 71:177-199. [DOI: 10.1111/his.13228] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- James R Conner
- Department of Pathology and Laboratory Medicine; Mount Sinai Hospital; Toronto ON Canada
| | - Richard Kirsch
- Department of Pathology and Laboratory Medicine; Mount Sinai Hospital; Toronto ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
| |
Collapse
|
84
|
Kotarkonda LK, Kulshrestha R, Ravi K. Role of insulin like growth factor axis in the bleomycin induced lung injury in rats. Exp Mol Pathol 2017; 102:86-96. [DOI: 10.1016/j.yexmp.2017.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/21/2016] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
|
85
|
Abstract
Eosinophilic esophagitis (EoE) is an emerging chronic atopic clinical-pathologic disease with an estimated prevalence of 1/1000 similar to the one of Crohn's diseases. Usually, EoE is firstly suspected due to symptoms that are caused by esophageal dysfunction and/or fibrosis. EoE diagnosis is confirmed if the esophageal biopsy shows at least 15 eosinophils per high power field (eos/hpf) as a peak value in one or more of at least four specimens obtained randomly from the esophagus. Most of the patients affected by EoE have other atopic diseases such as allergic rhinitis, asthma, IgE-mediated food allergies, and/or atopic dermatitis. The local inflammation is a T helper type 2 (Th2) flogosis, which most likely is driven by a mixed IgE and non-IgE-mediated reaction to food and/or environmental allergens. Recently published genetic studies showed also that EoE is associated with single nucleotide polymorphism (SNP) on genes which are important in atopic inflammation such as thymic stromal lymphopoietin (TSLP) located close to the Th2 cytokine cluster (IL-4, IL-5, IL-13) on chromosome 5q22. When the EoE diagnosis is made, it is imperative to control the local eosinophilic inflammation not only to give symptomatic relief to the patient but also to prevent complications such as esophageal stricture and food impaction. EoE is treated like many other atopic diseases with a combination of topical steroids and/or food antigen avoidance.
Collapse
Affiliation(s)
- Antonella Cianferoni
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Jonathan Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
86
|
Abstract
Activity of Eosinophilic Esophagitis (EoE) can be measured by patient reported outcomes (symptoms and quality of life) and clinician-reported outcomes (endoscopic, histologic, or biochemical alterations). Over the last years efforts have been underway to develop and validate instruments to assess EoE activity in the different domains. Such instruments are urgently needed to standardize the language of EoE activity assessment and, in so doing, to facilitate communication among various stakeholders. Such standardization will ultimately allow EoE researchers to define meaningful endpoints for use in clinical trials and observational studies, to compare the efficacy of different therapeutic modalities, and to develop algorithms in order to provide patients with the appropriate therapy. This review provides an overview of the current status of instruments that assess EoE activity in the different domains.
Collapse
Affiliation(s)
- A Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (University Hospital Lausanne), Lausanne, Switzerland
| | - E Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - A Straumann
- Praxis Römerhof, Swiss EoE Clinic, Olten, Switzerland
| |
Collapse
|
87
|
Molina-Infante J, Schoepfer AM, Lucendo AJ, Dellon ES. Eosinophilic esophagitis: What can we learn from Crohn's disease? United European Gastroenterol J 2016; 5:762-772. [PMID: 29026590 DOI: 10.1177/2050640616672953] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/14/2016] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an emerging esophageal inflammatory disorder affecting children and young adults. As a relatively new disease, EoE is still burdened by frequent diagnostic and therapeutic pitfalls in clinical practice. This manuscript posits a number of similarities with Crohn's disease, which may help optimize EoE patient management. Commonalities include epidemiologic trends (Westernized diseases, rising incidence, early-life risk factors), diagnostic considerations (symptoms are poor predictors of disease activity, difficulties in disease activity assessment) and therapeutic issues (similar natural history and therapeutic goals, induction and maintenance phases, combination of drug and endoscopic treatment, potential drug interchangeability, long-term unsolved issues). Physicians devoted to EoE should learn from the extraordinary achievements fulfilled in Crohn's disease: increased disease awareness, multidisciplinary specialized clinics, structured childhood and transition programs, and an ongoing roadmap for personalized treatments, including genetic susceptibility, risk factors for progression, genotype-phenotype correlation, drug monitoring and microbial data.
Collapse
Affiliation(s)
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| |
Collapse
|
88
|
Hua S, Cook D, Walker MM, Talley NJ. Pharmacological treatment of eosinophilic gastrointestinal disorders. Expert Rev Clin Pharmacol 2016; 9:1195-209. [PMID: 27191032 DOI: 10.1080/17512433.2016.1190268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Eosinophilic gastrointestinal disorders (EGIDs) are increasingly prevalent chronic inflammatory diseases characterized by eosinophilic infiltration of the gastrointestinal (GI) tract, in the absence of other known causes of eosinophilia. AREAS COVERED Clinical management of EGIDs is challenging, as there are currently limited therapeutic options available. The most common EGID is eosinophilic esophagitis (EoE), and rarer forms are eosinophilic gastritis, eosinophilic gastroenteritis, and eosinophilic colitis. Clinical presentation depends on the affected GI site. Recently duodenal eosinophilia has been recognized to commonly be present in patients with functional dyspepsia. This review will provide an overview of the pathogenesis and therapeutic management of EGIDs, with particular focus on the pharmacological strategies for these conditions. Expert commentary: Despite the considerable progress made in understanding the pathogenesis of EGIDs, there is still an urgent need for the development of specific and effective therapeutic approaches. Therapeutic management protocols are required that are based on rigorous clinical investigation in large prospective controlled trials to better understand the risks, benefits and limitations of each therapy. More well-defined and consistent end-points are also required to assess treatment outcomes, as there has been variability between patient reported outcomes, clinical outcomes, and histological outcomes in the studies to date.
Collapse
Affiliation(s)
- Susan Hua
- a School of Biomedical Sciences and Pharmacy , University of Newcastle , Callaghan , NSW , Australia
- b Hunter Medical Research Institute , New Lambton Heights , NSW , Australia
| | - Dane Cook
- c John Hunter Hospital , New Lambton Heights , NSW , Australia
| | - Marjorie M Walker
- b Hunter Medical Research Institute , New Lambton Heights , NSW , Australia
- d School of Medicine & Public Health , University of Newcastle , Callaghan , NSW , Australia
| | - Nicholas J Talley
- b Hunter Medical Research Institute , New Lambton Heights , NSW , Australia
- d School of Medicine & Public Health , University of Newcastle , Callaghan , NSW , Australia
| |
Collapse
|
89
|
Rawson R, Yang T, Newbury RO, Aquino M, Doshi A, Bell B, Broide DH, Dohil R, Kurten R, Aceves SS. TGF-β1-induced PAI-1 contributes to a profibrotic network in patients with eosinophilic esophagitis. J Allergy Clin Immunol 2016; 138:791-800.e4. [PMID: 27212082 PMCID: PMC5014565 DOI: 10.1016/j.jaci.2016.02.028] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 12/29/2015] [Accepted: 02/11/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is an allergic disease of increasing worldwide incidence. Complications are due to tissue remodeling and involve TGF-β1-mediated fibrosis. Plasminogen activator inhibitor 1 (PAI-1/serpinE1) can be induced by TGF-β1, but its role in EoE is not known. OBJECTIVE We sought to understand the expression and role of PAI-1 in patients with EoE. METHODS We used esophageal biopsy specimens and plasma samples from control subjects and patients with EoE, primary human esophageal epithelial cells, and fibroblasts from patients with EoE in immunohistochemistry, quantitative PCR, and immunoassay experiments to understand the induction of PAI-1 by TGF-β1, the relationship between PAI-1 and esophageal fibrosis, and the role of PAI-1 in fibrotic gene expression. RESULTS PAI-1 expression was significantly increased in epithelial cells of biopsy specimens from patients with active EoE compared with that seen in biopsy specimens from patients with inactive EoE or control subjects (P < .001). Treatment of primary esophageal epithelial cells with recombinant TGF-β1 increased PAI-1 transcription, intracellular protein expression, and secretion. Esophageal PAI-1 expression correlated with basal zone hyperplasia, fibrosis, and markers of esophageal remodeling, including vimentin, TGF-β1, collagen I, fibronectin, and matrix metalloproteases, and plasma PAI-1 levels correlated with plasma TGF-β1 levels. PAI-1 inhibition significantly decreased baseline and TGF-β1-induced fibrotic gene expression. CONCLUSIONS PAI-1 expression is significantly increased in the epithelium in patients with EoE and reflects fibrosis, and its inhibition decreases TGF-β1-induced gene expression. Epithelial PAI-1 might serve as a marker of EoE severity and form part of a TGF-β1-induced profibrotic network.
Collapse
Affiliation(s)
- Renee Rawson
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Tom Yang
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Robert O Newbury
- Department of Pediatric Pathology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Melissa Aquino
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Ashmi Doshi
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Braxton Bell
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - David H Broide
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Ranjan Dohil
- Division of Pediatric Gastroenterology and Nutrition, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif
| | - Richard Kurten
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital Research Institute, Little Rock, Ark
| | - Seema S Aceves
- Division of Allergy and Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif; Center for Infection, Immunity, and Inflammation, Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, and Rady Children's Hospital, San Diego, Calif.
| |
Collapse
|
90
|
Deeper Than the Epithelium: Role of Matrix and Fibroblasts in Pediatric and Adult Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2016; 63:168-9. [PMID: 27457777 PMCID: PMC4965178 DOI: 10.1097/mpg.0000000000001183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
91
|
Schoepfer A, Safroneeva E, Straumann A. Eosinophilic Esophagitis: Impact of Latest Insights Into Pathophysiology on Therapeutic Strategies. Dig Dis 2016; 34:462-8. [PMID: 27333298 DOI: 10.1159/000445201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Eosinophilic esophagitis (EoE) has been defined as a 'chronic, immune/antigen-mediated, esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation'. A peak value of ≥15 eosinophils/high power field has been defined as histologic diagnostic cutoff. Other conditions associated with esophageal eosinophilia, such as gastro-esophageal reflux disease, PPI-responsive esophageal eosinophilia or Crohn's disease, need to be ruled out before EoE can be diagnosed. Males are affected more frequently than females and most of the patients have concomitant allergies. Currently, the EoE prevalence is about 1 of 2,000 inhabitants in Westernized countries. The first EoE patients were described only 2 decades ago. Despite this short period, considerable progress has been made regarding the understanding of the pathophysiology, natural history, assessment of disease activity and with respect to evaluating different therapeutic options. Untreated EoE can lead to esophageal remodeling with reduced compliance and stricture formation, which represents the main risk factor for food bolus impactions. The therapeutic options can be summarized with the 3 D's, which stand for drugs, diets and dilation. Of note, as of yet, there is no EoE-specific drug that has been approved by regulatory authorities. This is, among other reasons, related to the lack of validated outcome measurement instruments until recently. Swallowed topical steroids such as budesonide or fluticasone represent the standard of care for treating symptomatic pediatric and adult EoE patients with inflammatory activity. Several trials have already evaluated different biologic therapies, such as anti-interleukin-5 or anti-IgE. Further studies are on the way. As a non-pharmacologic alternative, different dietary regimens exist. Dilation can offer long-lasting symptomatic response in case of stricturing EoE but does not have any impact on the underlying inflammation. This review highlights the latest insights regarding pathophysiology and its impact regarding current and future therapeutic strategies.
Collapse
Affiliation(s)
- Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | | |
Collapse
|
92
|
Davis BP, Rothenberg ME. Mechanisms of Disease of Eosinophilic Esophagitis. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2016; 11:365-93. [PMID: 26925500 DOI: 10.1146/annurev-pathol-012615-044241] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a recently recognized inflammatory disease of the esophagus with clinical symptoms derived from esophageal dysfunction. The etiology of EoE is now being elucidated, and food hypersensitivity is emerging as the central cornerstone of disease pathogenesis. Herein, we present a thorough picture of the current clinical, pathologic, and molecular understanding of the disease with a focus on disease mechanisms.
Collapse
Affiliation(s)
- Benjamin P Davis
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242;
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229;
| |
Collapse
|
93
|
Outcomes of Esophageal Dilation in Eosinophilic Esophagitis: Safety, Efficacy, and Persistence of the Fibrostenotic Phenotype. Am J Gastroenterol 2016; 111:206-13. [PMID: 26753894 PMCID: PMC4758887 DOI: 10.1038/ajg.2015.399] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 11/01/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Esophageal dilation is commonly performed in eosinophilic esophagitis (EoE), but there are few long-term data. The aims of this study were to assess the safety and long-term efficacy of esophageal dilation in a large cohort of EoE cases, and to determine the frequency and predictors of requiring multiple dilations. METHODS We conducted a retrospective cohort study in the University of North Carolina EoE Clinicopathological Database from 2002 to 2014. Included subjects met consensus diagnostic criteria for EoE. Clinical, endoscopic, and histologic features were extracted, as were dilation characteristics (dilator type, change in esophageal caliber, and total number of dilations) and complications. Patients with EoE who had undergone dilation were compared with those who did not and also stratified by whether they required single or multiple dilations. RESULTS Of 509 EoE patients, 164 were dilated a total of 486 times. Those who underwent dilation had a longer duration of symptoms before diagnosis (11.1 vs. 5.4 years, P<0.001). Ninety-five patients (58%) required >1 dilation (417 dilations total, mean of 4.4±4.3 per patient). The only predictor of requiring multiple dilations was a smaller baseline esophageal diameter. Dilation was tolerated well, with no major bleeds, perforations, or deaths. The overall complication rate was 5%, primarily due to post-procedural pain. Of 164 individuals dilated, a majority (58% or 95/164) required a second dilation. Of these individuals, 75% required repeat dilation within 1 year. CONCLUSIONS Dilation in EoE is well-tolerated, with a very low risk of serious complications. Patients with long-standing symptoms before diagnosis are likely to require dilation. More than half of those dilated will require multiple dilations, often needing a second procedure within 1 year. These findings can be used to counsel patients with fibrostenotic complications of EoE.
Collapse
|
94
|
Dellon ES, Gebhart JH, Higgins LL, Hathorn KE, Woosley JT, Shaheen NJ. The esophageal biopsy "pull" sign: a highly specific and treatment-responsive endoscopic finding in eosinophilic esophagitis (with video). Gastrointest Endosc 2016; 83:92-100. [PMID: 26142556 PMCID: PMC4691559 DOI: 10.1016/j.gie.2015.05.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 05/23/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Esophageal biopsy specimens from patients with eosinophilic esophagitis (EoE) can feel firm, with resistance felt when pulling the forceps to obtain the tissue sample. We aimed to assess the diagnostic utility of the esophageal biopsy "pull" sign and determine its histologic associations and response to treatment. METHODS This was a prospective cohort study of adults undergoing outpatient upper endoscopy. Cases of EoE were diagnosed per consensus guidelines, and patients were subsequently treated with either topical steroids or dietary elimination. Control subjects were individuals who did not have EoE. The frequency of the esophageal biopsy "pull" sign was assessed in EoE patients and controls, and diagnostic metrics were calculated. The "pull" sign was also reassessed in patients after therapy. RESULTS A total of 83 EoE patients and 121 control subjects were included. Sixty-three EoE patients (76%) were "pull" sign positive compared with just 2 control subjects (2%; P < .001), corresponding to a sensitivity and specificity of 76% and 98%, positive and negative predictive values of 97% and 86%, and positive and negative likelihood ratios of 45.9 and 0.245, respectively. The "pull" sign was the strongest endoscopic predictor of EoE case status at baseline and was less frequent after successful treatment (20% vs 79%; P < .001). CONCLUSIONS The "pull" sign is highly specific for EoE and is rarely seen in non-EoE control subjects. In patients with EoE who respond to treatment, the "pull" sign often resolves. The "pull" sign may be a simple and easily obtained measure of esophageal remodeling.
Collapse
Affiliation(s)
- Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jessica H. Gebhart
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Leana L. Higgins
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kelly E. Hathorn
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - John T. Woosley
- Department of Pathology and Laboratory Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nicholas J. Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| |
Collapse
|
95
|
Lorenz KJ, Kraft K, Graf F, Pröpper C, Steinestel K. [Importance of cellular tight junction complexes in the development of periprosthetic leakage after prosthetic voice rehabilitation]. HNO 2015; 63:171-2, 174-8, 180-1. [PMID: 25515126 DOI: 10.1007/s00106-014-2951-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The use of voice prostheses is currently the gold standard in voice rehabilitation after total laryngectomy. This method combines low complication rates and excellent rehabilitation results; however, approximately 30% of patients show periprosthetic leakage or severe fistula enlargement after laryngectomy and prosthetic voice restoration within the first 4 years. The development of this enlargement is controversially discussed in the literature but recently published studies have shown that high esophageal reflux plays a key role in this process, which leads to an inflammatory reaction and disturbs the intercellular tight junctions in the sense of an epithelial mesenchymal transition (EMT). MATERIAL AND METHODS A total of 44 patients underwent 24 h pH monitoring, a sample biopsy from the region of the fistula and a subsequent biomolecular examination for intracellular junction proteins as well as a correlation between the severity of reflux and tracheoesophageal fistula problems before and after antireflux therapy with proton pump inhibitors (PPI). RESULTS Immunohistochemical staining revealed decreases in membrane E-cadherin and β-catenin and a significant increase in the cytoplasmic fraction, depending on the severity of inflammation in the fistula tissue. In patients with an improvement of clinical fistula problems under oral PPI treatment an increase of membrane E-cadherin could be shown, whereas patients with persisting fistula enlargement demonstrated a further decrease of E-cadherin. CONCLUSION The data indicate a central role of EMT in the development of fistula enlargement after total laryngectomy. Patients with periprosthetic leakage showed a loss of membrane bound E-cadherin and β-catenin with an up-regulation of vimentin expression. In patients with mild or no leakage problems EMT could be resolved by aggressive antireflux treatment, whereas patients without any effect of PPI treatment on the fistula showed no reversal of EMT. These data contribute to the understanding of treatment resistant fistula enlargement after total laryngectomy.
Collapse
Affiliation(s)
- K J Lorenz
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf-Hals-Chirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland,
| | | | | | | | | |
Collapse
|
96
|
Abstract
OBJECTIVES In contrast to peptic strictures, clinically significant strictures in patients with eosinophilic esophagitis (EoE) may be subtle and go unrecognized at the time of endoscopy. We aimed to identify how often stricture was identified by endoscopy as compared with contrast esophagram. METHODS We retrospectively reviewed esophagram and endoscopy examinations of all of the patients with EoE with esophageal stricture seen at a tertiary care pediatric hospital over a 6-year period who had both procedures completed within a 3-month time frame. Medical charts were reviewed for clinicopathologic information including age, duration of symptoms, histology, and treatment. RESULTS Twenty-two children with EoE-associated stricture completed both esophagram and endoscopic assessments. Esophageal strictures were identified by esophagram, and not endoscopy, in 55% of these children. Patients with stricture identified at esophagram alone had a shorter duration of symptoms (2.1 years duration vs 5.4 years duration, P = 0.03) than the group identified by endoscopy. Preoperative radiographic identification of a stricture was associated with dilation more often being performed. CONCLUSIONS Esophagram is a valuable test to assess esophageal anatomy in children with complicated EoE. Esophagram may be able to detect subtle fibrostenosis earlier in the natural history of the disease than endoscopy.
Collapse
|
97
|
Abstract
Once considered a rare condition, eosinophilic esophagitis is now one of the most common conditions diagnosed during the assessment of feeding problems in children and during the evaluation of dysphagia and food impaction in adults. The entity exists worldwide but has been most extensively studied in Western countries, where its prevalence has been estimated to be 0.4% among all children and adults. Whether eosinophilic esophagitis is truly a new disease or simply a recently recognized one is uncertain. In this review, we consider the diagnostic criteria, pathophysiological and clinical features, and treatment of this increasingly prevalent disease.
Collapse
|
98
|
Current Approach to the Management of Eosinophilic Esophagitis in Adults. ACTA ACUST UNITED AC 2015; 13:441-51. [DOI: 10.1007/s11938-015-0069-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
99
|
Eosinophils and IL-33 Perpetuate Chronic Inflammation and Fibrosis in a Pediatric Population with Stricturing Crohn's Ileitis. Inflamm Bowel Dis 2015; 21. [PMID: 26218140 PMCID: PMC4567482 DOI: 10.1097/mib.0000000000000512] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fibrostenosis and stricture are well-recognized endpoints in Crohn's disease (CD). We hypothesized that stricturing CD is characterized by eosinophilia and epithelial IL-33. We proposed that eosinophil exposure to IL-33 would perpetuate inflammatory chronicity and subsequent fibrostenosis. METHODS We performed a retrospective study of 74 children with inflammatory and stricturing ileal CD comparing clinicopathological features to immunohistochemical measures of eosinophilia and IL-33. To scrutinize eosinophil patterns, we developed a novel eosinophil peroxidase score encompassing number, distribution, and degranulation. Human eosinophils and intestinal fibroblasts were cultured with IL-33 and IL-13, and inflammatory and remodeling parameters were assessed. Antieosinophil therapy was also administered to the Crohn's-like ileitis model (SAMP1/SkuSlc). RESULTS Our novel eosinophil peroxidase score was more sensitive than H&E staining, revealing significant differences in eosinophil patterns, comparing inflammatory and stricturing pediatric CD. A significant relationship between ileal eosinophilia and complicated clinical/histopathological phenotype including fibrosis was determined. IL-33 induced significant eosinophil peroxidase secretion and IL-13 production. Exposure to eosinophils in the presence of IL-33, "primed" fibroblasts to increase proinflammatory cytokines (TNF-α, IL-1β, and IL-6), eosinophil-associated chemokines (CCL24 and CCL26), and IL-13Rα2 production. Production of fibrogenic molecules (collagen 1A2, fibronectin, and periostin) increased after exposure of "primed" fibroblasts to IL-13. Epithelial-IL-33 was increased in pediatric Crohn's ileitis and strongly associated with clinical and histopathological activity, ileal eosinophilia, and complicated fibrostenotic disease. SAMP1/SkuSlc eosinophil-targeted treatment resulted in significant improvements in inflammation and remodeling. CONCLUSIONS Our study of specimens from pediatric patients with ileal CD linked eosinophil patterns and IL-33 to fibrosis and suggested that these may contribute to the perpetuation of inflammation and subsequent stricture in pediatric CD.
Collapse
|
100
|
Kochar B, Dellon ES. Management of proton pump inhibitor responsive-esophageal eosinophilia and eosinophilic esophagitis: controversies in treatment approaches. Expert Rev Gastroenterol Hepatol 2015; 9:1359-69. [PMID: 26365201 PMCID: PMC4644096 DOI: 10.1586/17474124.2015.1088384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated clinicopathologic disease. The prevalence of EoE is approximately 1/2000 persons, EoE is now the most common cause of food impactions, with healthcare expenditures approaching US$ 1 billion annually. This article will discuss challenges related to proton pump inhibitor responsive esophageal eosinophilia, including distinguishing this condition from EoE and understanding the mechanisms behind the PPI response. For EoE, we will review multiple ongoing debates about treatment and monitoring strategies, including selecting treatment outcomes, optimizing medication formulations, approaching the steroid-refractory patient, conducting dietary elimination, prescribing long-term maintenance therapy and performing esophageal dilation.
Collapse
Affiliation(s)
- Bharati Kochar
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| |
Collapse
|