Epidemiology and Natural History of Eosinophilic Esophagitis

Impact of transfer from pediatric gastroenterology to adult gastroenterology care in eosinophilic esophagitis

Given the chronic and progressive course of eosinophilic esophagitis (EoE), patients with pediatric-onset EoE will require uninterrupted gastroenterology (GI) care as they reach adulthood. Yet, the effectiveness of transferring and integrating EoE patients from pediatric GI (pGI) to adult GI (aGI) care has not been studied. To address this gap, we assessed loss to follow-up, duration from the last pGI to the first aGI encounters (clinic visit and EGD), and its impact on clinical course and medication non-adherence in EoE patients. We identified 58 EoE patients who initially received pGI care and were transferred to aGI between 2017 and 2023 within our institution's shared electronic medical record environment. Demographic, clinical, endoscopic, and histologic data were analyzed using descriptive statistics, survival analysis, Cox regression models, and paired comparisons. Loss to follow-up was 16%. The median duration from the last pGI clinic visit to the first aGI clinic visit was 299 days, and that for the last pGI EGD to the first aGI EGD was 730 days. A significantly higher odds of heartburn (McNemar P-value = 0.01) and higher medication non-adherence rates (7% vs. 26%) were noted in 49 patients who established care with the aGI. The endoscopic and histologic severity remained unchanged. In EoE patients, transferring from pGI to aGI care is associated with loss of follow-up, deterioration of symptoms, and medication non-adherence. There is a critical need to develop optimized protocols to ensure a seamless transfer of care for EoE patients.

Segmental overlap is common in eosinophilic gastrointestinal diseases and impacts clinical presentation and treatment

Little is known about the extent or importance of overlapping gastrointestinal (GI) tract involvement in eosinophilic gastrointestinal diseases (EGIDs), how presentations differ by areas of involvement, and whether overlap impacts treatments. We aimed to evaluate overlapping GI tract involvement in EGIDs and whether clinical differences existed. To do this, we assessed the EGID Partners cohort, an online patient-centered research network. Adults (≥18 years) and caregivers of children <18 years old with EoE or non-EoE EGIDs could join. Surveys were completed at enrollment, comparing patients with EoE alone, EGID without esophageal involvement ('EGID-NE'), and EGID with esophageal involvement ('EGID-WE'). Of 527 cases enrolled, 402 had EoE alone and 125 had non-EoE EGID, 57 (46%) with EGID-NE, and 68 (53%) with EGID-WE. There were 10, 18, and 9 with eosinophilic gastritis, gastroenteritis, and colitis alone, respectively; 88 had overlap. EGID-NE had a higher proportion of females (79%; P < 0.001), and family history of EoE/EGID was more common in EGID-WE (19% vs. 11% in EoE and 7% in EGID-NE; P = 0.007). Patient-Reported Outcomes Measurement Information System measures for anxiety were above general population averages and highest for EGID-WE. Treatments such as elemental formula (47% vs. 32% vs. 20%; P = 0.001), systemic steroids (33% vs. 56% vs. 14%; P < 0.001), and biologics were also more common in EGID-WE and EGID-NE. In conclusion, overlap in regions with eosinophilic infiltration is common for non-EoE EGIDs, with more than half of non-EoE EGIDs having esophageal involvement and a high proportion of multisegmental involvement. EGID-WE patients tended to have more disease burden.

Impact of cannabis use on presentation and treatment response in eosinophilic esophagitis

Cannabis use is becoming increasingly common, both for recreational and medical purposes. However, there is a paucity of data regarding cannabis use in the context of eosinophilic esophagitis (EoE). We aimed to determine the impact of cannabis use on presentation and treatment response in EoE. To this end, we conducted a retrospective cohort study at a large academic medical center of newly diagnosed EoE patients age ≥ 12 years. Self-reported cannabis use status, baseline characteristics, and treatment response to topical corticosteroids and dietary therapy data were extracted. Bivariate and multivariable analyses were used to compare cannabis users and non-users at time of EoE diagnosis and to assess treatment response. Of 983 EoE patients, 80 reported using cannabis, with the majority reporting daily use and administration by inhalation. Baseline symptoms and peak eosinophil count were similar between cannabis users and non-users; cannabis users were less likely to have baseline endoscopic findings of exudates, edema, and stricture, and lower total Endoscopic Reference Score. On multivariable analysis, younger age, male sex, non-White race, and psychiatric diagnosis were independently associated with history of cannabis use at EoE presentation and stricture was independently associated with cannabis non-use. Post-treatment symptom and histologic responses were similar between cannabis users and non-users though there was a higher odds of post-treatment endoscopic inflammatory features with cannabis use. In conclusion, despite presenting with milder initial endoscopic findings, cannabis users exhibited greater inflammatory findings after treatment, highlighting a potential negative influence of cannabis use on EoE management.

Exploring X: barriers to care for eosinophilic esophagitis

Patients with chronic diseases have increasingly turned to social media to discuss symptoms and share the challenges they face with disease management. The primary aim of this study is to use naturally occurring data from X (formerly known as Twitter) to identify barriers to care faced by individuals affected by eosinophilic esophagitis (EoE). For this qualitative study, the X application programming interface with academic research access was used to search for posts that referenced EoE between 1 January 2019 and 10 August 2022. The posts were identified as being either related to barriers to care for EoE or not. Those related to barriers to care were further categorized by the type of barrier that was expressed. A total of 8636 EoE-related posts were annotated of which 12.1% were related to barriers to care in EoE. The themes that emerged about barriers to care included: dietary challenges, limited treatment options, lack of community support, lack of physician awareness of disease, misinformation, cost of care, lack of patient belief in disease or trust in physician, and limited access to care. Saturation of themes was achieved. This study highlights barriers to care in EoE using readily accessible social media data that is not derived from a curated research setting. Identifying these obstacles is key to improving care for this chronic disease.

Role of endoscopy in eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease involving inflammation of the esophagus. Endoscopy is essential in the diagnosis and treatment of EoE and shows typical findings, including esophageal edema, rings, exudates, furrows, and stenosis. However, studies involving pediatric and adult patients with EoE suggest that even a normally appearing esophagus can be diagnosed as EoE by endoscopic biopsy. Therefore, in patients with suspected EoE, biopsy samples should be obtained from the esophagus regardless of endoscopic appearance. Moreover, follow-up endoscopies with biopsy after therapy initiation are usually recommended to assess response. Although previous reports of endoscopic ultrasonography findings in patients with EoE have shown diffuse thickening of the esophageal wall, including lamina propria, submucosa, and muscularis propria, its role in EoE remains uncertain and requires further investigation. Endoscopic dilation or bougienage is a safe and effective procedure that can be used in combination with medical and/or dietary elimination therapy in patients with esophageal stricture for the management of dysphagia and to prevent its recurrence.

No Association Between Eosinophilic Oesophagitis and Oesophageal Cancer in US Adults: A Case-Control Study

BACKGROUND

While inflammation is implicated in the development of numerous cancers, whether eosinophilic oesophagitis (EoE) increases the risk of oesophageal cancer (OCa) remains understudied.

AIM

To assess whether adults with EoE were more likely to have subsequent OCa diagnosis.

METHODS

This case-control study used data from the MarketScan commercial claims database. Cases were 18-64 years old with an oesophageal cancer diagnosis (≥ two coding instances) who had no previous oesophageal cancer code. Controls were matched 10:1 by age and time in health plan. All cases and controls had at least 2 years of continuous healthcare coverage before the index date. EoE status required ≥ two coding instances. We used conditional logistic regression modelling to assess the association between EoE and oesophageal cancer.

RESULTS

Of 5562 eligible cases and 55,620 matched controls, median age was 58.8 years and median number of years in health plan was 5.1. The proportions of male cases and controls were 81.3% and 41.4%, respectively. A history of EoE was rare in both cases and controls. Only two oesophageal cancer cases (0.04%) and 44 controls (0.08%) had evidence of an EoE diagnosis (OR 0.46; 95% CI 0.11-1.88).

CONCLUSIONS

EoE is not associated with the development of oesophageal cancer in privately insured adults under 65 years old; co-incidence of EoE and oesophageal cancer is extremely rare. Additional studies are needed to confirm these findings and to evaluate whether they hold in older adults or over longer follow-up, and whether EoE might protect against oesophageal cancer.

Distribution of esophageal inflammation in patients with eosinophilic esophagitis and its impact on diagnosis and outcome

BACKGROUND

This study aimed to assess the distribution of esophageal inflammation in patients with eosinophilic esophagitis (EoE) and its impact on diagnosis and outcome.

AIMS AND METHODS

Data from consecutive adult EoE patients who were followed-up at four Italian referral centers from October 2022 to October 2023 were retrospectively collected.

RESULTS

One hundred forty-nine patients were included. Proximal EoE was observed in 8.1 % of patients; distal EoE in 27.5 %; and diffuse EoE in 64.4 %. Allergic rhinitis was more prevalent in distal and diffuse than proximal EoE (72.5 % vs. 61.5 % vs 33.3 %; P = 0.049). The prevalence of asthma, atopic dermatitis, oral allergy syndrome, and gastroesophageal reflux disease was not significantly different among the three EoE extent groups. Endoscopic inflammatory features at diagnosis were more prevalent in proximal EoE (91.7 % vs. 53.8 % distal [P = 0.01] vs. 66 % diffuse[P = 0.05]). No significant differences in fibrotic features and esophageal stenoses were observed. The clinical and histological remission rates after first-line therapy were comparable in all groups.

CONCLUSION

Esophageal inflammation in EoE more frequently involves the entire esophagus, followed by isolated distal and proximal involvement. No clear correlation was observed between the histological extent of EoE at diagnosis and comorbidities or treatment response.

Development and Validation of the PICK-UP-STRICS Score to Predict Fibrostenosis in Patients with EoE Prior to Endoscopy

BACKGROUND

Predicting fibrostenotic complications prior to endoscopy in eosinophilic esophagitis (EoE) is challenging and esophageal strictures and narrowing are commonly missed on endoscopy.

AIM

To develop and validate a score to predict fibrostenosis in EoE patients prior to endoscopy.

METHODS

We leveraged a large database of newly diagnosed EoE patients. Fibrostenosis was defined as esophageal stricture, luminal narrowing, or dilation performed during the diagnostic endoscopy. Patients were randomly divided into a development and validation set. We compared features between patients with and without fibrostenosis to inform the initial model and assess predictive ability, as measured by area under curve (AUC). We tested the model in the independent validation set and generated a score to predict low, medium and high fibrostenosis risk.

RESULTS

In 655 newly diagnosed EoE patients in the development set, fibrostenosis was associated with age ≥ 18 years (OR 10.64; 95% CI 5.61-20.17), symptoms for ≥ 5 years prior to diagnosis (OR 2.07; 1.32-3.24), dysphagia (OR 3.72; 1.68-8.22), food impaction (OR 1.68; 1.07-2.62), and lack of abdominal pain (OR 0.28; 0.14-0.60). The model predicted fibrostenosis (AUC = 0.841). In the validation set (n = 654), AUC was preserved (0.831). A scoring system was generated, with scores of ≤ 2 being low risk (< 10% chance of stricture), 2.5-4.5 medium risk (10-50% stricture), and 5-6 high risk (> 50%).

CONCLUSIONS

We developed and validated the PICK-UP-STRICS score to increase suspicion and detection of fibrostenotic disease in EoE using readily available clinical features prior to endoscopy. This score may guide clinical decisions on the need of endoscopic dilation.

The epidemiology of eosinophilic esophagitis in Sweden - a nationwide population-based study

INTRODUCTION

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition that affects the esophagus. Previous studies have indicated a substantial increase of EoE over the last decades. The aim of the current study was to describe the incidence and prevalence of EoE over time and by geographical regions in Sweden, utilizing nationwide population-based registries.

MATERIAL AND METHODS

The number of hospital admissions (in-patient and out-patient) for patients were identified using ICD-10-SE code K20.9A from the National Patient Registry between 1st January 2011 and 31st December 2021. Crude incidence and prevalence numbers were presented per 100,000 person years and persons, respectively.

RESULTS

In 2011, no hospital visits of EoE were recorded. A total of 3,243 incident patients (2,379 (73.4%) men and 864 (26.6%) women) had a record of EoE between 2012 and 2021. The incidence increased over calendar year in where the incidence was from 1.59 per 100,000 person years in 2012 to 5.34 per 100,000 person years in 2021. The prevalence was 1.29 per 100,000 person years and 31.02 per 100,000 person years in 2012 and 2021, respectively. Major differences in the prevalence between geographical regions in Sweden were observed, e.g. in 2021, the prevalence was 12.24 in Västernorrland compared to 43.26 in Västra Götaland per 100,000 person years, which is similar to the prevalence in the Stockholm region.

CONCLUSION

The incidence and prevalence of eosinophilic esophagitis has significantly increased over calendar year but differs between geographical regions in Sweden. These differences should be further investigated.

Dupilumab is efficacious for eosinophilic esophagitis irrespective of prior swallowed budesonide or fluticasone, or prior treatments used alongside swallowed topical corticosteroids: results from the phase 3, randomized, placebo-controlled, LIBERTY EoE TREET trial

BACKGROUND

Standard treatments for eosinophilic esophagitis (EoE) may present adherence, tolerance, and efficacy challenges. Dupilumab 300 mg weekly is approved for the treatment of EoE in patients ≥ 1 year old, weighing ≥ 15 kg. This analysis aimed to evaluate dupilumab efficacy in patients from the LIBERTY EoE TREET trial (NCT03633617), with prior history of different EoE interventions.

RESEARCH DESIGN AND METHODS

This analysis included patients from Parts B/B - C of LIBERTY EoE TREET. Dupilumab efficacy was analyzed according to prior swallowed budesonide or fluticasone use and in those patients with previously trialed food elimination diet, esophageal dilation, or baseline proton pump inhibitor use, as stratified by prior swallowed topical corticosteroid (STC) use or STC inadequate response/intolerance/contraindication.

RESULTS

Dupilumab improved the proportion of patients achieving peak intraepithelial eosinophil count ≤ 6 eosinophils/high-power field, absolute change in Dysphagia Symptom Questionnaire score, and other histologic, symptomatic, and endoscopic endpoints vs. placebo at Week (W) 24, irrespective of prior swallowed budesonide/fluticasone use. Improvements were maintained at W52. Similar results were observed across the other subgroups.

CONCLUSION

Dupilumab was efficacious in patients with EoE irrespective of prior treatments/interventions.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov identifier is NCT03633617.

Epidemiology of Eosinophilic Esophagitis: Really a Novel and Evolving Disease?

Background

Eosinophilic esophagitis (EoE) has been described as a chronic allergen/immune-mediated disease characterized by symptoms of esophageal dysfunction and eosinophilic infiltration of the mucosa.

Summary

Over the past decades, EoE has been increasingly recognized in various geographical areas with a high socioeconomic development (mostly industrialized countries) and has evolved from an unknown to a clinically distinct disease with increasing prevalence and incidence. An average age at diagnosis between 30 and 50 years and a male predominance have been consistently observed. In both children and adults, EoE is clearly associated with allergies, predominantly food - but also aeroallergens. Most EoE patients present with a personal allergic background such as asthma, rhino-conjunctivitis, and oral allergy syndrome.

Key Message

Knowledge of epidemiological characteristics is crucial for identifying risk factors and understanding of the pathogenic mechanisms.

Assessment of Disease Activity in Eosinophilic Esophagitis: Is It Clinically Relevant or Simply an Amusement for Experts?

Background

Since the first description of eosinophilic esophagitis (EoE) as clinicopathologic syndrome three decades ago, considerable progress has been made to standardize and validate instruments to assess symptom severity, quality of life, endoscopic, and histologic activity for the purpose of randomized controlled trials (RCTs) and observational studies. Standardized assessment of EoE activity is crucial to be able to compare the results of therapeutic interventions and bring much needed therapies to patients. This review focuses on outcome assessment of disease activity in adults with EoE.

Summary

The choice of endpoints/instruments to be used depends on the setting, which might be either an RCT, an observational study, or clinical practice. In RCTs, the choice of endpoints further depends on requirements from regional regulatory authorities. Primary endpoints chosen in RCTs typically focused on symptoms and esophageal peak eosinophil counts, although that likely will change, as therapies with new mechanism of action are explored. Validated symptom-based PRO instruments used in RCTs include the Daily Symptom Questionnaire (DSQ), the EoE activity index (EEsAI) PRO instrument, and numeric rating scales for dysphagia and pain. Histologic activity in RCT is assessed using the EoE histologic scoring system (EoEHSS) that takes into account the severity and extent of eight distinct histologic features. Endoscopic activity is assessed using the EREFS (Exudates, Rings, Edema, Furrows, Stricture) grading system. For observational studies, activity assessment is based on EEsAI PRO, epithelial peak eosinophil counts, and EREFS. In daily clinical practice, EoE activity is based on assessment of symptoms using a visual analog scale (VAS, from 0-10), peak eosinophil count, and EREFS. Several other instruments including the I-SEE, dysphagia-free days over a defined period, the dysphagia stress test, and impedance planimetry (EndoFLIP), to assess EoE severity in clinical practice are currently under evaluation.

Key Messages

EoE activity assessment based on symptom-based PRO, histology, and endoscopy has become increasingly complex and varies depending on the setting. While more stringent endpoints and daily recall PRO instruments are being used in RCTs, new instruments aimed at broader disease activity assessment and weekly recall PRO instruments are being used in observational studies and daily clinical practice.

Clinical description of adults with eosinophilic esophagitis treated at a Chilean university center

INTRODUCTION AND AIM

Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disease that affects the esophagus. Its epidemiology in Chile and Latin America is unknown due to the absence of population studies. Our aim was to describe the clinical, endoscopic, and histologic characteristics of adult patients diagnosed with EoE, as well as their treatment response.

MATERIAL AND METHODS

A descriptive prospective study was conducted on a cohort of patients ≥ 18 years of age with an eosinophil count greater than 15 eosinophils/high power field.

RESULTS

A total of 62 patients were included, 75.8% of whom were men. Mean patient age was 38 years, mean age at diagnosis was 34 years, and diagnosis was made later in men. Sixty-five percent had a concomitant immunoallergic disease, and allergic rhinitis was the most frequent. Dysphagia was the most frequent referral, with a predominance of men. Women presented more often with food allergies and peripheral eosinophilia. The most frequent endoscopic finding was edema, followed by rings, with a mean eosinophilic esophagitis endoscopic reference score (EREFS) of 3.5 and a mean eosinophil count in biopsies of 37.5 eosinophils/high power field. Men presented with a higher EREFS and eosinophil count at diagnosis. All patients received treatment and the most frequent was with proton pump inhibitors, followed by combination treatment with corticosteroids. Endoscopic (partial/total) and histologic response rates were 93.5 and 77%, respectively.

CONCLUSION

We found characteristics in our cohort similar to those described in international groups. Women presented with greater autoimmune comorbidity, peripheral eosinophilia, and food allergies, but had a lower eosinophil count and endoscopic score. We found no differences between the different therapeutic regimens.

Eosinophilic esophagitis: Current concepts of pathophysiology, diagnosis, and treatment

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by the infiltration of eosinophils into the esophageal mucosa. It is the most frequent cause of dysphagia and food impaction in adults. Due to its similar pathophysiology to allergic rhinitis, asthma, and atopic dermatitis, it has been considered the esophageal manifestation of allergy. It is more frequently seen in the United States, Europe, and Australia. Incidence and prevalence have increased significantly in those countries over the past three decades, to such a degree that some consider it an epidemic. The disease is infrequently diagnosed in Mexico and Latin America, and so little information on this disease is produced in our region of the world. The precise factors explaining this low incidence are unknown. On the other hand, there has been intense research on EoE in other parts of the world in recent years. Its pathophysiology has been better understood and endoscopic and clinical procedures have been refined for making the diagnosis. In addition, new drugs and special formulations of existing ones have been introduced for treating the disease. Simpler and more effective dietary treatment strategies have also been evaluated. The aim of the present work was to review the current status of EoE globally and in Mexico, emphasizing the probable factors (environmental and technical) that intervene in the low incidence recorded in our country. In addition, we conducted a review of the advances in research on the different aspects of EoE carried out in recent years.

Treatment Preference Archetypes in Eosinophilic Esophagitis and Their Implications for Therapy

INTRODUCTION

Little is known about how patients make decisions about and prioritize therapies and disease management in eosinophilic esophagitis (EoE). We aimed to systematically identify and characterize patient perspectives and attitudes that influence decision making for EoE management.

METHODS

To understand the diverse attitudes and values of patients with EoE, we designed a study using the Q-method. We iteratively developed 31 statements related to EoE disease management. Participants sorted statements by ranking from +4 (most agree) to -4 (most disagree). By-person factor analysis, using 2-factor and 3-factor rotation, revealed distinct preference archetypes.

RESULTS

Thirty-four adults with EoE (mean age 40.9 years, 51.4% male, 82.9% White) were recruited from gastroenterology and allergy clinics from a single center. We identified 2 treatment-centered archetypes: Medication preference, driven by symptoms and the desire to minimize risk of complications and Natural treatment preference , focusing on identifying trigger foods and diet adherence. Three-factor analysis revealed an additional archetype: Treatment ambivalent, a view of EoE as a mild and episodic (not chronic) disease with low priority to treat. Comparison by factor revealed 54% of those in the natural preference archetype were recategorized as treatment ambivalent , suggesting that they see natural treatment as a less complicated or milder strategy and may be at risk of nonadherence and reduced treatment uptake.

DISCUSSION

We identified 3 distinct treatment preference archetypes among individuals with EoE, underscoring the need for personalized treatment strategies, especially for those favoring natural approaches but masking ambivalence, and may be at risk of nonadherence or loss to follow-up.

Esophageal ILC2s mediate abnormal epithelial remodeling in eosinophilic esophagitis via Areg-EGFR signaling

Eosinophilic esophagitis (EoE) is a chronic allergic disorder characterized by eosinophilia and epithelial thickening, resulting in dysphagia. While emerging evidence implicates increased frequencies of group 2 innate lymphoid cells (ILC2s) and increased interleukin (IL)-33 expression in EoE pathogenesis, the precise mechanisms remain unclear. In this study, we investigated the role of ILC2s in EoE pathogenesis. We observed an abundance of KLRG1+ ILC2s in the esophagi of healthy mice, with their numbers significantly increasing in murine EoE models and humans. Using a murine EoE model, we demonstrated the recapitulation of EoE-associated features, including basal-cell hyperproliferation, epithelial thickening, and eosinophilia. Notably, these characteristics are absent in ILC-deficient mice, whereas mice lacking IL-5 or eosinophils display epithelial defects, highlighting the pivotal role of ILC2s in EoE pathogenesis. Further investigations revealed increased amphiregulin (Areg) production by esophageal ILC2s in mice. The administration of Areg induced epithelial defects similar to those observed in EoE. Mechanistic studies using human esophageal cell lines revealed Areg-induced phosphorylation of epidermal growth factor receptor (EGFR). Significatntly, treatment with anti-Areg agents and EGFR inhibitors effectively attenuated EoE development, highlighting the therapeutic potential of targeting the Areg-EGFR axis.

Adaptive Behaviors, Esophageal Anxiety, and Hypervigilance Modify the Association Between Dysphagia Perception and Histological Disease Activity in Eosinophilic Esophagitis

INTRODUCTION

Adaptive behaviors at mealtime, esophageal symptom-specific anxiety and hypervigilance may affect dysphagia reporting in patients with eosinophilic esophagitis (EoE), but this has not been investigated. Moreover, the relationship between such confounding factors and histological disease activity (HDA) is unclear.

METHODS

This was a prospective study on adults with EoE. Dysphagia, anxiety, and hypervigilance were assessed using specific questionnaires (i.e., modified dysphagia symptom questionnaire [mDSQ], Dysphagia Symptom Score [DSS], and Esophageal Hypervigilance and Anxiety Scale). Adaptive behaviors were assessed using the Pisa EoE Adaptation Questionnaire. Appropriate statistics was used to investigate correlation between dysphagia, anxiety, hypervigilance, adaptive behaviors, and HDA.

RESULTS

Ninety-five patients were included. Esophageal anxiety, hypervigilance, and use of adaptive behaviors were found in about 50% of patients with EoE. Esophageal anxiety and hypervigilance were significantly higher ( P = 0.03 for both), and adaptive behaviors were significantly more prevalent in histologically active EoE compared with EoE in remission (76.8% vs 25.6%, P < 0.001). As a standalone measurement, mDSQ and DSS had area under the receiver operating characteristic curve of 77.7% and 75.3% for predicting HDA. Adjustments of mDSQ and DSS based on individual Esophageal Hypervigilance and Anxiety Scale scores and adaptive behaviors at mealtime significantly improved the area under the receiver operating characteristic curve of mDSQ and DSS to 86.6% and 84.3%, respectively ( P < 0.05 for both).

DISCUSSION

Use of adaptive behaviors, higher esophageal anxiety and hypervigilance are associated with active EoE and represent clinical markers of HDA. Adaptive behaviors provide complementary clinical information that is not detected by symptoms alone. The assessment of adaptive behaviors, anxiety, and hypervigilance improves the correlation between clinical and HDA in EoE.

Eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is an atopic condition of the esophagus that has become increasingly recognized. Diagnosis of the disorder is dependent on the patient's clinical manifestations and must be confirmed by histologic findings on esophageal mucosal biopsies. The epidemiology, pathophysiology, diagnosis, treatment, and prognosis of EoE are discussed in this review.

Clinical, Histologic, and Safety Outcomes With Long-term Maintenance Therapies for Eosinophilic Esophagitis: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Our aim was to evaluate the outcomes of maintenance treatments for eosinophilic esophagitis (EoE) among observational studies (OSs) and randomized controlled trials (RCTs).

MATERIALS AND METHODS

Studies reporting histologic success of maintenance therapy ≥48 weeks were included. The primary outcome was histologic success rate (defined as <15/<6 eosinophils/high-power field). Risk ratios (RRs) for histologic success of maintenance therapy vs placebo or induction and drug safety were also assessed. Random effects meta-analyses with heterogeneity measured with I2 were performed. RCTs and OSs were analyzed separately.

RESULTS

In RCTs, histologic <15 eosinophils/high-power field rates were 86% (95% confidence interval [CI], 71%-96%) for corticosteroids and 79% (95% CI, 69%-87%) for biologics. Dupilumab alone accounted for 82% (95% CI, 72%-89%), whereas small molecules yielded 28%. Biologics showed higher <6 eosinophils/high-power field rates compared with corticosteroids (70% vs 59%). Clinical success was 58% (95% CI, 31%-83%) for corticosteroids and 59% (95% CI, 34%-82%) for biologics. Budesonide showed common-effect adjusted RR of 7.87 (95% CI, 4.19-14.77) of maintaining histologic remission over therapy discontinuation. In OSs, proton pump inhibitors showed 64% (95% CI, 43%-83%) histologic and 80% (95% CI, 53%-97%) clinical success, whereas corticosteroids achieved 49% (95% CI, 30%-68%) and 51% (95% CI, 18%-83%) rates, respectively. Therapy de-escalation was not associated with histologic relapse (RR, 1.04; 95% CI, 0.72-1.51). Long-term safety was confirmed with 3% (95% CI, 1%-6%) severe adverse events in RCTs and 5% (95% CI, 2%-9%) in OSs. Treatment withdrawal rates were low (10% for RCTs, 4% for OSs). Moderate to substantial heterogeneity was observed for most outcomes.

CONCLUSIONS

Maintenance therapies prevent histologic relapse in the long term, without clear disadvantage of dose de-escalation from induction to maintenance phase. Low adverse events and withdrawal rates confirm long-term treatment is well-tolerated.

A New Differential Gene Expression Based Simulated Annealing for Solving Gene Selection Problem: A Case Study on Eosinophilic Esophagitis and Few Other Gastro-intestinal Diseases

Identifying the set of genes collectively responsible for causing a disease from differential gene expression data is called gene selection problem. Though many complex methodologies have been applied to solve gene selection, formulated as an optimization problem, this study introduces a new simple, efficient, and biologically plausible solution procedure where the collective power of the targeted gene set to discriminate between diseased and normal gene expression profiles was focused. It uses Simulated Annealing to solve the underlying optimization problem and termed here as Differential Gene Expression Based Simulated Annealing (DGESA). The Ranked Variance (RV) method has been applied to prioritize genes to form reference set to compare with the outcome of DGESA. In a case study on Eosinophilic Esophagitis (EoE) and other gastrointestinal diseases, RV identified the top 40 high-variance genes, overlapping with disease-causing genes from DGESA. DGESA identified 40 gene pathways each for EoE, Crohn's Disease (CD), and Ulcerative Colitis (UC), with 10 genes for EoE, 8 for CD, and 7 for UC confirmed in literature. For EoE, confirmed genes include KRT79, CRISP2, IL36G, SPRR2B, SPRR2D, and SPRR2E. For CD, validated genes are NPDC1, SLC2A4RG, LGALS8, CDKN1A, XAF1, and CYBA. For UC, confirmed genes include TRAF3, BAG6, CCDC80, CDC42SE2, and HSPA9. RV and DGESA effectively elucidate molecular signatures in gastrointestinal diseases. Validating genes like SPRR2B, SPRR2D, SPRR2E, and STAT6 for EoE demonstrates DGESA's efficacy, highlighting potential targets for future research.

Sex-related differences in the presentation, management and response to treatment of eosinophilic esophagitis: Cross sectional analysis of EoE CONNECT registry

BACKGROUND

Eosinophilic esophagitis (EoE) predominantly affects males across all ages; however, little is known about sex differences for other aspects of EoE.

OBJECTIVE

To investigate associations between sex and clinical presentation, endoscopic features, treatment choice and response in EoE patients in real-world practice.

METHODS

Cross-sectional analysis of the multicenter EoE CONNECT registry. The independent contribution of patients' sex and other relevant variables were statistically assessed by multivariate models.

RESULTS

A total of 2976 patients (76% male) were evaluated. Males were diagnosed at a younger age compared to females (32.7 ± 14.8 vs. 34.8 ± 15.6 years, respectively; p = 0.002) with similar diagnostic delay. EoE symptoms varied significantly between sexes, with food impaction predominating in males and dysphagia, heartburn, regurgitation and abdominal and epigastric pain in females. However, female sex contributed to higher symptom severity at diagnosis as measured with Dysphagia Symptom Score (R2 = 0.57; p = 0.013) and presented higher peak eosinophil count in esophageal biopsies (p = 0.005). Males showed increased risk of stricturing or mixed phenotypes (adjusted OR 1.43, 95%CI:1.05-1.96; p = 0.024). No association was found between patients' sex and first-line treatment modality: proton pump inhibitors (PPI) were preferred over topical corticosteroids in patients with inflammatory phenotypes instead of stricturing or mixed phenotypes, and in patients who did not present food impaction. Both topical corticosteroids and dietary interventions were preferred over PPI in pediatric patients regardless of sex.

CONCLUSIONS

Sex is associated with clinical and phenotypical presentation of EoE at diagnosis, with more fibrotic findings in males but higher symptom score in females.

Exploring the Impact of Gender on the Characteristics and Complications of Eosinophilic Esophagitis

Background

Eosinophilic esophagitis (EoE) is a chronic inflammatory process of the esophagus often associated with structural and motility problems. Previous studies have shown an increased prevalence in males over females, however there is little data exploring the risk of esophageal complications among genders, which may be indicative of differences in disease severity.

Methods

This is a retrospective cohort study using National Inpatient Sample data including adults hospitalized between 2016 and 2020 presenting with EoE. The primary outcome measured was inpatient complications related to the patient's history of EoE and secondary outcomes include demographics, comorbidities, month of presentation, and age of patients.

Results

Of the 21 755 patients with history of EoE, 112 260 (52%) were male and 10 495 (48%) were female. Males had higher rates of several EoE complications, including esophageal obstruction, food bolus, esophageal rupture, requiring esophageal dilation, requiring esophageal laceration repair with p < 0.05 for all. Higher rates of females with EoE were seen in the Black population (p < 0.05). We also found that males were most likely to have esophageal impaction and esophageal rupture in the month of March (p < 0.05). Esophageal impaction was more common in males ages 25-29 (p < 0.05), whereas females were more likely from age 75-79 (p < 0.05).

Conclusion

Males have an overall high rate of complication from EoE. There was a higher prevalence of females with EoE in the Black population although the rates of complication remained higher in males in this subpopulation. The month of March carries a risk of esophageal impaction and rupture pronounced particularly in men. Age also appears to have an influence on the rate of esophageal impaction.

Proton pump inhibitor effect on esophageal protein signature of eosinophilic esophagitis, prediction, and evaluation of treatment response

BACKGROUND

Recently, we have identified a dysregulated protein signature in the esophageal epithelium of eosinophilic esophagitis (EoE) patients including proteins associated with inflammation and epithelial barrier function; however, the effect of proton pump inhibitor (PPI) treatment on this signature is unknown. Herein, we used a proteomic approach to investigate: (1) whether PPI treatment alters the esophageal epithelium protein profile observed in EoE patients and (2) whether the protein signature at baseline predicts PPI response.

METHODS

We evaluated the protein signature of esophageal biopsies using a cohort of adult EoE (n = 25) patients and healthy controls (C) (n = 10). In EoE patients, esophageal biopsies were taken before (pre) and after (post) an 8-week PPI treatment, determining the histologic response. Eosinophil count PostPPI was used to classify the patients: ≥15 eosinophils/hpf as non-responders (non-responder) and < 15 eosinophils/hpf as responders (R). Protein signature was determined and differentially accumulated proteins were characterized to identify altered biological processes and signaling pathways.

RESULTS

Comparative analysis of differentially accumulated proteins between groups revealed common signatures between three groups of patients with inflammation (responder-PrePPI, non-responder-PrePPI, and non-responder-PostPPI) and without inflammation (controls and responder-PostPPI). PPI therapy almost reversed the EoE specific esophageal protein signature, which is enriched in pathways associated with inflammation and epithelial barrier function, in responder-PostPPI. Furthermore, we identified a set of candidate proteins to differentiate responder-PrePPI and non-responder-PrePPI EoE patients before treatment.

CONCLUSION

These findings provide evidence that PPI therapy reverses the alterations in esophageal inflammatory and epithelial proteins characterizing EoE, thereby providing new insights into the mechanism of PPI clinical response. Interestingly, our results also suggest that PPI response could be predicted at baseline in EoE.

Design of a phase 3, randomized, double-blind, placebo-controlled, 48-week study to evaluate the efficacy and safety of cendakimab in adult and adolescent patients with eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory condition that interferes with normal food ingestion, negatively impacting quality of life (QoL). Treatment options include proton pump inhibitors, corticosteroids, biologics, or dietary elimination; however, ∼1/3 of patients remain insufficiently controlled. The pathogenesis of EoE involves interleukin-13 (IL-13); therefore, targeted IL-13 inhibition may be beneficial. In a phase 2 study, cendakimab, a recombinant, humanized anti-IL-13 monoclonal antibody, significantly reduced mean esophageal eosinophil counts and improved other inflammatory parameters in patients with EoE. These findings prompted further investigation of the efficacy and safety of cendakimab in adults and adolescents with EoE in a phase 3 registrational study (NCT04753697), the design of which is presented here.

METHODS

This multicenter, multinational, randomized, double-blind, placebo-controlled, 48-week, treat-through study plans to enroll 399 adults and adolescents. Randomized patients (1:1:1) will receive subcutaneous administration of 1) cendakimab 360 mg once weekly (QW) for 48 weeks, 2) cendakimab 360 mg QW for 24 weeks followed by cendakimab 360 mg every other week (with matching placebo on alternative weeks to maintain the blind) for 24 weeks, or 3) placebo QW for 48 weeks. Co-primary endpoints are mean change from baseline in dysphagia days and proportion of patients with eosinophil histologic response, defined as peak esophageal eosinophil count ≤6 per high-power field, at 24 weeks. Secondary and exploratory endpoints will address endoscopic and histologic features, QoL, safety, and pharmacokinetic assessments.

CONCLUSION

This phase 3 pivotal study will determine whether cendakimab provides an effective, safe, targeted treatment for patients with EoE.

Dupilumab Improves Health-Related Quality of Life and a Range of Symptoms in Patients With Eosinophilic Esophagitis

INTRODUCTION

Improvements in symptomatic experience and health-related quality of life (HRQoL) are among the most important treatment benefits in patients with eosinophilic esophagitis (EoE). We assessed the impact of dupilumab treatment on HRQoL, patients' impression of dysphagia, and symptoms beyond dysphagia in adults/adolescents (≥12 years) with EoE in parts A and B of the LIBERTY EoE TREET (NCT03633617) study.

METHODS

The EoE Symptom Questionnaire (EoE-SQ; frequency and severity of nondysphagia symptoms), EoE Impact Questionnaire (impact of EoE on HRQoL), and Patient Global Impression of Severity and Patient Global Impression of Change of dysphagia were used to assess the efficacy of weekly dupilumab 300 mg vs placebo.

RESULTS

At week 24, dupilumab reduced EoE-SQ Frequency (least squares mean difference vs placebo [95% confidence interval] part A -1.7 [-2.9, -0.5], part B -1.4 [-2.3, -0.5]; both P < 0.01) and EoE-SQ Severity (part A -2.0 [-3.9, 0.0], P < 0.05, part B -1.5 [-3.0, 0.1], P = 0.07) overall scores, and improved scores across all individual items. Improvement in the dupilumab group was clinically meaningful to patients. Dupilumab also meaningfully improved EoE Impact Questionnaire average scores and improved individual item scores at week 24, particularly emotional and sleep disturbance. More dupilumab-treated patients reported improvement in the Patient Global Impression of Change of dysphagia vs placebo or reported having no symptoms per the Patient Global Impression of Severity of dysphagia at week 24.

DISCUSSION

Dupilumab reduced the impact of EoE on multiple aspects of HRQoL, patients' impression of dysphagia, and frequency and severity of symptoms beyond dysphagia in adults/adolescents with EoE.

Prevalence of Abnormalities at Tandem Endoscopy in Patients Referred for Colorectal Cancer Screening/Surveillance Colonoscopy

Introduction: Performing a tandem endoscopy and colonoscopy in selected individuals has advantages, such as the early detection of benign and/or precancerous foregut diseases; it is efficient, and it may allow added therapies. It may also have disadvantages, such as generating anxiety from false-positive screening, possible harm from further testing, and unproven cost-effectiveness. Aims: We aimed to examine the prevalence of foregut endoscopic and histologic abnormalities in subjects referred for screening/surveillance colonoscopy who also underwent a tandem endoscopy. We wanted to (1) assess implications for cancer detection, intervention, and surveillance of precancerous foregut abnormalities, (2) identify benign foregut lesions, and (3) generate data on the utilities of this tandem approach. Patients and Methods: A retrospective cohort study of consecutive subjects referred for screening or surveillance colonoscopy who also underwent an endoscopy. Based on national screening guidelines, responses to prompting questions, personal or family history, or other risk factors, subjects were assigned to tandem endoscopy with biopsies (modified Seattle and Sydney protocols), under one anesthesia. Results: Of the 1004 patients referred for colonoscopy, 317 (32%) underwent tandem endoscopy. There were 214 women and 103 men. There were 237 Whites, 16 Asians, 40 Blacks, and 24 Hispanics. Median age was 59 (range 19-85). At endoscopy, we identified actionable benign (45%) peptic, inflammatory, and H. pylori-related abnormalities, and premalignant findings (i.e., intestinal metaplasia, 27%, dysplasia, 2%, and cancer 0.9%), comparable to the premalignant (40.3%) and malignant (0.6%) colonoscopy yield. Conclusions: When implemented based on national screening guidelines, tandem EGD and colonoscopy combines Barrett's esophagus and gastric cancer screening in one examination, and it has a high yield in a diverse US population.

Effect of Esophageal Dilation History on Efficacy Outcomes in Patients With Eosinophilic Esophagitis Receiving Budesonide Oral Suspension

INTRODUCTION

The effect of esophageal dilation history on efficacy outcomes in patients with eosinophilic esophagitis (EoE) receiving swallowed corticosteroids is not well established.

METHODS

This post hoc analysis assessed data from a 12-week, randomized, double-blind, placebo-controlled phase 3 study (NCT02605837) of budesonide oral suspension (BOS) 2.0 mg twice daily in patients aged 11-55 years with EoE and dysphagia. Coprimary efficacy outcomes were histologic (≤ 6 eosinophils per high-power field [eos/hpf]) and dysphagia symptom (≥ 30% reduction in Dysphagia Symptom Questionnaire scores from baseline) responses at week 12. Secondary efficacy outcomes included histologic response (< 15 eos/hpf) and change from baseline to week 12 in Dysphagia Symptom Questionnaire scores and EoE Endoscopic Reference Scores. Data were analyzed post hoc by esophageal dilation history (dilation history vs no dilation history).

RESULTS

Of 318 patients who received ≥ 1 dose of study drug, 42.8% had a history of esophageal dilation (dilation history: BOS, n = 91; placebo, n = 45; no dilation history: BOS, n = 122; placebo, n = 60). Histologic responses (≤ 6 and < 15 eos/hpf) were similar regardless of dilation history. Fewer BOS-treated patients with dilation history than no dilation history achieved a dysphagia symptom response (44.0% vs 59.0%); conversely, a slightly greater improvement from baseline in total EoE Endoscopic Reference Scores was observed for BOS-treated patients with dilation history than no dilation history (least-squares mean [SE of the mean]: -4.1 [0.3] vs -3.4 [0.4]).

DISCUSSION

Esophageal dilation history may confound the association between histologic outcomes and dysphagia symptom or endoscopic efficacy outcomes in patients with EoE receiving swallowed corticosteroids.

Real world treatment patterns in patients with eosinophilic esophagitis in Japan

The management of eosinophilic esophagitis (EoE) has not been completely established yet. There is a controversy over the universal maintenance therapy for EoE to prevent esophageal fibrostenotic complications. Using an employer-based insurance claim database from January 2005 to September 2022, we investigated the treatment patterns of EoE and the occurrence of esophageal complications. The treatment patterns were analyzed at a 6-month interval from the diagnosis of EoE. The time to treatment discontinuation of proton pump inhibitor (PPI)/potassium-competitive acid blocker (P-CAB) was evaluated by the Kaplan-Meier method. Of 15,200,895 individuals, 615 patients with EoE were ultimately analyzed with the median follow-up time from the index date of 700 days. PPI/P-CAB and swallowed topical steroids accounted for 80% and 4.6% of the initial therapy, respectively. PPI/P-CAB use rapidly decreased by 40% in the first 6 months and afterwards reinitiation was rarely seen. The median time to treatment discontinuation were 172 days (95% CI 147-206 days) for PPI/P-CAB. Only 1 EoE patient developed esophageal fibrostenotic complications after the diagnosis. With the low incidence of esophageal complications, the universal maintenance therapy may not be necessary for mild EoE patients often seen in Japan.

Off-Label Use of Monoclonal Antibodies for Eosinophilic Esophagitis in Humans: A Scoping Review

Background: Eosinophilic esophagitis (EoE) is a rare, chronic immune-mediated disorder with limited treatment options. Despite the U.S. Food and Drug Administration (FDA) approval of dupilumab for EoE, other monoclonal antibodies remain unapproved and are used off-label with limited evidence on their efficacy and safety. This systematic review rigorously and comprehensively evaluates the evidence for monoclonal antibody therapies used off-label to treat EoE. Methods: We conducted a systematic review across PubMed, EMBASE, Cochrane Central, and ClinicalTrials.gov, assessing the efficacy and safety of off-label monoclonal antibodies in EoE through clinical outcomes and the FDA Adverse Event Reporting System (FAERS) data. Results: Among ten monoclonal antibodies reviewed, mepolizumab that targets IL-5 showed the most promise with a moderate recommendation based on Level 2 evidence. Others like omalizumab (anti-IgE), dectrekumab (anti-IL-13), and reslizumab (anti-IL-5) showed limited utility. Safety evaluations via the FAERS database revealed significant adverse drug reactions, including serious events like asthmatic crises, pneumonia, and adrenal insufficiency for mepolizumab and reslizumab, as well as chronic obstructive pulmonary disease and gastroenteritis for omalizumab. Dectrekumab's safety profile remains unclear due to a lack of data. Conclusions: While mepolizumab demonstrates potential as an off-label treatment, none of the antibodies reviewed have FDA approval for EoE. Clinicians should consider the balance between local and systemic effects and exercise caution, closely monitoring for adverse effects, particularly in patients with respiratory comorbidities. Continued research is crucial to establish a more robust evidence base for these therapies.

Long-term durability between parent and child patient-reported outcomes in eosinophilic esophagitis

BACKGROUND

Because young children cannot self-report symptoms, there is a need for parent surrogate reports. Although early work suggested parent-child alignment for eosinophil esophagitis (EoE) patient-reported outcomes (PROs), the longitudinal alignment is unclear.

OBJECTIVE

We sought to assess the agreement and longitudinal stability of PROs between children with EoE and their parents.

METHODS

A total of 292 parent-child respondents completed 723 questionnaires over 5 years in an observational trial in the Consortium of Eosinophilic Gastrointestinal Disease Researchers. The change in and agreement between parent and child Pediatric Eosinophilic Esophagitis Symptom Score version 2 (PEESSv2.0) and Pediatric Quality of Life Eosinophilic Esophagitis Module (PedsQL-EoE) PROs over time were assessed using Pearson correlation and Bland-Altman analyses. Clinical factors influencing PROs and their agreement were evaluated using linear mixed models.

RESULTS

The cohort had a median disease duration equaling 3.7 years and was predominantly male (73.6%) and White (85.3%). Child and parent PEESSv2.0 response groups were identified and were stable over time. There was strong correlation between child and parent reports (PEESSv2.0, 0.83;PedsQL-EoE, 0.74), with minimal pairwise differences for symptoms. Longitudinally, parent-reported PedsQL-EoE scores were stable (P ≥ .32), whereas child-reported PedsQL-EoE scores improved (P = .026). A larger difference in parent and child PedsQL-EoE reports was associated with younger age (P < .001), and differences were driven by psychosocial PRO domains.

CONCLUSIONS

There is strong longitudinal alignment between child and parent reports using EoE PROs. These data provide evidence that parent report is a stable proxy for objective EoE symptoms in their children.

Advances in omics data for eosinophilic esophagitis: moving towards multi-omics analyses

Eosinophilic esophagitis (EoE) is a chronic, allergic inflammatory disease of the esophagus characterized by eosinophil accumulation and has a growing global prevalence. EoE significantly impairs quality of life and poses a substantial burden on healthcare resources. Currently, only two FDA-approved medications exist for EoE, highlighting the need for broader research into its management and prevention. Recent advancements in omics technologies, such as genomics, epigenetics, transcriptomics, proteomics, and others, offer new insights into the genetic and immunologic mechanisms underlying EoE. Genomic studies have identified genetic loci and mutations associated with EoE, revealing predispositions that vary by ancestry and indicating EoE's complex genetic basis. Epigenetic studies have uncovered changes in DNA methylation and chromatin structure that affect gene expression, influencing EoE pathology. Transcriptomic analyses have revealed a distinct gene expression profile in EoE, dominated by genes involved in activated type 2 immunity and epithelial barrier function. Proteomic approaches have furthered the understanding of EoE mechanisms, identifying potential new biomarkers and therapeutic targets. However, challenges in integrating diverse omics data persist, largely due to their complexity and the need for advanced computational methods. Machine learning is emerging as a valuable tool for analyzing extensive and intricate datasets, potentially revealing new aspects of EoE pathogenesis. The integration of multi-omics data through sophisticated computational approaches promises significant advancements in our understanding of EoE, improving diagnostics, and enhancing treatment effectiveness. This review synthesizes current omics research and explores future directions for comprehensively understanding the disease mechanisms in EoE.

Exposures and coexisting conditions in pediatric nodular tracheobronchitis

BACKGROUND

The aim of our study was to investigate the prevalence of coexisting conditions and exposures in children with nodular tracheobronchitis diagnosed by flexible bronchoscopy.

METHODS

We conducted a single-center retrospective review of 100 children diagnosed with nodular tracheobronchitis by flexible bronchoscopy between 2012 and 2023.

RESULTS

Common coexisting diagnoses included gastroesophageal reflux disease (GERD, 50%), dysphagia/aspiration (40%), asthma (30%), recurrent croup (30%), tracheostomy dependence (19%) and eosinophilic esophagitis (EOE) (12%). Bronchoalveolar lavage (BAL) demonstrated cellular inflammation with elevated proportions of neutrophils in 63%, and lymphocytes in 24%. Among 88 patients in whom bacterial cultures were performed, 52% were positive, with Moraxella, Haemophilus, Streptococcal and Pseudomonas species predominating. Among 30 patients who underwent viral testing, 57% were positive, with rhinovirus (82%) and adenovirus (29%) predominating. Patients with neutrophilic inflammation were more likely to have a positive respiratory bacterial culture and/or viral polymerase chain reaction (p = 0.003, 0.005). Evaluation of the gastrointestinal tract included 79 patients with a history of esophagogastroduodenoscopy, 45 patients with a videofluoroscopic swallow study (VFSS), and 45 patients with multi-channel intraluminal impedance and pH testing. The majority of VFSS were abnormal (60%) demonstrating either laryngeal penetration (33%) or intratracheal aspiration (27%). Median pH reflux and impedance proximal reflux indices were 3.8% and 0.5% respectively.

CONCLUSION

Potential contributing factors in the pathophysiology of nodular tracheobronchitis include bacterial and viral infections, GERD, dysphagia/aspiration, and EOE. When nodular tracheobronchitis is observed during bronchoscopy, further evaluation to assess for these conditions should be considered.

Concurrent Celiac Disease and Eosinophilic Esophagitis in a Pediatric Cohort: More Than a Coincidence

Celiac disease (CeD) and eosinophilic esophagitis (EoE) are immune-mediated disorders that can occur in the same patient. A retrospective study at a tertiary care hospital was conducted to determine the prevalence of EoE in a pediatric population with CeD and to compare characteristics of patients with both diseases to patients with CeD-only. Among the 148 patients with CeD identified in the study, 11 patients had both CeD and EoE (7.4%). Patients with both CeD and EoE had a higher absolute eosinophil count (per μL) at diagnosis compared to patients with CeD-only (454.1 ± 122.7 vs 231.9 ± 19.4, P = .003). In conclusion, there was a higher proportion of EoE in patients with CeD than would be expected in the general population, suggesting a potential pathophysiological overlap between the 2 diseases. An elevated peripheral absolute eosinophil count may help predict which patients with CeD may additionally have EoE.

Oral viscous budesonide solution for enhanced localized treatment of eosinophilic esophagitis through improved mucoadhesion and permeation

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus that is immune/antigen-mediated and often requires targeted treatment. In clinical practice, an oral viscous budesonide suspension prepared by adding sucralose to a budesonide suspension for inhalation (Pulmicort®) is used to treat adult EoE and enhance retention in the esophageal mucosa. Inspired by this off-label drug use, oral viscous budesonide solutions (OVBSs) were developed in this study, and their capacities for adhesion, permeation, and stability were explored. Given the insolubility of budesonide as a BCS II drug, we first evaluated its equilibrium solubility and found that Transcutol® HP was an excellent choice for creating an OVBS at a concentration of 0.2 mg/g. The rheological properties of the OVBSs were evaluated with a rheometer, and shear-thinning, which aids in swallowing, was observed. The addition of hydroxyethyl cellulose (HEC) increased the adhesion strength of the preparation, which was associated with the hydration and thickening mechanism. This result was confirmed in a dynamic gelation study and in vitro elution experiment conducted with porcine esophagus tissue. Furthermore, the permeabilities of the OVBSs in the porcine esophagus were evaluated with a Franz diffusion cell device. >80 % of the budesonide was released after 24 h, and the release profile was similar to that of the solution. To explore the storage conditions of OVBSs, critical factors such as pH, content, and impurities were determined. It was found that OVBSs exhibited different behaviors at different pH values and temperatures. Notably, the OVBSs containing 1.7 % HEC could be stored for >6 months at a temperature of 5 °C ± 3 °C and a pH of 4.5 without significant degradation. Overall, this study demonstrated that OVBSs have the potential to adhere to the esophageal mucosa, permeate the tissue, and remain stable during storage. Moreover, OVBSs exhibit a distinct advantage over traditional converted inhalation-to-oral budesonide therapies by enabling flexible dose adjustment in clinical applications, thereby potentially minimizing systemic side effects commonly associated with oral glucocorticoid administration.

EUS in children with eosinophilic oesophagitis - a new method of measuring oesophageal total wall thickness area. An artificial intelligence application feasibility study. A pilot study

Aim

In the study, we aimed to introduce a formula for measuring the oesophageal total wall thickness area, which could be used for developing an artificial intelligence-based algorithm for the detection of patients whose total wall thickness area exceeds the norms.

Material and methods

Mathematical formulas for measuring the square area of the oesophageal total wall thickness area were introduced and applied. Children were grouped according to their weight in clusters. For each cluster, the range (minimal and maximal value) were established. The measurements were done by using the formula for the area of the circular ring according to the formula A = n (B2-b2); the product of n and subtraction square b (smaller radius) and square B (bigger radius). The basic data for our calculations were derived from papers published by Dalby et al., 2010 and Loff et al., 2022.

Results

The square area (in mm2) of the oesophageal wall was calculated and proposed to be introduced for further analysis. This value set could be used for creating an algorithm for computer-aided analysis of patients diagnosed with sonographic examination and isolating patients for surveillance. Our newly introduced approach could be implemented in sonographic, computer tomography, and magnetic resonance examinations in eosinophilic oesophagitis and other oesophageal diseases.

Conclusions

Total wall thickness area could be used for monitoring children with eosinophilic oesophagitis and other oesophageal diseases. The method could also be applied for adults. Therefore, it can be a foundation for further progress with applying artificial intelligence algorithms.

Optimal Diagnostic and Treatment Response Threshold of the Eosinophilic Esophagitis Endoscopic Reference Score: A Single-Center Study of 102 Patients With Eosinophilic Esophagitis

Background/Aims

The proposed eosinophilic esophagitis (EoE) endoscopic reference score serves to diagnose and evaluate treatment responses in EoE. Nevertheless, the validated reference score thresholds for diagnosis and treatment response in Asian patients are yet to be established. This study aims to establish these thresholds for the first time among Asian patients with EoE.

Methods

Patients presenting with ≥ 15 eosinophils/high power field and esophageal dysfunction symptoms between August 2007 and November 2021 were included. Age- and sex-matched non-EoE controls were also enrolled. Baseline characteristics, endoscopic reference score features, and scores were compared between patients and controls. Among patients, endoscopic reference score features and scores, along with peak eosinophil counts, were evaluated both before and after treatment. The optimal threshold was determined based on sensitivity, specificity, and the Youden index.

Results

Overall, 102 patients were enrolled (74.5% men; mean age, 46.9 years). The mean endoscopic reference score was 2.65 and 0.52 for patients and controls, respectively (P < 0.001). An endoscopic reference score ≥ 2 was identified as the optimal diagnostic threshold for EoE (sensitivity, 0.79; specificity, 0.86; Youden index, 0.66). Post-treatment data regarding endoscopic findings and histology were available for 30 patients. Regarding histologic response, an endoscopic reference score of ≤ 3 demonstrated the optimal threshold (sensitivity, 0.95; specificity, 0.88; Youden index, 0.83).

Conclusions

The optimal diagnostic and treatment response thresholds were determined to be endoscopic reference scores of ≥ 2 and ≤ 3, respectively. Further studies involving a larger patient cohort are necessary to validate these findings.

A retrospective real-world study on the safety and efficacy of budesonide orodispersible tablets for the induction therapy of eosinophilic oesophagitis

Background

An orodispersible form of budesonide has recently been approved for the targeted treatment of eosinophilic oesophagitis in the United Kingdom, Europe, Australia, Canada and the United States, following favourable results from a randomised controlled trial. This is the first dedicated real-world study exploring the safety and efficacy of budesonide orodispersible tablets for induction therapy in the treatment of eosinophilic oesophagitis while providing insights into its management.

Objectives

The primary objective was histologic remission, defined as less than 5 eosinophils per high-powered field. The secondary objectives included histologic response (>50% reduction in peak eosinophil count), clinical remission (complete resolution of symptoms documented on clinic letters), clinical response (improvements in symptoms as reported on clinical letters), endoscopic remission (Endoscopic Reference Score (EREFS) score = 0), and endoscopic response (improvement in EREFS score). The EREFS scores were calculated based on the severity and presence of rings, longitudinal furrows, strictures, oedema and exudates on endoscopic images. Adverse events and safety profiles were also recorded.

Design

A multicentre cohort study examining the effectiveness of 1 mg, twice daily, budesonide orodispersible tablet induction therapy for the treatment of eosinophilic oesophagitis.

Methods

Ethics approval was obtained through the Western Australia Health: Governance, Evidence, Knowledge, Outcomes system for assessment of Audit and Quality Activities. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

Results

A total of 43 patients (29 males, 14 females; median age 39) were recruited. Forty-one patients were included in the analysis. After induction therapy, 30 patients (73%) achieved histologic remission, and 35 patients (85%) demonstrated histologic response. Thirty-nine patients (95%) achieved clinical response, and 28 patients (68%) achieved clinical remission. An endoscopic response was seen in 37 patients (90%), and 16 patients (39%) achieved endoscopic remission. No significant adverse events were identified.

Conclusion

Budesonide orodispersible tablet is an effective induction therapy for eosinophilic oesophagitis, as evidenced by its high histologic remission rate and favourable safety profile.

Epidemiology and Risk Factors of Eosinophilic Esophagitis in Japan: A Population-Based Study

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) has been increasingly diagnosed globally. However, there have been few general population-based studies in Asia. The aim of this study was to investigate EoE epidemiology in the Japanese general population.

METHODS

We analyzed an employer-based health insurance claim database from January 2005 to September 2022. EoE cases were identified on the basis of the International Statistical Classification of Diseases and Health-related Problems, 10th Revision code, K20.0. We calculated the incidence and prevalence of EoE using Poisson regression and binomial distribution, respectively. Using 10 matched controls for each EoE case, a nested case-control study was performed to identify potential risk factors for EoE.

RESULTS

Of 15,200,895 individuals, 1010 EoE cases were identified. The incidence and prevalence of EoE were 2.82 (95% confidence interval [CI], 2.44-3.26) per 100,000 person-years and 10.68 (95% CI, 10.01-11.37) per 100,000 people in 2022, nearly 3 and 8 times as high as those in 2017, respectively. Smoking was associated with decreased risk of EoE (odds ratio [OR], 0.45, 0.36-0.56, P < .001), whereas alcohol consumption (OR, 1.51, 1.21-1.88, P < .001) was associated with increased risk of EoE along with several allergic conditions and psychiatric disorders. EoE was not related to either body mass index or lifestyle-related diseases such as hypertension, diabetes mellitus, hyperuricemia, and dyslipidemia.

CONCLUSIONS

The incidence and prevalence of EoE in Japan have steadily increased over the past 2 decades. Nevertheless, EoE remains less common in Japan compared with the United States and Western Europe. Factors contributing to the epidemiology of EoE on a global basis may improve our understanding of the contribution of genetic and environmental risk factors.

Advances and ongoing challenges in eosinophilic gastrointestinal disorders presented at the CEGIR/TIGERs Symposium at the 2024 American Academy of Allergy, Asthma & Immunology meeting

The Consortium of Eosinophilic Gastrointestinal disease Researchers (CEGIR) and The International Gastrointestinal Eosinophil Researchers (TIGERs) organized a daylong symposium at the 2024 annual meeting of the American Academy of Allergy, Asthma & Immunology. The symposium featured new discoveries in basic and translational research as well as debates on the mechanisms and management of eosinophilic gastrointestinal diseases. Updates on recent clinical trials and consensus guidelines were also presented. We summarize the updates on eosinophilic gastrointestinal diseases presented at the symposium.

Single-cell RNA-sequencing of human eosinophils in allergic inflammation in the esophagus

BACKGROUND

Eosinophils are elusive cells involved in allergic inflammation. Single-cell RNA-sequencing (scRNA-seq) is an emerging approach to deeply characterize cellular properties, heterogeneity, and functionality.

OBJECTIVES

We sought to comprehensively characterize the transcriptome and biological functions of human eosinophils at a site of severe allergic inflammation in the esophagus (ie, eosinophilic esophagitis [EoE]).

METHODS

We employed a gravity-based scRNA-seq methodology to sequence blood eosinophils from patients with EoE and control individuals compared to a reanalyzed public scRNA-seq dataset of human esophageal eosinophils of EoE patients. We used flow cytometry, immunostaining, and a stimulation assay to verify mRNA findings.

RESULTS

In total, scRNA-seq was obtained from 586 eosinophils (188 from blood [n = 6 individuals] and 398 from esophagus [n = 6 individuals]). The esophageal eosinophils were composed of a population of activated eosinophils (enriched in 659 genes compared with peripheral blood-associated eosinophils) and a small population of eosinophils resembling peripheral blood eosinophils (enriched in 62 genes compared with esophageal eosinophils). Esophageal eosinophils expressed genes involved in sensing and responding to diverse stimuli, most notably IFN-γ, IL-10, histamine and leukotrienes, and succinate. Esophageal eosinophils were most distinguished from other esophageal populations by gene expression of the receptors CCR3, HRH4, SUCNR1, and VSTM1; transcription factors CEBPE, OLIG1, and OLIG2; protease PRSS33; and the hallmark eosinophil gene CLC. A web of bidirectional eosinophil interactions with other esophageal populations was derived. Comparing esophageal eosinophils and mast cells revealed that esophageal eosinophils expressed genes involved in DNAX-activation protein-12 (also known as TYROBP) interactions, IgG receptor-triggered events, immunoregulation, and IL-10 signaling.

CONCLUSIONS

In EoE, esophageal eosinophils exist as 2 populations, a minority population resembling blood eosinophils and the other population characterized by high de novo transcription of diverse sensing receptors and inflammatory mediators readying them to potentially intersect with diverse cell types.

Central neuromodulators for patients with functional esophageal disorders: A systematic review and meta-analysis

BACKGROUD

The use of neuromodulators is prevalent in various functional gastrointestinal disease. However, data concerning the outcomes of these treatments in functional esophageal disorders (FED) remains limited and inadequate.

AIMS

The aim of the present study is to examine the efficacy of central neuromodulators in FED.

METHODS

We searched PubMed, EMBASE, and the Cochrane library databases from inception to April 2023. Randomized controlled trials that compared the effects of neuromodulators and placebos on FED are included. Primary outcome is the symptom improvement, and Rome IV criteria is used to assess eligible studies.

RESULTS

Eleven randomized controlled studies (three for functional chest pain, four for reflux hypersensitivity/functional heartburn, three for globus, and one for functional dysphagia) were included in the final analysis. Neuromodulators reduced chest pain by 52%-71% in patients with functional chest pain, and alleviated symptom by 46%-75% in patients with globus (n = 3, Odds ratio 6.30, 95% confidence interval 4.17-9.50). However, the results were inconsistent for reflux hypersensitivity and functional heartburn. There was a lack of convincing evidence to support the use of neuromodulators for functional dysphagia. The use of neuromodulators did not have a significant impact on the quality of life.

CONCLUSIONS

Functional chest pain and globus may potentially benefit from the use of neuromodulators, but their effectiveness for functional dysphagia, functional heartburn and reflux hypersensitivity remains controversial. More controlled trials are needed to confirm the therapeutic effects on these conditions.

Investigating immune profile by CyTOF in patients with eosinophilic esophagitis after treatment with orodispersible budesonide

Eosinophilic esophagitis (EoE) is a chronic Th2-mediated inflammatory disease of the esophagus driven by dietary or inhalant allergens which if left untreated, leads to fibrosis and poor esophageal function. Although the inflammation in the esophagus is dominated by eosinophils, there are also elevated levels of T and B cells. Blood samples from ten patients with EoE before and after treatment with orodispersible budesonide and 10 healthy controls were compared using cytometry by time-of-flight. An antibody panel was designed that covers the major immunological cell populations with a particular focus on eosinophils. The data was analyzed with multivariate methods and cluster analysis. Correlation analysis was done between immune markers and endoscopic, histological, and symptomatologic assessments. Our analysis revealed that patients with EoE had lower levels of effector memory T cells after treatment with orodispersible budesonide to the same level as healthy subjects. In addition, more suppressive eosinophils were present in the circulation of EoE patients before treatment and more immature eosinophils were present after treatment. Furthermore, levels of galectin-10+ eosinophils correlated with histological findings in esophageal tissue from EoE patients. In all patients, the peak eosinophils were decreased after treatment with orodispersible budesonide. Intriguingly, 90% of the patients had remission in the histological assessment and 50% improved in the endoscopic assessment. This study reports a detailed immune profile in patients with EoE before and after treatment with orodispersible budesonide and it is a step toward finding blood-based immune parameters that could be useful to monitor response to treatment.

Noninvasive Disease Assessment in Eosinophilic Esophagitis With Fractionated Exhaled Nitric Oxide, Blood, and Fecal Biomarkers

BACKGROUND

Eosinophilic Esophagitis (EoE) is a chronic inflammatory condition of the esophagus triggered by food and aeroallergens. There is a need for noninvasive biomarkers that reliably detect EoE in patients with cardinal symptoms and predict treatment response to reduce endoscopic evaluations.

STUDY

Nonasthmatic patients 18 years or above with suspected or diagnosed EoE, gastroesophageal reflux disease (GERD), and control individuals with indication for endoscopy were enrolled prospectively between November 2020 and May 2022. Participants underwent body plethysmography with fractionated exhaled nitric oxide (FeNO) level measurement. Besides, serum and fecal biomarkers were measured by ELISA. A follow-up examination was scheduled after treatment initiation in patients with active EoE.

RESULTS

The median FeNO level in active EoE (20 ppb) was higher compared with GERD (15 ppb, P=0.038) and control individuals (14 ppb, P=0.046). Median FeNO did not significantly differ in EoE patients who underwent follow-up assessment after treatment response (20 ppb vs. 18 ppb, P=0.771). Serum EDN, ECP, and the absolute eosinophil blood count (AEC) were elevated in active EoE compared with control individuals but not compared with GERD except for AEC. Serum EDN, ECP and AEC decreased in EoE in remission at follow-up assessment. None of the fecal biomarkers was elevated in active EoE or during treatment.

CONCLUSIONS

Assessment of FeNO may have diagnostic value in differentiating patients with active EoE from non-EoE patients but is not a suitable marker for monitoring disease activity. Serum EDN, ECP, TARC, and AEC levels are emerging as potential candidates for monitoring disease activity in EoE.