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

Association between Schatzki ring and eosinophilic esophagitis: a systematic review and meta-analysis

BACKGROUND/OBJECTIVE

The involvement of hydrochloric acid in the etiology of eosinophilic esophagitis and numerous reports on its coexistence and interaction with reflux disease, as well as the rings of the esophageal mucosa formed with the advancement of the disease, suggest a potential association of eosinophilic esophagitis with another disorder of esophageal morphology potentially caused by exposure to acid reflux-Schatzki ring. Therefore, it seems reasonable to check the relationship of eosinophilic esophagitis with the coexistence of the Schatzki ring as a potential effect of advanced esophageal trachealization, which is the subject of this systematic review with a meta-analysis.

METHODS

The protocol of this meta-analysis was performed according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. A systematic search of the indexed literature in the MEDLINE and Scopus databases from early to December 2019 was performed to identify all original research articles on the association between the occurrence of the Schatzki ring and eosinophilic esophagitis in adults.

RESULTS

Out of 68 searched studies, after the analysis and evaluation of the works, only 4 met the criteria set according to the protocol and were included in the meta-analysis. Based on the performed meta-analysis, no relationship was found between the occurrence of Schatzki ring and eosinophilic esophagitis.

CONCLUSION

The present study did not show a significant relationship between the occurrence of the Schatzki ring and eosinophilic esophagitis in the adult population, which suggests that these are two independent causes of dysphagia in this patient population.

A Model Using Clinical and Endoscopic Characteristics Identifies Patients at Risk for Eosinophilic Esophagitis According to Updated Diagnostic Guidelines

BACKGROUND AND AIMS

Updated diagnostic guidelines for eosinophilic esophagitis (EoE) have eliminated the requirement for a proton pump inhibitor (PPI) trial, but there are no models to identify patients with EoE based on these new criteria. We aimed to develop a predictive model for diagnosis of EoE based on the updated EoE diagnostic guidelines.

METHODS

We performed a secondary analysis of a prospective study of adult patients referred for outpatient esophagogastroduodenoscopy at University of North Carolina who had symptoms of esophageal dysfunction; patients with prevalent EoE were excluded. We analyzed data from 206 EoE cases (mean age 40.1, 62.6% male, 93.2% white) and 306 controls (mean age 52.3, 37.9% male, 79.7% white). We built predictive models for case-control status, using clinical, endoscopic, and histologic features, and defining EoE by either the new or historical definition of PPI non-response. Model discrimination was assessed by the area under the receiver-operator characteristic curve (AUC).

RESULTS

Before endoscopy, younger age, male sex, history of atopic condition or food allergy, and dysphagia identified patients with EoE with an AUC of 0.83. When we included endoscopy findings suggestive of EoE, the model identified patients with EoE with an AUC of 0.92; this increased to 0.99 when histology was included.

CONCLUSION

We developed a model to identify patients with EoE, without a trial of PPIs, based on updated diagnostic guidelines. Clinical features and endoscopic findings identified patients with EoE with an AUC of 0.92-even without histologic data and in the absence of dysphagia. This model can be used to select patients with upper gastrointestinal symptoms but without dysphagia for early diagnostic endoscopy. The model can also be used to identify cases of EoE when eosinophil counts are greater than 15 in biopsies but other causes of esophageal eosinophilia cannot necessarily be excluded.

Clinical features and time trends associated with an endoscopically normal esophagus in active eosinophilic esophagitis

BACKGROUND

A proportion of patients with active eosinophilic esophagitis (EoE) have a normal-appearing esophagus on esophagogastroduodenoscopy (EGD). We aimed to determine the associations between the baseline clinical features and the endoscopically normal esophagus in EoE, as well as time trends in reporting.

METHODS

In this retrospective study of active EoE cases from 2002 - 2018, patients with and without esophageal endoscopic abnormalities were compared. Multivariable logistic regression identified the independent predictors of a normal EGD. The proportion of patients with a normal EGD was determined per year, and before and after the introduction of the first EoE guidelines and the EoE Endoscopic Reference Score (EREFS).

RESULTS

Of 878 EoE patients, 101 (11.5 %) had an endoscopically normal esophagus; they were younger (8.3 vs. 25.4 years), had shorter median symptom duration before diagnosis (2.8 vs. 5.0 years), were less likely to have dysphagia (40 % vs. 76 %) or food impaction (8 % vs. 33 %), and more likely to have abdominal pain (37 % vs. 19 %) (P < 0.01 for all). On multivariable logistic regression, independent predictors of a normal esophagus were younger age (odds ratio [OR] 0.96, 95 % confidence interval [CI] 0.94 - 0.98), abdominal pain (OR 2.03, 95 %CI 1.13 - 3.67), and lack of dysphagia (OR 0.49, 95 %CI 0.26 - 0.93). The proportion of patients with a normal esophagus decreased from 21 % before the first EoE guidelines to 7 % (P < 0.01) after introduction of the EREFS.

CONCLUSIONS

An endoscopically normal esophagus is seen in ~10 % of active EoE patients and should not preclude biopsies; younger age, abdominal pain, and lack of dysphagia are independent predictors. The proportion of normal EGDs decreased over time, suggesting improved recognition of endoscopic findings.

Improving Delivery of Care through Standardized Monitoring in Children with Eosinophilic Esophagitis

Introduction:

Eosinophilic esophagitis (EoE) is a chronic, antigen-driven disorder for which endoscopic monitoring and multidisciplinary care are recommended to achieve histologic remission. The EoE team at our large academic center developed a quality improvement (QI) initiative aimed to reduce variability in monitoring. This QI project focused on completing 3 process metrics within 6 months of diagnosis: (1) outpatient follow-up with a gastroenterologist; (2) referral to an allergist; and (3) Follow-up esophagogastroduodenoscopy (EGD).

Methods:

In January 2015, our QI team developed a registry of newly diagnosed EoE patients and maintained ongoing, weekly tracking of the process measures. Interventions to increase the completion of the process metrics included educational sessions, proactive reminders to providers, and targeted communications with patient families. Missed opportunities were evaluated by more in-depth chart review and categorized as provider- or patient-driven.

Results:

We tracked 6-month process metrics from 2015 through 2018. During this interval, follow-up visit rates in GI improved from 77% to 86%, and the percentage of referrals placed to allergy increased from 65% to 77%. The percentage of patients completing a repeat EGD improved from 33% to 61%. Among patients without a repeated EGD, nearly 70% of those missed opportunities were provider-driven.

Conclusions:

In patients newly diagnosed with EoE, QI interventions, including patient registry development, implementation of a local standard of care, and creating a patient tracking system, improved adherence with national EoE monitoring guidelines.

Emerging incidence trends of eosinophilic esophagitis over 25 years: Results of a nationwide register-based pathology cohort

RATIONALE

Eosinophilic esophagitis (EoE) has emerged from a case-reportable illness in the early 1990s to a distinct clinicopathological entity. Increasing worldwide incidences have been observed, although due to various study designs estimates are inconsistent.

AIM

To determine population-based annual incidence rates over a time period of 25 years.

METHODS

A nationwide register-based pathology (PALGA) search was performed to identify reports describing esophageal eosinophilia between 1995 and 2019. EoE was identified if the diagnosis was confirmed by the pathologist. Crude incidence rates were estimated by the number of new EoE cases per year and matched with population data.

RESULTS

Between 1995 and 2019, 7361 unique patients' reports mentioned esophageal eosinophilia, of these 4061 were classified as EoE (71% male, mean age 37.9 ± 18.4 years). In total, 639 (16%) children (<18 years) were diagnosed. The EoE incidence increased from 0.01 in 1995 (95% CI: 0.0 - 0.04) to 3.16 (95% CI: 2.90 - 3.44) per 100.000 inhabitants in 2019. EoE was significantly more prevalent in males (OR 2.48 | 95% CI: 2.32 - 2.65; vs. females p < 0.001) and adults (OR 1.42 | 95% CI: 1.31 - 1.55; vs. children p < 0.001). Highest incidences were observed in 2019, being 4.37 (95% CI: 3.94 - 4.84) vs. 1.97 (95% CI: 1.68 - 2.29) per 100.000 males and females, respectively (p < 0.001). No seasonal variation was observed.

CONCLUSION

Over the past quarter century, the annual rates of newly diagnosed EoE patients raised dramatically and this increase has not reached a deceleration yet.

Similarity and difference in the characteristics of eosinophilic esophagitis between Western countries and Japan

Over the past two decades, the incidence and prevalence of eosinophilic esophagitis (EoE) have risen rapidly, especially in Western countries, with cases in Japan also showing a gradual increase in recent years. However, similarities and differences regarding the characteristics of EoE between Western countries and Japan remain to be clearly elucidated. The current clinical guidelines for diagnosis include symptoms related to esophageal dysfunction and dense eosinophilic infiltration in the esophageal epithelium. Most affected patients in Japan are diagnosed incidentally during a medical health check-up and asymptomatic cases with typical endoscopic findings suggestive of EoE are frequently encountered. Clinical characteristics of EoE in Japanese are similar to those seen in Western populations. The predominant symptom is dysphagia, with food impaction extremely rare in Japanese cases. Linear furrows are the most frequently reported characteristic endoscopic finding, while an esophageal stricture or narrow caliber is rarely observed. Treatment strategies for EoE include drugs, dietary restrictions, and endoscopic dilation when the disease is advanced with stricture formation. Although single therapy using a proton-pump inhibitor has been shown to achieve symptomatic and histological response in the majority of patients in Japan, no prospective randomized control studies that evaluated drug or elimination diet therapy have been presented. Overall, EoE has similar clinical characteristics between Japanese and Western populations, while disease severity seems to be milder in Japan. Additional studies are necessary to determine genetic factors, natural history of the disease, and treatment efficacy of drugs and elimination diet as compared to Western populations.

Esophageal Food Impaction: A Retrospective Chart Review

Background

Esophageal food impaction (EFI) is the third most common non-biliary emergency in gastroenterology, with an annual incidence rate of 13 episodes per 100,000 person-years and 1,500 deaths per year. Patients presenting with food impaction often have underlying esophageal pathology. We evaluated the possible risk factors for EFI in our study.

Methods

We performed a retrospective chart review of 455 patients at Staten Island University Hospital (SIUH) that presented with symptoms of food impaction from 1999 to 2017. We analyzed relevant clinical data such as age, risk factors, type of food bolus, location, administration of glucagon, endoscopic technique and complications.

Results

Overall, 174 patients had endoscopically confirmed EFI. The majority were males 102/174 (58.6%). Esophageal pathological findings included esophagitis in 58/174 (33.3%), strictures in 43/174 (24.7%), hiatal hernias in 29/174 (16.6%) and Schatzki’s rings in 15/174 (8.6%). Thirty-two out of 174 (18.3%) had normal endoscopic findings. Diabetes mellitus (DM) was reported in 20/174 (11.4%) patients. The type of food impacted was mostly meat in 73/174 (41.9%) cases. The location of EFI was mainly in the lower one-third of the esophagus in 94/174 (54%). The endoscopic push technique was used in 95/174 (54.5%) patients and the pull technique in 83/174 (47.7%) cases. The endoscopic therapeutic intervention was successful as a first attempt in 165/175 (94.8%) patients. Complications were reported in only 5/174 (2.8%), and these mostly comprised of perforations and tears. Glucagon was given to 74/174 (42.5%) patients. The median door-to-scope time (time of presentation at the emergency department to endoscopic intervention) was 7 h (range 1.5 - 24 h) in patients who had received glucagon as opposed to 7 h (range 1 - 24 h) in patients who did not receive it.

Conclusion

EFI is more common in males. Esophageal strictures and hiatal hernias were the most common pathologies found in endoscopy. Esophagitis was evident in 33.3% of patients, but if it was the cause or consequence of EFI is not clearly understood. DM was associated with food impaction in only 11.4% of patients, but more studies are needed to determine if DM has a stronger association with EFI. The door-to-scope time was shorter in patients who had received glucagon. Endoscopy is a safe and effective therapeutic intervention for EFI, and complications reported were minimal.

Searching for Noninvasive Predictors of the Diagnosis and Monitoring of Eosinophilic Esophagitis-The Importance of Biomarkers of the Inflammatory Reaction Involving Eosinophils

Background: Invasive and costly endoscopic diagnosis is obligatory for the diagnosis and monitoring of eosinophilic esophagitis (EoE). This study aims to evaluate the usefulness of serum biomarkers involved in eosinophil-mediated inflammation in the management of EoE. Methods: A prospective cohort study was conducted in 58 patients with dysphagia. Each participant completed a health questionnaire, underwent esophagogastroduodenoscopy with esophageal biopsy for histopathological examination and assessment of total, inflammatory and fibrostenotic Eosinophilic Esophagitis Reference Score (EREFS). Serum levels of interleukin 5 (IL-5), interleukin 13 (IL-13), transforming growth factor β1 (TGF-β1), major basic protein (MBP), and eotaxin 3 were determined by enzyme immunoassays. Total of 16 patients meeting the histological criteria for EoE were treated with proton pump inhibitors for 8 weeks, and then the same diagnostics was performed again. Results: Statistically significantly higher concentrations of MBP and TGF-β1 were demonstrated in the group of patients with EoE, while MBP and eotaxin 3 correlated with the peak eosinophil count (PEC). Baseline MBP levels and eotaxin 3 after treatment significantly positively correlated with EREFS. There was a negative correlation between IL-13 and fibrostenotic EREFS. Additionally, after treatment, a negative correlation TGF-β1 was noted with the inflammatory EREFS and a positive correlation with the fibrostenotic EREFS. Conclusions: The potential role of MBP in predicting the diagnosis of EoE, eotaxin 3 in predicting the advancement and correlation of IL-13 and TGF-β1 in differentiating the inflammatory and fibrotic course of the disease may facilitate the management and individualization of EoE therapy.

A diagnostic delay of 10 years in the DanEoE cohort calls for focus on education - a population-based cross-sectional study of incidence, diagnostic process and complications of eosinophilic oesophagitis in the North Denmark Region

Background

In the North Denmark Region with a population of 580,000 the awareness of eosinophilic oesophagitis (EoE) increased after 2011 due to a regional biopsy guideline. However, very little was known of the incidence, diagnostic process, or complications of EoE in Denmark.

Objective

The objectives of the study were to establish a cohort of EoE patients and describe the incidence, diagnostic process, and complications of EoE.

Methods

Patient files and histology reports for the 308 DanEoE cohort of patients with eosinophilia in the oesophagus in 2007–2017 identified by the histopathology registry were analyzed.

Results

The incidence of EoE in the North Denmark Region increased to 5.5–8.7/100,000 after 2011, where the regional biopsy guideline was implemented. The diagnostic delay was 10 (12) years for the EoE population. There was an insufficient number of biopsies sampled in 40 % of the patients. At the diagnostic endoscopy, the macroscopic appearance of the oesophagus was often described as normal (24%), and infrequently having one or more macroscopic signs of EoE (43%). Food bolus obstruction was observed in 38%, and strictures in 7.5% of EoE patients. In 22.2% of EoE patient's treatment was not initiated at debut.

Conclusions

The EoE incidence was documented. The diagnostic process was analyzed and showed an unmet need for education among referring physicians and endoscopists: A diagnostic delay of a decade, infrequently noted macroscopic EoE changes and lack of treatment at the debut in one fifth. Strictures in the DanEoE cohort were rare whereas food bolus obstruction was frequent.

Esophageal granular cell tumor and eosinophils: a multicenter experience

Background

Esophageal granular cell tumor (eGCT) is rare, and the recent literature suggests a link between eosinophilic esophagitis (EoE) and eGCT. The aim of our study was to determine if EoE or other disorders associated with eosinophilia are consistently associated with eGCT.

Methods

We retrospectively searched pathology databases of three academic institutions from 1999 to 2018 for eGCTs. The archived slides and medical records were reviewed.

Results

From 294,855 esophagogastroduodenoscopy procedures, 45 patients (17 males and 28 females) with eGCTs were identified. The patients (30–73 years in age, median 50) had eGCT 0.2–2.0 cm in size (average 0.71). Thirteen had a history of gastroesophageal reflux disease, 5 had Barrett esophagus/goblet cell metaplasia and 1 had EoE. Thirty-four eGCTs had intralesional eosinophils (14 with peak > 10 eosinophils/400x hpf); of these, 21 also had eosinophils in lamina propria (9 with peak > 10 eosinophils/hpf). eGCT with atypical features (including nuclear enlargement and prominent nucleoli) were more likely to have increased eosinophils in non-epithelial compartments than those without atypia. Pleomorphism and spindled cells were seen in 3 eGCT cases (mean peak intralesional eosinophils: 43 per hpf); 2 of these had goblet cell metaplasia. We found no association between EoE and eGCT, p = 0.5966, (95% C.I. 0.0276, 6.5389, Fisher’s exact test). Instead, most patients had gastroesophageal reflux disease or Barrett esophagus.

Conclusion

Eosinophilia, common in eGCT and adjacent stroma, likely drives atypical/reactive histologic features, but a pathogenic relationship between eosinophil rich inflammatory conditions and eGCT has not yet been established.

Eosinophilic esophagitis-established facts and new horizons

Despite dramatic advances in our understanding of the pathogenesis and course of disease in the relatively short timeframe since the discovery and first description of eosinophilic esophagitis (EoE) less than three decades ago, many open questions remain to be elucidated. For instance, we will need to better characterize atypical clinical presentations of EoE and other forms of esophageal inflammatory conditions with often similar clinical presentations, nut fulfilling current diagnostic criteria for EoE and to determine their significance and interrelationship with genuine EoE. In addition, the interrelationship of EoE with other immune-mediated diseases remains to be clarified. Hopefully, a closer look at the role of environmental factors and their interaction with genetic susceptibility often in context of atopic predisposition may enable identifying the candidate substances/agents/allergens and potentially earlier (childhood) events to trigger the condition. It appears plausible to assume that in the end—comparable to current concepts in other immune-mediated chronic diseases, such as for instance inflammatory bowel disease or asthma bronchiale—we will not be rewarded with the identification of a “one-and-only” underlying pathogenetic trigger factor, with causal responsibility for the disease in each and every EoE patient. Rather, the relative contribution and importance of intrinsic susceptibility, i.e., patient-driven factors (genetics, aberrant immune response) and external trigger factors, such as food (or aero-) allergens as well as early childhood events (e.g., infection and exposure to antibiotics and other drugs) may substantially differ among given individuals with EoE. Accordingly, selection and treatment duration of medical therapy, success rates and extent of required restriction in dietary treatment, and the need for mechanical treatment to address strictures and stenosis require an individualized approach, tailored to each patient. With the advances of emerging treatment options, the importance of such an individualized and patient-centered assessment will increase even further.

Reversibility of Endoscopic Features after Treatment for Eosinophilic Esophagitis

PURPOSE

The prevalence and incidence of eosinophilic esophagitis (EoE) are increasing worldwide. Despite increased understanding of inflammatory pathogenesis, changes in endoscopic features after treatment of EoE have not been clearly described. We aimed to investigate the reversibility of endoscopic features of EoE after treatment.

MATERIALS AND METHODS

Out of 58 adult subjects who were diagnosed with EoE at the Yonsei University Health System from July 2006 to August 2019, we recruited 33 subjects (30 males; mean age: 42 years) whose pre-treatment and post-treatment endoscopic images were available. Endoscopic features included both inflammatory and fibrostenotic features. Exudate, edema, furrow, and crepe paper-like mucosa were classified as inflammatory features. Ring and stricture were classified as fibrostenotic features. We compared changes in endoscopic features after treatment for EoE.

RESULTS

After treatment, clinical symptoms improved in all patients. The following endoscopic features were observed before treatment: furrow (81.8%), edema (90.9%), exudate (42.4%), ring (27.3%), crepe paper-like mucosa (15.2%), and stricture (3.0%). Endoscopic remission was achieved in 21 patients (63.6%). Inflammatory features were reversible (72.7%, p<0.001), whereas fibrostenotic features were not (10%, p=0.160). Exudate had resolved in 92.9% of patients, edema in 70% and furrow in 88.9%. Ring and stricture persisted in almost all of the patients (9/10) who had these endoscopic features before treatment.

CONCLUSION

We outlined the reversibility of endoscopic inflammatory features of EoE. Fibrostenotic features were irreversible after esophageal remodeling in patients with EoE. However, further validation studies with long-term follow-up are needed.

Race-specific characteristics in pediatric eosinophilic esophagitis in an urban inner-city clinic

BACKGROUND

Manifestations of pediatric eosinophilic esophagitis (EoE) are varied and dictated by multiple factors. The influence of race is limited to small observational cohorts of dichotomized data (Whites vs non-Whites) or single-racial analysis.

OBJECTIVE

To better understand phenotypic variability in the manifestation and atopic sensitization of pediatric EoE, from the perspective of race.

METHODS

Retrospective observational cohort study performed at a tertiary referral center. Subjects were included if less than 21 years old, with suggestive clinical features and histopathologic (>15 eosinophils/high-power field [hpf]) confirmation of EoE. Statistical computation was performed using Stata/IC 11 on variables of interest.

RESULTS

A total of 34 subjects were included in the analysis. The median (interquartile range [IQR]) age for initial atopy was 2 (1-5) years. The median (IQR) age for EoE diagnosis was 5 (3-8) years. Age of EoE diagnosis was higher for Black or African Americans than non-Black or African Americans (P = .01). Between the racial groups, there was no difference in the total number of food sensitizations (P = .13), yet environmental allergy testing revealed that Black or African Americans were more likely to be sensitized for weeds (P = .03), dog (P = .009), and mold (P = .006). On histopathologic analysis, Black or African American subjects were found to have more prominent midesophageal eosinophilia at median 50/hpf (20-80/hpf), whereas Hispanic or LatinXs have more prominent lower esophageal eosinophilia at median 40/hpf (IQR, 20-40/hpf), compared with the other races (P = .04 and P = .04, respectively).

CONCLUSION

Black or African Americans are more likely to present at an older age, have aeroallergen sensitization, and have more prominent midesophageal eosinophilia.

Utility of gastric and duodenal biopsy sampling in adult eosinophilic esophagitis patients to rule out other gastrointestinal disorders

RATIONALE

According to consensus guidelines, if eosinophilic esophagitis (EoE) is suspected, not only esophageal but also gastric and duodenal biopsy specimens should be sampled in order to exclude other generalized or eosinophilic gastrointestinal (GI) disorders, such as eosinophilic gastroenteritis or celiac disease. However, the diagnostic yield for this remains unclear.

AIM

To assess the diagnostic yield of biopsy sampling from the stomach and duodenum in adult EoE patients to rule out generalized or eosinophilic GI disorders.

METHODS

A retrospective chart-review was conducted in untreated adult EoE patients that underwent upper endoscopy with biopsies sampled from the esophagus, stomach and duodenum. Standardized (electronic) case-report forms were used to extract clinical, endoscopic and histologic data.

RESULTS

In total, 93 adults (71% males, age 36.4 (interquartile range 28.4 - 49.1) years) with untreated EoE (≥15 eosinophils/high-power-field) were included. Symptoms of dysphagia and food impaction were reported in 93% and 58%, respectively of the patients. Typical endoscopic EoE-features were present in 77 (85%) patients. The yield of routinely sampled gastric and duodenal biopsy specimens in our cohort was 3.6% (95% confidence interval: 2.6-4.8%) (n/N = 1/93) for a relevant other generalized or eosinophilic GI diagnosis and 30% for other histological diagnosis such as non-specific or H. Pylori gastritis. In total, 62 (67%) patients presented with other GI symptoms and/or endoscopic abnormalities of the stomach and/or duodenum - which both may be suggestive for other relevant GI conditions. The diagnostic yield for a relevant generalized or eosinophilic GI disorder in this subgroup was, 4.8% (95%CI 3.4 - 6.7%) (n/N = 1/62).

CONCLUSION

Gastric and duodenal biopsy specimens seem to have limited diagnostic value for the exclusion of generalized or eosinophilic GI disorders in adults with EoE.KEY POINTSEvidence is lacking on the diagnostic value of additional biopsies sampled form the stomach and duodenum to rule out other relevant generalized or eosinophilic gastrointestinal (GI) disorders.The yield of gastric and duodenal biopsies routinely sampled in our cohort was 3.6% for a relevant other generalized or eosinophilic GI diagnosis and 30% for other histological diagnosis such as non-specific or H. Pylori gastritis.The diagnostic yield for a relevant generalized or eosinophilic GI disorder in the subgroup of patients (67%) presenting with other GI symptoms and/or endoscopic abnormalities of the stomach and/or duodenum - which both may be suggestive for other relevant GI conditions was, 4.8%.Gastric and duodenal biopsy specimens seem to have limited diagnostic value for the exclusion of generalized or eosinophilic GI disorders in adults with EoE.

A Network Meta-Analysis of Randomized Controlled Trials on the Treatment of Eosinophilic Esophagitis in Adults and Children

BACKGROUND

Network meta-analysis is used as a data synthesizer, incorporating direct and indirect evidence about treatments in a series of randomized control trials.

OBJECTIVE

To evaluate the comparative efficacy of various treatments for eosinophilic esophagitis (EoE).

METHODS

We performed a network meta-analysis to combine direct and indirect data to investigate the efficiency of drug therapies, which were evaluated in relevant randomized control trials for EoE.

RESULTS

Seventeen eligible studies (14 two-arm and 3 multiple-arm) were introduced to the meta-analysis. A total of 1011 patients were included, in whom 15 therapeutic interventions were used, namely: (1) budesonide oral suspension, (2) budesonide 1 mg orodispersible tablet twice daily, (3) budesonide 2 mg orodispersible tablet twice daily, (4) esomeprazole, (5) fluticasone, (6) nebulized steroid, (7) placebo, (8) prednisone, (9) anti-IL-5-mab (mepolizumab), (10) anti-IL-5-mab [reslizumab(1), ie, 1 mg/kg], (11) anti-IL-5-mab [reslizumab(2), ie, 2 mg/kg], (12) anti-IL-5-mab [reslizumab(3), ie, 3 mg/kg], (13) anti-IL-13-mab (QAX 576), (14) anti-IL-13-mab [RCP 4046 (180)], and (15) anti-IL-13-mab [RCP 4046 (360)]. Budesonide 1 mg orodispersible tablet twice daily showed the highest efficacy (SUCRA 0.91), whereas placebo was the least effective. In adult patients budesonide 1 mg orodispersible tablet twice daily remained the optimal treatment approach, whereas the corresponding therapeutic approach in pediatric patients was fluticasone.

CONCLUSIONS

This meta-analysis showed that budesonide 1 mg orodispersible tablet twice daily was the best treatment for EoE, as it was the most effective. This treatment remained the optimal approach in adult patients, whereas fluticasone was the best treatment in pediatric patients.

Long-term Follow-up for Missed Cases of Eosinophilic Esophagitis in Children With Previous Foreign Body in the Esophagus

OBJECTIVES

A foreign body impacted in the esophagus could be a sign of eosinophilic esophagitis (EoE). Our aim was to investigate if children previously diagnosed with a foreign body in the esophagus had a missed diagnosis of EoE.

METHODS

In this population-based longitudinal study, all children (0-18 years) diagnosed with a foreign body in the esophagus in Stockholm, Sweden 2006 to 2016, were identified. In addition to a review of medical files, each family was contacted (n = 325) and asked standardized questions. Children with symptoms indicating EoE were offered esophagogastroduodenoscopy (EGD).

RESULTS

We found 325 pediatric cases of foreign body. Two hundred and seven (64%) underwent an endoscopy at the event, 3 of these had biopsies taken, whereby 2 were diagnosed with EoE. Six additional patients were diagnosed with EoE between the initial event and the study follow-up. Children with persisting symptoms suggestive of EoE at the follow-up (n = 21), were offered EGD whereof 7 accepted. Four new cases of EoE were found. Hence, 12 (3.7%) of the children with a previous foreign body, either spontaneously released or endoscopically removed, were diagnosed with EoE. In the structured interview, dysphagia, food impactions and drinking excessively with meals, as well as food allergies, were significantly more common in EoE patients.

CONCLUSIONS

Children with a foreign body in the esophagus are at risk of having EoE. Biopsies should be taken during foreign body removal and questions about swallowing problems and allergic diseases should be carefully explored also in children who do not need EGD because of spontaneous release.

Esophagitis in Cats and Dogs

Esophagitis in cats and dogs is a consequence of increased exposure of the esophageal mucosa to gastroduodenal reflux. Causes can include anesthesia-related reflux, frequent vomiting, or lodged foreign bodies. An exception is eosinophilic esophagitis, an emerging primary inflammatory disease of the esophagus with a presumed allergic etiology. Reflux esophagitis owing to lower esophageal sphincter incompetence is often suspected; a tentative diagnosis can be made by endoscopic assessment, wireless esophageal pH-monitoring, or histologic examination. Because it can be difficult to distinguish diet-responsive upper gastrointestinal disease from esophagitis, response to treatment with gastric acid suppressants is needed to confirm the tentative diagnosis.

Dietary Management of Eosinophilic Esophagitis: Man Versus Food or Food Versus Man?

An alternative to pharmacologic management of eosinophilic esophagitis, elimination of food antigens for diet therapy is an effective first-line treatment strategy to induce and maintain symptomatic, histologic, and endoscopic disease remission. The 3 dietary strategies for eosinophilic esophagitis include elemental diet, empiric elimination diet, and targeted elimination diet. We review the studies supporting various diet therapy strategies, practical considerations and challenges for applying an elimination diet, and novel testing to identify triggers and optimize food reintroduction.

Steroid Eluting Esophageal-Targeted Drug Delivery Devices for Treatment of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic atopic disease that has become increasingly prevalent over the past 20 years. A first-line pharmacologic option is topical/swallowed corticosteroids, but these are adapted from asthma preparations such as fluticasone from an inhaler and yield suboptimal response rates. There are no FDA-approved medications for the treatment of EoE, and esophageal-specific drug formulations are lacking. We report the development of two novel esophageal-specific drug delivery platforms. The first is a fluticasone-eluting string that could be swallowed similar to the string test "entero-test" and used for overnight treatment, allowing for a rapid release along the entire length of esophagus. In vitro drug release studies showed a target release of 1 mg/day of fluticasone. In vivo pharmacokinetic studies were carried out after deploying the string in a porcine model, and our results showed a high local level of fluticasone in esophageal tissue persisting over 1 and 3 days, and a minimal systemic absorption in plasma. The second device is a fluticasone-eluting 3D printed ring for local and sustained release of fluticasone in the esophagus. We designed and fabricated biocompatible fluticasone-loaded rings using a top-down, Digital Light Processing (DLP) Gizmo 3D printer. We explored various strategies of drug loading into 3D printed rings, involving incorporation of drug during the print process (pre-loading) or after printing (post-loading). In vitro drug release studies of fluticasone-loaded rings (pre and post-loaded) showed that fluticasone elutes at a constant rate over a period of one month. Ex vivo pharmacokinetic studies in the porcine model also showed high tissue levels of fluticasone and both rings and strings were successfully deployed into the porcine esophagus in vivo. Given these preliminary proof-of-concept data, these devices now merit study in animal models of disease and ultimately subsequent translation to testing in humans.

Advancing Eosinophilic Esophagitis Diagnosis and Phenotype Assessment with Deep Learning Computer Vision

Eosinophilic Esophagitis (EoE) is an inflammatory esophageal disease which is increasing in prevalence. The diagnostic gold-standard involves manual review of a patient's biopsy tissue sample by a clinical pathologist for the presence of 15 or greater eosinophils within a single high-power field (400× magnification). Diagnosing EoE can be a cumbersome process with added difficulty for assessing the severity and progression of disease. We propose an automated approach for quantifying eosinophils using deep image segmentation. A U-Net model and post-processing system are applied to generate eosinophil-based statistics that can diagnose EoE as well as describe disease severity and progression. These statistics are captured in biopsies at the initial EoE diagnosis and are then compared with patient metadata: clinical and treatment phenotypes. The goal is to find linkages that could potentially guide treatment plans for new patients at their initial disease diagnosis. A deep image classification model is further applied to discover features other than eosinophils that can be used to diagnose EoE. This is the first study to utilize a deep learning computer vision approach for EoE diagnosis and to provide an automated process for tracking disease severity and progression.

Eosinophilic esophagitis: clinical, endoscopic, histologic and therapeutic differences and similarities between children and adults

In the absence of secondary causes, eosinophilic esophagitis (EoE) is a chronic, local, progressive, T-helper type 2 immune-mediated disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. In the last 20 years, the incidence and prevalence of EoE have risen sharply, and the chances of encountering affected patients in clinics and endoscopy rooms have increased. Nevertheless, it is estimated that the mean diagnostic delay of EoE is 4-6 years in both children and adults. Unfortunately, the longer the disease stays unrecognized, the likelier it is for the patient to have persistent or increased esophageal eosinophilic inflammation, to complain of non-resolving symptoms, and to develop fibrotic complications. Early detection depends on the recognition of initial clinical manifestations that vary from childhood to adulthood and even among patients of the same age. The disease phenotype also influences therapeutic approaches that include drugs, dietary interventions, and esophageal dilation. We have herein reviewed epidemiologic, clinical, endoscopic, and histologic features and therapeutic options of EoE focusing on differences and similarities between children and adults that may certainly serve in daily clinical practice.

Eosinophilic Esophagitis: Etiology and Therapy

Eosinophilic esophagitis (EoE) is a relatively recently identified but now frequently encountered antigen/immune-mediated disease which places significant burden on patients and the healthcare system. With its growing prevalence and recognition by healthcare providers in multiple disciplines, substantial progress has been made regarding the diagnostic criteria, clinical evaluation, tools for disease assessment, and immune pathways related to pathogenesis. Current treatment goals focus on the amelioration of inflammation and prevention of remodeling consequences using proton pump inhibitors, swallowed topical steroids, elimination diets, and esophageal dilation. Ongoing research holds promise for more efficacious and targeted therapies as well as a personalized approach to the care of patients with EoE.

Eosinophilic esophagitis: novel concepts regarding pathogenesis and clinical manifestations

Eosinophilic esophagitis is a chronic disease whose incidence and prevalence are increasing, based on a genetic-driven interaction between environment and immune system. Several gene loci involved in the development of the disease have been identified. A two-step mechanism has been hypothesized: a thymic stromal lymphopoietin-induced allergic sensitization followed by upregulation of CAPN14-related esophageal-specific pathways. Environment seems to have a larger effect than genetic variants. Factors that could play a role are allergens, drugs, colonizing bacteria and possibly Helicobacter Pylori infection. Acting on these modifiable risk factors may be a tool to prevent the disease. EoE is characterized by a typical eosinophilic infiltrate limited to the esophageal epithelium, supported by a Th2-mediated immune response, found in other atopic conditions. The key of the pathogenesis is the disfunction of the epithelial barrier which allow the interaction between allergens and inflammatory cells. Eosinophilic-predominant inflammation leads to the typical wall remodeling, histologically characterized by epithelial and smooth muscle hyperplasia, lamina propria fibrosis and neo-angiogenesis. These alterations find their clinical expression in the pattern of symptoms: dysphagia, food impaction, chest pain, heartburn.

The Habitual Diet of Dutch Adult Patients with Eosinophilic Esophagitis Has Pro-Inflammatory Properties and Low Diet Quality Scores

We determined the nutritional adequacy and overall quality of the diets of adult patients with eosinophilic esophagitis (EoE). Dietary intakes stratified by sex and age were compared to Dietary Reference Values (DRV). Overall diet quality was assessed by two independent Diet-Quality-Indices scores, the PANDiet and DHD-index, and compared to age- and gender-matched subjects from the general population. Lastly, food and nutrient intakes of EoE patients were compared to intakes of the general population. Saturated fat intake was significantly higher and dietary fiber intake significantly lower than the DRV in both males and females. In males, the DRV were not reached for potassium, magnesium, selenium, and vitamins A and D. In females, the DRV were not reached for iron, sodium, potassium, selenium, and vitamins A, B2, C and D. EoE patients had a significantly lower PANDiet and DHD-index compared to the general population, although the relative intake (per 1000 kcal) of vegetables/fruits/olives was significantly higher (yet still up to 65% below the recommended daily amounts) and alcohol intake was significantly lower compared to the general Dutch population. In conclusion, the composition of the habitual diet of adult EoE patients has several pro-inflammatory and thus unfavorable immunomodulatory properties, just as the general Dutch population, and EoE patients had lower overall diet quality scores than the general population. Due to the observational character of this study, further research is needed to explore whether this contributes to the development and progression of EoE.

Diagnostic Value of Mid-esophageal Biopsies in Pediatric Patients With Eosinophilic Esophagitis

INTRODUCTION

Eosinophilic esophagitis (EoE) is histologically defined as the presence of 15 or more intraepithelial eosinophils per high-power fields. Limited consensus exists on where to sample the esophagus in pediatrics. This study aimed to identify whether endoscopic and histologic examination of the mid esophagus offers diagnostic value compared to proximal/distal esophageal biopsies.

METHODS

A retrospective chart review of pediatric patients with EoE was performed. Endoscopic and histologic parameters were assessed at the initial and follow-up visits, and concordance between proximal/distal biopsy and mid biopsy was determined.

RESULTS

A total of 100 patients with a mean age of 9.6 ± 4.07 years were included. Endoscopic parameters between proximal/distal and mid esophagus were concordant in 84% to 97% of patients (initial assessment) and in 80% to 97% of patients (at follow-up). Mid esophagus showed endoscopic abnormalities, which were absent at the proximal/distal esophagus in 1% to 5% of patients, as well as histologic abnormalities in 2% to 8% of patients overall at initial and follow-up examinations.

CONCLUSIONS

We recommend continued endoscopic and histologic assessment of the proximal/distal biopsy; however, examination of the mid esophagus does offer small diagnostic value in our subset of patients. Future studies need to be conducted before conclusive recommendations supporting the use of mid-esophageal biopsies can be made.

The "caterpillar sign": a novel endoscopic indicator of eosinophilic esophagitis

BACKGROUND

Although several endoscopic findings of eosinophilic esophagitis (EoE), such as the EoE endoscopic reference score (EREFS), have been reported thus far, these endoscopic findings exhibit low specificity. Furthermore, most of these endoscopic findings were evaluated solely in patients from Western nations. We have recently noted a fragile, protruded mucosal lesion sandwiched between longitudinal furrows (similar to caterpillar tracks) on the esophagus in patients with EoE. We have termed this novel finding the "caterpillar sign". This study evaluated the clinical significance of the caterpillar sign and the EREFS for diagnosis of EoE in Japanese patients.

METHODS

We retrospectively analyzed endoscopic images from 165 consecutive patients who underwent tissue collection on suspicion of EoE. We compared the clinical significance between the EREFS and the caterpillar sign. We defined EoE as the presence of ≥ 15 eosinophils on esophageal mucosa per high-power field; control images had < 15 eosinophils per high-power field. For evaluation of endoscopic diagnosis capacity using the total EREFS, 2 points was set as the cutoff value. The presence or absence of the caterpillar sign was evaluated.

RESULTS

The sensitivity, specificity, positive predictive value, and negative predictive value of total EREFS ≥ 2 for the diagnosis of EoE were 100%, 56.2%, 56.6%, and 100%; for the caterpillar sign, those values were 83.3%, 98.1%, 96.2%, and 91.2%, respectively. Interobserver agreement for identification of the caterpillar sign was substantial (κ = 0.80) CONCLUSIONS: The caterpillar sign could be a novel reliable indicator for endoscopic diagnosis of EoE.

Food-induced immediate response of the esophagus-A newly identified syndrome in patients with eosinophilic esophagitis

BACKGROUND

Dysphagia is the main symptom of adult eosinophilic esophagitis (EoE). We describe a novel syndrome, referred to as "food-induced immediate response of the esophagus" (FIRE), observed in EoE patients.

METHODS

Food-induced immediate response of the esophagus is an unpleasant/painful sensation, unrelated to dysphagia, occurring immediately after esophageal contact with specific foods. Eosinophilic esophagitis experts were surveyed to estimate the prevalence of FIRE, characterize symptoms, and identify food triggers. We also surveyed a large group of EoE patients enrolled in the Swiss EoE Cohort Study for FIRE.

RESULTS

Response rates were 82% (47/57) for the expert and 65% (239/368) for the patient survey, respectively. Almost, 90% of EoE experts had observed the FIRE symptom complex in their patients. Forty percent of EoE patients reported experiencing FIRE, more commonly in patients who developed EoE symptoms at a younger age (mean age of 46.4 years vs 54.1 years without FIRE; P < .01) and in those with high allergic comorbidity. Food-induced immediate response of the esophagus symptoms included narrowing, burning, choking, and pressure in the esophagus appearing within 5 minutes of ingesting a provoking food that lasted less than 2 hours. Symptom severity rated a median 7 points on a visual analogue scale from 1 to 10. Fresh fruits/vegetables and wine were the most frequent triggers. Endoscopic food removal was significantly more commonly reported in male patients with vs without FIRE (44.3% vs 27.6%; P = .03).

CONCLUSIONS

Food-induced immediate response of the esophagus is a novel syndrome frequently reported in EoE patients, characterized by an intense, unpleasant/painful sensation occurring rapidly and reproducibly in 40% of surveyed EoE patients after esophageal contact with specific foods.

Endoscopy in Pediatric Eosinophilic Esophagitis

Endoscopy and mucosal biopsies are essential to the diagnosis of EoE. Together they either confirm or exclude mucosal eosinophilia and provide a visual inspection of the esophagus that may be consistent with EoE or suggest other underlying etiologies. Endoscopy also plays an important therapeutic role in the management of EoE including the assessment of treatment response and treatment of associated complications including esophageal stricture and food impaction. Assessment of treatment response largely depends on endoscopy and mucosal biopsies although less invasive strategies may eventually provide alternative means to assess mucosal inflammation. Herein we will review current use of endoscopy in EoE, including recently developed technologies and their role in the management of EoE.

Implementation of a biopsy protocol to improve detection of esophageal eosinophilia: a Danish registry-based study

BACKGROUND : In the North Denmark Region (580 272 inhabitants), only 0-4 cases of possible eosinophilic esophagitis (EoE) were identified annually in 1999-2010, suggesting underdiagnosis. This study aimed to increase the diagnosis of EoE by introducing a regional biopsy protocol for patients with dysphagia. METHODS : In 2011, leaders of regional endoscopy units attended a consensus meeting where a biopsy protocol was proposed. The national pathology registry was used to identify patients with esophageal eosinophilic inflammation during 2007-2017. RESULTS : Discussion resulted in consensus on a protocol to take eight biopsy samples in dysphagia patients (four biopsies from 4 cm and 14 cm above the esophagogastric junction-"4-14-4 rule") regardless of the macroscopic appearance, and to code eosinophilia systematically in the pathology registry. A pictogram showing the 4-14-4 rule was sent to all endoscopy units. The number of patients with esophageal eosinophilia detected per year increased 50-fold after the protocol was implemented in 2011 (median of 1 [interquartile range 0-3] vs. 52 [47-56]; P < 0.001), and the number of biopsy samples per patient doubled (median 4 [4-5] vs. 8 [6-9]; P < 0.04). Of 309 patients diagnosed with esophageal eosinophilia in 2007-2017, 24 % had erosive esophagitis or Barrett's esophagus, and 74 % had EoE. CONCLUSIONS : A consensus-based biopsy protocol and improved coding of eosinophilia in the pathology registry resulted in a 50-fold increase in patients diagnosed with esophageal eosinophilia/year. These patients can now receive treatment. The effort to establish the protocol and change the culture of endoscopists and pathologists was minimal.

Novel and rare forms of oesophagitis

Our understanding of inflammatory diseases of the gastrointestinal tract, including those of the oesophagus, has expanded in recent years. Once attributed almost exclusively to gastro-oesophageal reflux disease or infection, it is now recognised that oesophagitis may occur due to a variety of distinct disease entities. Many of these conditions cause debilitating and persistent symptoms, impacting upon quality of life and necessitating ongoing surveillance and treatment. This review will consider the clinical, endoscopic and histopathological features of these novel and rare forms of oesophagitis.

Treatment with compounded fluticasone suspension improves the clinical, endoscopic, and histologic features of eosinophilic esophagitis

No approved medication exists for the treatment of eosinophilic esophagitis (EoE) in the United States, which forces patients to utilize off-label drugs and/or create their own formulations. We assessed the efficacy of a standardized compounded fluticasone suspension. To do this, we performed a retrospective cohort study identifying all EoE patients treated with compounded fluticasone. Compounded fluticasone was prescribed during routine clinical care and dispensed by a specialty compounding pharmacy. Clinical data were extracted from medical records. Outcomes (symptomatic, endoscopic, and histologic) were assessed after the initial and last compounded fluticasone treatment in our system. There were 27 included patients (mean age 34.2; 67% male; 96% white) treated for a mean length of 5.4 ± 4.4 months. The majority (89%) previously utilized dietary elimination or topical corticosteroids, and many (75%) had primary non-response or secondary loss of response to these treatments. After starting compounded fluticasone, symptoms and endoscopic findings improved [dysphagia (89 vs. 56%, P = 0.005), food impaction (59 vs. 4%, P = 0.003), heartburn (26 vs. 4%, P = 0.01), chest pain (26 vs. 8%, P = 0.05), white plaques (63 vs. 32%; P = 0.005), furrows (81 vs. 60%; P = 0.06), and edema (15 vs. 4%; P = 0.16)]. The median of the peak eosinophil counts decreased from 52 to 37 eos/hpf (P = 0.10) and 35% of patients achieved <15 eos/hpf. In conclusion, compounded fluticasone provided a significant improvement in symptoms and endoscopic findings, with more than a third achieving histologic response in a treatment refractory EoE population. Compounded fluticasone should be considered as an EoE management option.

The role of endoscopy in eosinophilic esophagitis: from diagnosis to therapy

Endoscopy plays an important role in the management of eosinophilic esophagitis (EoE), since it is involved in the diagnosis, follow-up and treatment of this condition. In patients presenting with food impaction, dysphagia and other symptoms of suspected EoE, esophago-gastric-duodenoscopy (EGD) with multiple esophageal biopsies should be performed to confirm or rule out the diagnosis of EoE. The EREFS system, a validated instrument for assessment of the endoscopically-identified esophageal features in EoE (edema, rings, exudates, longitudinal furrows and strictures), is currently used in the clinical practice for the evaluation of the macroscopic aspects of esophageal mucosa during EGD. Multiple esophageal biopsies are mandatory to further confirm EoE diagnosis and subsequent response to treatment, since symptoms reported by patients do not always correlate with histological activity, and considering the low sensitivity of endoscopic assessment; a cut-off of ≥15 eosinophils in at least one high power field is the density threshold considered the standard for diagnosis (sensitivity 100%, specificity 96%). Other histological features, included in the EoE histologic scoring system (EoEHSS), are supportive for the diagnosis and for the assessment of inflammatory activity during follow-up. Esophageal dilation, performed either with Savary dilators/bougie or hydrostatic balloon, is an effective and safe treatment in both adult and pediatric EoE patients with fibrostenotic features, mainly in association with other therapeutic strategies which can control eosinophilic inflammation.

Eosinophilic esophagitis: definition, epidemiology and quality of life

Eosinophilic esophagitis (EoE) is a clinicopathological disease defined by symptoms of esophageal dysfunction and ≥15 eosinophils/HPF after excluding other causes of esophageal eosinophilia. Increasing attention has been paid by clinicians and researchers after its first description in 1978. Many consensuses and guidelines have been issued over the years, as gastroenterologists did not reach an agreement on EoE definition, especially regarding the controversial responsiveness to proton pump inhibitor (PPI) therapy. Of note, recent evidence suggests that the incidence and prevalence of EoE have been increasing through the years: many risk factors have been advocated as possible reasons for this, although further studies are needed. In this brief review, we will first cover the history of EoE in the literature, with a focus on its varying definition throughout the years. Then, we will discuss EoE epidemiology, emphasizing potential risk factors explaining its increasing incidence and prevalence. Last, we will deal with the quality of life of adult and pediatric patients with EoE.

Vascular Changes in Eosinophilic Esophagitis (EOE), Report of an Unusual Case

Background: Submucosal or lamina propria arteries are not often included in esophageal biopsies. We report an esophageal biopsy with eosinophilic esophagitis (EOE) overlying small arteries with medial hypertrophy to the point of obstruction. Case presentation: A two-year-old boy with a 1-year history of asthma frequently vomited after coughing. Esophageal biopsy showed EOE. Within the lamina propria there were small arteries with markedly thickened media to the point of luminal obstruction next to a hyperplastic lymphoid aggregate. There was no significant inflammatory infiltrate in the arterial walls. Subsequent biopsies did not show these vascular changes. Conclusion: Small artery changes in EOE have not previously been reported, and although the significance is unknown, in this case may be incidental to eosinophilic esophagitis.

The utility of multichannel intraluminal impedance-pH testing in tailoring the management of paediatric gastro-oesophageal reflux disease

AIM

To determine whether combined multichannel intraluminal impedance and pH (MII-pH) testing led to a change in management of children with gastro-oesophageal reflux disease (GORD).

METHODS

Retrospective chart review was done in all patients who underwent MII-pH testing for GORD symptoms at Sydney Children's Hospital between 2008 and 2016. Changes to anti-reflux medications and referral for anti-reflux surgery were evaluated.

RESULTS

There were 365 patients, 260 (71.2%) of whom were on acid-suppressing therapy. The median age was 4.1 ± 4.8 years, 205 patients (56%) were males, 83 (22.7%) were infants (<1 year of age) and 145 (39.7%%) had comorbid conditions. We found 72.1% had abnormal MII-pH results, of which 17.5% had abnormal acid reflux, 8.2% had abnormal number of retrograde bolus movements and 46.3% had hypersensitive oesophagus (positive symptom association only). Infants were significantly more likely to have abnormal MII-pH results compared to older children (P = .04). Results of MII-pH testing led to medication changes in 44.7% and referral for anti-reflux surgery in 6.8% of patients.

CONCLUSION

Combined multichannel intraluminal impedance and pH testing is clinically useful in the management of children with symptoms of GORD and over half the patients had changes to their medical treatment or referral for anti-reflux surgery based on the results of MII-pH testing. It resulted in a treatment change in an additional 32% of patients over traditional pH-metry.

Prevalence and Predictors of Compromised Bone Mineral Density in Pediatric Eosinophilic Esophagitis

OBJECTIVES

The aim of the study was to determine whether patients with eosinophilic esophagitis (EoE) have lower bone mineral density (BMD) than expected and if bone deficits are more pronounced in subgroups of patients according to comorbidities (atopic disease and joint hypermobility) or treatments (dietary restriction, medication exposure).

STUDY DESIGN

Retrospective chart review was performed to obtain clinical data, including length of diagnosis, comorbidities, and methods of treatment for patients with EoE ages 3 to 21 years who had a lumbar spine dual-energy x-ray absorptiometry scan performed between 2014 and 2017. BMD was standardized by calculation of age, sex, and race-specific z scores.

RESULTS

A total of 269 patients met study criteria. The mean BMD z score (-0.55, 95% confidence interval: -0.68, -0.42) was lower than expected (P < 0.0001), and the prevalence of low BMD z score (≤-2.0) was higher than expected (8.5%, 95% confidence interval: 5.2%-11.9%, P < 0.0001). In multivariable regression models, BMD z scores were -0.27 lower among those following an elimination diet and -0.65 lower among those with any lifetime use of a proton pump inhibitor (93% of the sample). There was no association with swallowed steroid use.

CONCLUSIONS

In our sample, pediatric patients with EoE had a slightly lower BMD z score compared to peers, and the prevalence of low BMD was higher than expected. Taken cautiously given the limitations of our sample, risk factors for bone deficits included any lifetime use of proton pump inhibitor and a restrictive elimination diet, but not swallowed steroid use. Larger prospective studies are needed to better characterize risk factors for low BMD to help inform screening, selection of therapies, and provide appropriate anticipatory guidance for patients with EoE.

Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome

Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of esophageal dysfunction, including dysphagia. While EoE is still considered a rare disease, in practice it seems that more and more cases are diagnosed every week, research in the field is exploding, and the pipeline for treatments contains multiple agents, some of which are quite far along the development pathway. After only scattered cases and small series were published in the late 1970s and 1980, Stephen Attwood, Thomas Smyrk, Tom DeMeester, and James Jones, published in Digestive Diseases and Sciences in 1993 a seminal report that described a clinicopathologic syndrome of esophageal eosinophilia with dysphagia. This review details the origins of this paper and compares and contrast what was observed then and what is known now about multiple aspects of EoE, including the clinical presentation, diagnosis, epidemiology, natural history, and treatments and outcomes. Moreover, it will highlight how the paper presaged a number of controversies in the field that have yet to be resolved, as well as foreshadowed the collaborative, multidisciplinary approach that has led to rapid advances.

Eosinophilic Esophagitis as a Side Effect of Food Oral Immunotherapy

Food allergies (FAs) include a spectrum of immune-mediated serious and potentially life-threatening medical conditions with an overall estimated prevalence ranging from 4% to 8% in the U.S. and Europe. Significant progress in food allergen-specific immunotherapy has been accomplished over the past 10 years. The most studied strategy has been oral immunotherapy (OIT), also known as food desensitization, a treatment in which a child is slowly and deliberately given a small amount of the food to ingest (that previously was a food allergy trigger) with the ultimate goal of the child eating that food without a reaction. OIT is now recommended in the European guidelines for the treatment of milk, egg, and peanut allergies and was the first American Food Drug Administration (FDA) approved product for the prevention of severe reaction to peanuts in 4–17 year olds to be released on the market. The side effects associated with OIT treatment trials are mild to moderate, predominantly oropharyngeal, and easily treated. More severe reactions, such as generalized urticaria/angioedema, wheezing/respiratory distress, laryngeal edema, and repetitive emesis, have been reported. However systemic reactions are very rare. Low-dose immunotherapy is associated with significantly fewer side effects. Currently, its most limiting allergic side effect is that approximately 10–15% of subjects treated with OIT experience gastrointestinal symptoms, preventing the continuation of therapy. Eosinophilic esophagitis (EoE) has also been reported as a cause of persistent abdominal symptoms in OIT.

Utility of Direct Fast Scarlet Staining in the Histopathological Diagnosis of Eosinophilic Esophagitis: A Short Report

Eosinophilic esophagitis (EoE), an atopic disease of the esophagus, has become increasingly recognized over the last 15 years. The epidemiology of EoE has now been reported from many countries around the world. While the clinical diagnosis of this disease depends on the patient’s clinical manifestations, the final diagnosis should be made based on the histopathological examination of esophageal mucosal biopsies. In the diagnosis of EoE, to facilitate the appropriate treatment of patients, it is extremely important to precisely recognize the presence of eosinophils in biopsy specimens of the esophageal mucosa. If eosinophils are present, EoE patients should be referred to an allergist for appropriate management with dietary modification, pharmacological agents (including corticosteroids), and/or mechanical dilation of the esophagus. We herein present and recommend the use of direct fast scarlet staining for the easy and precise recognition of eosinophils in biopsy specimens of the esophageal mucosa, a technique that has been routinely used in our laboratory.

What is the role of high-resolution oesophageal manometry in paediatrics?

Abnormal oesophageal motility may impair oesophageal bolus transport leading to symptoms of chest pain and regurgitation. Oesophageal pathophysiology may include neuromuscular and/or structural defects leading to weak, incoordinate or absent peristalsis and impaired oesophago-gastric junction relaxation. Understanding these mechanisms is important to determine the appropriate course of therapy. Whilst, barium oesophagram is the mainstay for clinical investigation of oesophageal motility, high-resolution manometry is now more widely available. This review describes the potential value of high-resolution manometry in paediatric gastroenterology practise.

Clinical and anatomopathological features of eosinophilic oesophagitis in children and adults

INTRODUCTION

Eosinophilic oesophagitis (EoE) is a chronic clinical-pathological disorder with an immunological basis characterised by symptoms of oesophageal dysfunction and, histologically, eosinophilic inflammation.

OBJECTIVE

To evaluate the clinical characteristics and differences in children and adults diagnosed with EoE in a tertiary level hospital.

METHOD

Descriptive, retrospective and cross-sectional study. We randomly selected 40 children and 40 adults diagnosed with EoE between 2009 and 2016. The patient characteristics were analysed by means of epidemiological, clinical, diagnostic and therapeutic variables.

RESULTS

The average age at diagnosis was 10 years (children) and 34 years (adults), with a higher frequency in males. The majority were sensitised to aeroallergens (77.5% children vs. 82.5% adults) and foods (75% children vs. 82.5% adults). Statistically significant differences were detected in sensitisation to fruits (p=0.007) and grains (p<0.001). Differences were observed in impaction (22.5% children vs. 82.5% adults), dysphagia (42.5% children vs. 77.5% adults) and abdominal pain (25% children vs. 7.5% adults). Endoscopy showed that children had a higher frequency of exudates (92.5%) and adults, trachealisation (50% vs. 5%) and stenosis (17.5% vs. 2.5%). Statistically significant differences were found in treatment with topical corticosteroids (30% children vs. 77.5% adults), with a variable positive response. 77.5% of the patients received elimination diets.

CONCLUSIONS

Statistically significant differences were observed between the paediatric and adult populations in the food sensitisation profiles, clinical manifestations, endoscopic findings and treatments received. This is a complex pathology that calls for a multidisciplinary team and would require new non-invasive techniques to facilitate its management.

Long-term Continued Proton Pump Inhibitor Use is Common in Patients Diagnosed with Eosinophilic Esophagitis Despite Failure of Histologic Response: Data from a two-centre study: Long-term PPI Use in Patients with EoE

BACKGROUND AND AIMS

Treatment paradigms for proton pump inhibitors (PPIs) in eosinophilic esophagitis (EoE) are evolving. We aimed to determine patterns of long-term PPI use after EoE diagnosis in PPI histologic non-responders.

METHODS

We conducted a retrospective review at University of Colorado (UCH) and University of North Carolina (UNC) of EoE patients who were histologic non-responders to PPIs. Data were extracted from electronic medical records related to demographics, PPI use, and reasons for continuing or stopping PPI.

RESULTS

Of 67 patients in the UCH cohort, PPIs were initially discontinued in 9 (13%). Of 58 remaining on PPI, 48% were not instructed to discontinue therapy and 26% continued for symptom improvement. Of 675 patients at UNC, PPI was stopped in 185 (27%). Of patients remaining on PPI, 15% were not told to discontinue therapy and 62% were continued for symptom improvement. At last contact, >50% of patients remained on PPI at both centres with most common reasons for continuation being symptom improvement and not telling patients to discontinue. In the UNC cohort, clinical features associated with remaining on PPI included children younger than 18 years (p=0.01), males (p<0.001), heartburn symptoms (p<0.001) and hiatal hernia (p=0.004). Patients with dysphagia were less likely to remain on PPIs (p<0.001).

CONCLUSIONS

Long-term PPI use is common in EoE patients even without histologic response. Failure to instruct patients to discontinue therapy was a common reason for long-term use, thus PPI use should be revisited in all EoE patients to confirm clinical benefit.

Epidemiology and risk factors for eosinophilic esophagitis: lessons for clinicians

INTRODUCTION

The rapid expansion in the epidemiology of eosinophilic esophagitis (EoE) is being documented, along with cumulative research assessing environmental exposures associated with EoE and susceptibility due to genetic variants.

AREAS COVERED

Incidence rates for EoE of 5-10 new cases per 100,000 inhabitants annually have shown an increase in recent reports of up to 20 in some countries; the highest prevalence being reported for Europe and North America, where EoE now affects more than 1 out of 1,000 people. EoE has been shown to be associated with several disorders, Th2-mediated atopies being the most common. Patients with EoE exhibit increased frequency of asthma, allergic rhinitis and eczema, and EoE has been considered as a late component of the atopic march. Risk variants in TSLP, CAPN14 and LRCC32 genes, among others, have all been related to EoE, and interact with prenatal and early life exposure potentially modifying abundance and composition of gut microbiome. Dysregulated interactions between bacteria and mucosal immunity emerge as leading causes of EoE.

EXPERT OPINION

The expanding epidemiology of EoE, the resources needed and subsequent increasing healthcare costs require additional effort to optimize cost-effective management and unveil mechanisms that enhance the development of future preventive strategies.

A meta-analysis of efficacy of topical steroids in eosinophilic esophagitis: From the perspective of histologic, clinical, and endoscopic outcome

BACKGROUND

Swallowed topical steroids are a mainstay drug therapy for eosinophilic esophagitis (EoE), studies have demonstrated good histologic response, but with enormous discrepancy in clinical and endoscopic improvement. We conducted this meta-analysis to investigate the efficacy of topical steroids in EoE in histological, clinical and endoscopic improvement.

METHODS

Several databases were searched from inception to August 1, 2019 for randomized controlled trials (RCTs) comparing topical steroids with placebo for EoE in the short-term. The outcomes of interest mainly included basic characteristics of the studies, histologic, clinical, endoscopic response rate and adverse events. The results were pooled together using Reviewer Manager 5.3.5 software, and inconsistency was quantified using I² statistics.

RESULTS

Nine studies were eventually selected. The results showed that topical steroids were effective in inducing histologic response compared with placebo for both complete (OR 35.82, 95% CI 14.98-85.64, P<0.0001; I²=0, P=0.72) and partial response (OR 28.44, 95% CI 8.56-94.47, P<0.0001; I²=70%, P=0.0009). Moreover, topical steroids were useful in gaining clinical response (OR 2.53, 95% CI 1.14-5.60, P=0.02; I²=60%, P=0.02) and endoscopic response (OR 3.51, 95% CI 1.47-8.36, P=0.005; I²=0, P=0.57). Generally, topical steroids are well tolerated. The most common adverse events are infections and infestations (59 cases).

CONCLUSION

Topical steroids were effective in inducing histological, clinical and endoscopic response in the short-term, and the adverse events were almost tolerable; however, we should interpret the result of clinical and endoscopic response with caution.

(Re) Defining the High-Power Field for Digital Pathology

BACKGROUND

The microscope high-power field (HPF) is the cornerstone for histopathology diagnostic evaluation such as the quantification of mitotic figures, lymphocytes, and tumor grading. With traditional light microscopy, HPFs are typically evaluated by quantifying histologic events in 10 fields of view at × 400 magnification. In the era of digital pathology, new variables are introduced that may affect HPF evaluation. The aim of this study was to determine the parameters that influence HPF in whole slide images (WSIs).

MATERIALS AND METHODS

Glass slides scanned on various devices (Leica's Aperio GT450, AT2, and ScanScope XT; Philips UltraFast Scanner; Hamamatsu's Nanozoomer 2.0HT; and 3DHistech's P1000) were compared to acquired digital slides reviewed on each vendor's respective WSI viewer software (e.g., Aperio ImageScope, ImageScope DX, Philips IMS, 3DHistech CaseViewer, and Hamamatsu NDP.view) and an in-house developed vendor-agnostic viewer. WSIs were reviewed at "×40" equivalent HPF on different sized monitors with varying display resolutions (1900 × 1080-4500 × 3000) and aspect ratios (e.g., Food and Drug Administration [FDA]-cleared 27" Philips PS27QHDCR, FDA-cleared 24" Dell MR2416, 24" Hewlett Packard Z24n G2, and 28" Microsoft Surface Studio). Digital and microscopic HPF areas were calculated and compared.

RESULTS

A significant variation of HPF area occurred between differing monitor size and display resolutions with minor differences between WSI viewers. No differences were identified by scanner or WSIs scanned at different resolutions (e.g., 0.5, 0.25, 0.24, and 0.12 μm/pixel).

CONCLUSION

Glass slide HPF at × 400 magnification with conventional light microscopy was not equivalent to "×40" digital HPF areas. Digital HPF quantification may vary due to differences in the tissue area displayed by monitor sizes, display resolutions, and WSI viewers but not by scanner or scanning resolution. These findings will need to be further clinically validated with potentially new digital metrics for evaluation.

Documenting the Journey of Patients with Eosinophilic Esophagitis and the Impact of the Disease on Patients and their Caregivers: A Cross-sectional, Qualitative Research Study

INTRODUCTION

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated esophageal disease for which there is currently no approved treatment in the USA and only one approved therapy in Europe. EoE can significantly affect the lives of patients and caregivers; however, little has been published about patients' experiences from symptom onset to diagnosis and treatment.

METHODS

This was a cross-sectional, qualitative research study. During one-on-one semi-structured interviews, patients with EoE in the USA and their caregivers provided information about their experiences of EoE before and during diagnosis, and their current experiences. Qualitative data were analyzed using a content analysis approach.

RESULTS

The study included children aged 6-11 years with EoE (n = 4) and their caregivers (n = 4); adolescents aged 12-17 years with EoE (n = 7) and their caregivers (n = 7); and adults aged ≥ 18 years with EoE (n = 20). The diagnosis of EoE was often arduous and took many years. Patients and caregivers were frequently frustrated with the complexities of diagnosing EoE, which often involved multiple healthcare providers and procedures. Patients reported physical and psychosocial burdens associated with EoE before diagnosis, including interference with social activities, school, and work. Patients also reported feeling frustrated or anxious. These burdens frequently remained after diagnosis. Caregivers also reported anxiety and, in some cases, interference with their ability to work.

CONCLUSION

This study of EoE describes the difficult journey faced by patients and their caregivers from symptom onset to diagnosis and beyond.