Paediatric eosinophilic oesophagitis: towards early diagnosis and best treatment

Eosinophilic esophagitis: is it also a surgical disease?

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated disease with esophageal dysfunction and eosinophil-predominant inflammation. An association between EoE and gastro-esophageal reflux disease (GERD) has not been well established.

AIMS

The aim was to evaluate patients with EoE who underwent pH-Multichannel Intraluminal Impedance (pH-MII), investigating proton-pump-inhibitors (PPI) therapy/anti-reflux surgery requirement.

METHODS

Twenty-five patients [mean age 7.6 (range 1-17 years)] with EoE underwent pH-MII. The children were then divided into Group 1 (pathological pH-MII) and Group 2 (normal pH-MII). PPI was administered for two months in Group 1 and in those children in Group 2 unresponsive to standard EoE therapy (diet and corticosteroids). All patients underwent endoscopy and clinical follow-up. Data are described as mean (range).

RESULTS

Group 1 (n=16, M:F=14:2) had mean reflux index (RI) 13.9% (0.8%-53.4%) with a mean number of total reflux episodes (RE) of 65.8 (14-341). Group 2 (n=9, M:F=6:3) had a mean RI 1.2% (0.2%-2.7%) with a mean number of total RE of 27.4 (14-39). There was a histological response to repeated cycles of PPI in 11/16 (69%) children in Group 1 and 4/9 (44%) children in Group 2. Fundoplication, because of dependence on PPI, was required in 4/11 PPI-responders in Group 1, allowing discontinuation without relapse of EoE.

CONCLUSIONS

The use of PPI is suggested in EoE at time of diagnosis in addition to standard treatment and may even have benefit in children who do not appear to have significant GERD but are unresponsive to standard therapy.

The prevalence and diagnostic utility of endoscopic features of eosinophilic esophagitis: a meta-analysis

BACKGROUND & AIMS

Endoscopic findings such as esophageal rings, strictures, narrow-caliber esophagus, linear furrows, white plaques, and pallor or decreased vasculature might indicate the presence of eosinophilic esophagitis (EoE). We aimed to determine the prevalence and diagnostic utility of endoscopic features of EoE.

METHODS

We conducted a systematic review and meta-analysis. PubMed, EMBASE, and gastrointestinal meeting abstracts were searched to identify studies that included more than 10 patients with EoE and reported endoscopic findings. Pooled prevalence, sensitivity, specificity, and predictive values were calculated using random- and mixed-effects models.

RESULTS

The search yielded 100 articles and abstracts on 4678 patients with EoE and 2742 without (controls). In subjects with EoE, the overall pooled prevalence was as follows: esophageal rings, 44%; strictures, 21%; narrow-caliber esophagus, 9%; linear furrows, 48%; white plaques, 27%; and pallor/decreased vasculature, 41%. Substantial heterogeneity existed among studies. Results from endoscopy examinations were normal in 17% of patients, but this number decreased to 7% when the analysis was limited to prospective studies (P < .05). Overall levels of sensitivity were modest, ranging from 15% to 48%, whereas levels of specificity were greater, ranging from 90% to 95%. Positive predictive values ranged from 51% to 73% and negative predictive values ranged from 74% to 84%.

CONCLUSIONS

There is heterogeneity among studies in the reported prevalence of endoscopic findings in patients with EoE, but in prospective studies at least 1 abnormality was detected by endoscopy in 93% of patients. The operating characteristics of endoscopic findings alone are inadequate for diagnosis of EoE. Esophageal biopsy specimens should be obtained from all patients with clinical features of EoE, regardless of the endoscopic appearance of the esophagus.

Fluoroscopic findings in pediatric eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EE) is an inflammatory disorder of the esophagus characterized by symptoms such as dysphagia, food sticking and heartburn. Several fluoroscopic findings have been described in EE, but the frequency of these findings is unknown.

OBJECTIVE

To identify the frequency of imaging findings in pediatric-age patients with eosinophilic esophagitis.

MATERIALS AND METHODS

A retrospective study was performed evaluating all upper GI and esophagram studies performed between 2000 and 2008 in patients up to age 21 with a pathological diagnosis of EE. In order to be included in the study, the upper GI or esophagram had to be performed either before EE was diagnosed or within 30 days of the diagnosis. Two pediatric radiologists evaluated each study for the presence or absence of multiple findings of EE. The radiology reports from the time of the study were then read to establish a concurrent diagnosis of esophageal dysmotility or gastroesophageal reflux. Finally, the hospital electronic medical record was evaluated to obtain demographic and pathology information.

RESULTS

Of the 579 patients with biopsy-proven EE, 107 (18%) were included in the study and underwent a total of 112 upper GI or esophagram examinations. The most common finding on these examinations was a normal esophagus (58/112; 52%) followed by gastroesophageal reflux (21/112; 19%) and irregular contractions (17/112; 15%). Less frequent findings included strictures, dysmotility, mucosal irregularity, esophageal rings and filling defects.

CONCLUSION

Fluoroscopic studies are not a sensitive method to diagnose EE because nearly half of the studies are normal. Findings that have been described in the setting of EE such as food impaction, a ringed esophagus, a small-caliber esophagus and esophageal stricture do not occur with a high enough frequency to reliably make a diagnosis.

Eosinophils in the oesophageal mucosa: clinical, pathological and epidemiological relevance in children: a cohort study

Objectives Eosinophilic oesophagitis (EO) shows eosinophilic infiltration of the mucosa and can present with symptoms indistinguishable from gastrooesophageal reflux disease (GORD). The authors describe the clinical, endoscopic and histopathological features of all cases of histological EO presenting during 2007-2008 with a 2-year follow-up. The incidence of paediatric EO and the features of a subgroup with features of both GORD and EO ('overlap' syndrome (OS)) are described. Design Biopsies with an average of 15 eosinophils/high-power field (HPF) were reviewed in the cohort. OS was suggested when there was coexistence of clinical and histological features of EO and GORD (abnormal pH study), which improved with proton pump inhibitors. Setting Tertiary care. Participants All cases with ≥15 eosinophils/HPF entered the study. Primary outcome measures Patients with EO had an average of 15 eosinophils/HPF. Secondary outcome measures Other histological features of EO included microabscesses, dilated intercellular spaces, basal cell hyperplasia, papillary elongation, etc. Results 24 cases of EO were identified, 13 men and 11 women. The incidence of paediatric oesophageal eosinophilia in the region was 9/100 000 children. 11 of the 24 patients (46%) presented with some form of allergy, six with poor feeding/food aversion, five with dysphagia and four with vomiting. After follow-up, 56.5% were confirmed to have EO, 30.5% responded to treatment for GORD and were categorised as OS, 9% developed eosinophilic gastroenteritis and 4% did not have further upper gastrointestinal symptoms. Conclusions Accurate diagnosis of EO, especially the differentiation from GORD, requires appropriate clinicopathological correlation. A significant proportion of patients with eosinophilia in the mucosa also have GORD (OS). These patients improve after treating the underlying GORD. The study was registered as a Service Evaluation with the Trust (number SE74).

Esophageal Eosinophilia

The presence of esophageal eosinophilia encompasses a broad differential diagnosis, and at times a specific histologic diagnosis is not possible. This content provides a systematic approach to esophageal squamous eosinophilia with emphasis on specific, distinguishing features within this expansive differential.

Pediatric eosinophilic esophagitis: radiologic findings with pathologic correlation

BACKGROUND

Eosinophilic esophagitis is increasingly recognized as a cause of dysphagia or food impaction in pediatric patients. It has a high male predominance and is often associated with a history of allergy or asthma.

OBJECTIVE

To correlate fluoroscopic findings in eosinophilic esophagitis with the endoscopic and histologic findings.

MATERIALS AND METHODS

We retrospectively reviewed the upper gastrointestinal (UGI) findings of eosinophilic esophagitis and correlated them with the clinical, endoscopic and histologic findings in a series of 17 children (12 boys, 5 girls).

RESULTS

UGI findings were normal in 12 children, including 4 who had a normal UGI exam after endoscopic disimpaction for an obstructing food bolus. Five children had strictures identified on UGI: one was demonstrated with endoscopy. This suggests that the impactions and strictures were due to an esophageal dysmotility rather than a fixed anatomic abnormality.

CONCLUSION

Because the UGI findings are frequently normal in eosinophilic esophagitis, radiologists need to have a high index of suspicion for this disease. In children with a strong clinical history, especially impaction in the absence of an esophageal stricture, endoscopy and biopsy are indicated for further evaluation.

Severe dysphagia in children with eosinophilic esophagitis and esophageal stricture: an indication for balloon dilation?

BACKGROUND

Esophageal stricture is one of the most severe complications in eosinophilic esophagitis (EoE). Clinical practice is based on limited data and some treatments are still considered controversial. We report on our experience in the treatment of severe dysphagia and esophageal strictures in EoE, especially using balloon dilation, showing the clinical practice in our pediatric population.

PATIENTS AND METHODS

This was a single-center retrospective study between December 2002 to November 2007, identifying all of the pediatric patients with severe dysphagia in the context of EoE. Demographic data and the results of various treatment regimens were reviewed.

RESULTS

Severe dysphagia was identified in 13 cases (77% male, mean age 12.8 +/- 4.4 years). Endoscopic findings were mucosal edema (62%), long segment strictures, esophagitis, and off-white appearance in 31%. Histologically, >20 eosinophils per high-power field were present in all of the patients. Medical treatment consisted of proton pump inhibitor PPI (77%), montelukast (31%), local corticosteroids (54%), systemic corticosteroids (8%), elemental diet (15%), and food elimination diet (61%). A combined therapeutic approach was performed in all of the cases, due to clinical relapse or no response to monotherapy. Good response was obtained clinically in 70%, endoscopically in 62%, and histologically in 75%. Relapses were observed in 46% of the cases. Balloon dilation was necessary in 31% of the cases (mean dilation sessions 3.3 +/- 0.95), being effective in 100% of patients, without complications.

CONCLUSIONS

In our pediatric series, combined medical (corticosteroids, elemental diet, and food elimination diet) and endoscopic approach (repeated balloon dilation) were effective and safe in patients with severe EoE and esophageal stricture.

Histological evaluation of esophageal mucosa in children with acid gastroesophageal reflux

AIM

histological evaluation of esophageal mucosa in children, with regard to the duration of primary acid gastroesophageal reflux (GER) and acid GER secondary to cow's milk allergy and/or other food allergy (CMA/FA) (prospective study).

MATERIAL AND METHODS

264 children of both sexes suspected of GER were enrolled in the study. The age of examined children was 1.5-102 months, mean age 20.78+/-17.23 months. Pathological acid GER was confirmed with pH-monitoring in 138 children (52.3%). Taking into consideration complex differential diagnosis, including oral food challenge test with potentially noxious nutrient (open or blind study), children were assigned into study groups 1 and 2 (primary and secondary GER). Group 1: 76 patients (28.8%) aged 4-102 months (x=25.2+/-27.28 months) with primary GER. Group 2: 62 patients (23.5%) aged 4-74 months (x=21.53+/-17.79 months) with GER secondary to CMA/FA. Children with GERD underwent preliminary and control (after 1 year and 2 years of GERD diagnosis) endoscopic examination of the upper gastroinestinal tract.

RESULTS

Intensity of esophagitis was assessed initially in 25 children from group 1 (32.9%), in 29 children from group 2 (46.8%), and in 9 children from group 3 - reference group (28.1%). Histological evaluation revealed infiltration of inflammatory cells, mainly neutrophils and intraepithelial lymphocytes, and also eosinophils in 10 children (13.2%) with primary GER. Infiltration of eosinophils and lymphocytes was found in 5 children (8.1%) with secondary GER. In 8 children (25.0%) with food allergy there were only lymphocytes. Infiltration of neutrophils and lymphocytes and basal zone hyperplasia or infiltration of eosinophils and lymphocytes with elongation of lamina propria papillae was found in 10 children (13.1%) with primary GER and in 20 children (32.2%) with secondary GER. Differentiation of particular types of inflammatory cells in mucosal infiltration characterized histological picture in the following way: neutrophils in 21 children (27.6%) with primary GER, eosinophils in 22 children (35.5%) with secondary GER, lymphocytes in 15 children (19.7%) in children with primary GER and in 15 children (24.2%) with secondary GER. Histological examination of esophageal mucosa after 1 and 2 years of clinical observation and periodical conservative treatment in children with primary and secondary GER revealed significant alleviation of inflammatory abnormalities (with regard to the type of abnormalities and the number of particular types of inflammatory cells).

CONCLUSIONS

The value of histological findings obtained in own studies comprises the role of food allergy in pathogenesis of GER and is related to GER's contribution, both direct (primary reflux) and indirect (secondary reflux), to triggering off morphological results and clinical outcomes of esophagitis.

Immunopathological mechanisms of eosinophilic oesophagitis

BACKGROUND

Eosinophilic oesophagitis (EO) is a chronic inflammatory disease of the oesophagus, with an emergent character, defined by the presence of a dense infiltrate by eosinophilic leukocytes restricted to the mucosa of this organ after excluding gastro-oesophageal acid reflux. It is manifested by chronic and/or recurrent dysphagia and episodes of oesophageal alimentary impaction, with great variation in terms of intensity, frequency, and duration of the attacks.

METHODS

An Internet-based search was performed for the most recent articles with relevant information concerning immunopathological mechanisms involved in EO.

RESULTS

Bibliographical data allow us to define that EO is related to an allergic or hypersensitivity-induced reaction after exposure to foods or inhalants, with increased prevalence of sensitisation to these allergens. Data published up to now suggest a cellular hypersensitivity reaction rather than a humoral one in the physiopathology of EO. In this disease, sensitised T-lymphocytes mediate a Th2 type response, releasing cytokines such as IL-5, with a possible Th1 component that requires further investigation. The function of the abundant CD8+ T-lymphocytes present in the oesophageal epithelium has yet to be explained. Mast cells also participate in epithelial inflammatory infiltrate in EO, and it is still unknown if its activation, mainly through IgE, contributes to the immunopathology of the disease even though EO rarely manifests immediate hypersensitivity reactions. IL-5 and different forms of eotaxins perform an important active role in the recruitment of eosinophils to the oesophagus.

CONCLUSIONS

EO is an immunologically complex and little studied entity that is associated with other allergic diseases and in which different effector cells participate, determining an immunological response of cellular rather than a humoral hypersensitivity reaction. The data available point out that EO is a disorder of the Th2 retarded immune response, in which the triggering factor might not be IgE. Although the final inflammatory phenomena observed in EO are common for the different patients, the cascade of inflammatory mediators that lead to them might not be identical in all cases, and the morphological and functional disorders observed in EO would represent the final convergence of different activation forms of the mechanisms of inflammation.

Eosinophilic esophagitis

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

Eosinophilic esophagitis: management and pharmacotherapy

Eosinophilic esophagitis represents the most debated disease of the last 10 years, too often speculated or overestimated and certainly well known and examined. The aim of this study was to summarize the recent therapeutic trends in order to show persistent doubts regarding several debated therapies. The study combined the most recent international literature and the authors' daily experience to define the scope of the review, with limits caused by a lack of available randomized studies between dietetic and pharmacological treatment. It was concluded that eosinophilic esophagitis is an immunoallergic disease that is generally caused by identifiable food and environmental allergens although, in a minority of cases, the etiological trigger remains undetermined. Therapy usually fights the responsible agents, but sometimes they are not resolved. A need for more pathogenetically driven treatments is invoked.

Eosinophilic esophagitis is a component of the anticonvulsant hypersensitivity syndrome: description of two cases

Anticonvulsant hypersensitivity syndrome is a rare syndrome caused by a specific, severe unusual reaction to antiepileptic agents; anticonvulsant hypersensitivity syndrome develops 1 week to 3 months after the introduction of the drug and most frequently consists of a multisystemic and multiorgan involvement. Drug withdrawal usually leads to rapid improvement of symptoms. Up to now no oesophageal damage has been described. We present two cases of carbamazepine hypersensitivity syndrome with concomitant development of eosinophilic oesophagitis that resolved after drug withdrawal.

Eosinophilic esophagitis: association with allergic disorders

Atopy has been linked to eosinophilic gastrointestinal disorders because of the role eosinophils play in atopic disorders. It has also been found that these disorders coexist. The goal of this article is to take a step back, and considering only eosinophilic esophagitis, attempt to determine from the available body of clinical and research literature: (1) Is the coexistence of these disorders attributable to a preconceived bias? If so, what is the source of the bias and how can it be removed? (2) Is there a cause and effect relationship? If so, can this relationship be harnessed for diagnostic and therapeutic modalities?

Pharmacologic treatment of eosinophilic esophagitis

There are several treatment options available for patients who have eosinophilic esophagitis (EE). These options include dilatation for mechanical esophageal abnormalities, pharmacologic therapy, and dietary management. Providing the appropriate therapy depends on the significance of clinical symptoms, association of abnormal anatomy, and histologic involvement of underlying the esophageal tissue. This article focuses on the pharmacotherapy of EE.

Integrated approach to treatment of children and adults with eosinophilic esophagitis

Over the last decade, treatment plans for eosinophilic esophagitis included the use of elemental formula, elimination diets, systemic corticosteroids, and the gavage of aerosolized steroids. Except for one placebo-controlled blinded prospective study, most decision making has been based on retrospective or uncontrolled studies and clinical experience. In this article, three authors from diverse backgrounds combine their resources to propose treatment paths with justification based on their clinical experience and interpretation of the literature.

Eosinophilic esophagitis

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Variability in diagnostic criteria for eosinophilic esophagitis: a systematic review

BACKGROUND

Eosinophilic esophagitis (EoE) is an emerging clinicopathologic entity defined by abnormal esophageal eosinophilic infiltration. Our understanding of this disease is hampered by the lack of a uniform diagnostic standard. The aim of this systematic review was to determine the range of diagnostic strategies and histologic criteria in the EoE literature.

METHODS

The MEDLINE-indexed literature from 1950 through December 31, 2006 was independently searched by two investigators. To identify additional relevant studies, bibliographies were hand searched, as were the published proceedings of the 2000-2006 American College of Gastroenterology and American Gastroenterological Association national meetings. Data were extracted from all human EoE case reports, case series, cross-sectional and cohort studies, and clinical trials.

RESULTS

Of 318 publications initially identified, 116 original articles, 39 abstracts, and 69 reviews were included. We found 10 different histologic definitions of EoE, ranging from 5 to 30 eosinophils per high-powered field (hpf), though 41 (35%) of the original articles did not state their diagnostic criteria. In the 13 original articles (11%) reporting an hpf area, the eosinophil density per mm(2) varied 23-fold. There was also variation in esophageal biopsy protocols, but specific protocols were reported in just 45 (39%) original articles.

CONCLUSIONS

Significant variability in diagnostic criteria for eosinophilic esophagitis exists, and in a large proportion of studies, criteria are not reported. Because of this lack of a common disease definition, conclusions drawn from the cumulative EoE literature should be viewed with caution. A consensus research-quality standard for diagnosis of eosinophilic esophagitis is needed.

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

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

Reflux oesophagitis in children; the role of endoscopy. A multicentric Italian survey

BACKGROUND

The decision whether to perform endoscopy in children with suspected reflux oesophagitis is not a straightforward one. Few symptoms are specific for oesophagitis and the diagnosis is not always correlated even to visual findings on endoscopy.

AIM

The aim of this study was to define the role of endoscopy and especially of histology in the diagnosis of reflux oesophagitis and to examine the correlations between symptoms, endoscopic findings and histology in children with suspected gastroesophageal reflux disease.

PATIENTS AND METHODS

One hundred and thirty-six patients with a clinical diagnosis of reflux oesophagitis, aged 1-18 years (mean 8.43; standard deviation +/-4.4), were enrolled from 12 Italian Paediatrics Gastroenterology Centres; symptom score, endoscopic and histologic oesophagitis scores were observed before and after therapy with proton pump inhibitors.

RESULTS

Before therapy, a high correlation between the prevailing symptom score and endoscopic score was demonstrated, but not with histologic score: there was a significant tendency for histologic grade to exceed visual findings. After therapy, endoscopic score and histologic score were significantly improved.

CONCLUSIONS

Oesophageal biopsies increase the diagnostic accuracy of upper endoscopy. Histologic grading is often much more important than the endoscopic appearance, so that endoscopic oesophageal biopsies are very important aids in the diagnosis of oesophagitis. Appropriate clinical evaluation of symptoms must occur before endoscopic examination.

Eosinophilic esophagitis in adults and children: evidence for a food allergy component in many patients

PURPOSE OF REVIEW

Eosinophilic esophagitis is a recently recognized disorder receiving increasing attention. Patients present with symptoms of gastroesophageal reflux and are not responsive to standard or aggressive reflux medications. This article reviews all literature published in English from December 2005 to November 2006 from PubMed on the topic of eosinophilic esophagitis.

RECENT FINDINGS

Three articles have confirmed that food allergies are causative in more than 90% of patients. Three different diet strategies were used: elemental, elimination diet based on the prick-skin test, and the atopy patch test or removal of the six most common foods. The elemental diet had the highest success rate (> 95%), whereas the testing-based elimination diet (> 75%) and six-food elimination diet (> 70%) had lower success rates. There are no organized dietary trials in adults.

SUMMARY

Recent literature on pediatric patients with eosinophilic esophagitis confirms that nearly all patients respond to an elemental diet with resolution of symptoms and normalization of biopsies. Although diets based on testing or removal of the most common allergens showed success, they were less successful than a complete elimination diet. Unfortunately, there are very limited studies in adults that address this issue.

Eosinophilic esophagitis: an allergist's approach

OBJECTIVE

To enhance the recognition of eosinophilic esophagitis by reviewing the presentation, diagnosis, and pathogenesis and then summarizing the epidemiology and treatment options.

DATA SOURCES

MEDLINE was searched for articles using the keywords esophagitis and either allergy or eosinophil. Additional sources include searches limited to therapy, including corticosteroids and leukotrienes, and those limited to review articles, including chemokines and cytokines, from January 1990 to April 2006. All searches were limited to the English language.

STUDY SELECTION

The authors selected relevant and current sources for inclusion in this review.

RESULTS

Eosinophilic esophagitis is a diagnosis made by identifying 20 to 24 eosinophils per high-power field on examination of esophageal biopsy specimens. In recent years, a marked increase in incidence worldwide may have occurred. Although the pathogenesis is still unclear, therapy involves the use of corticosteroids and appropriate dietary elimination.

CONCLUSION

Patients with atopy, especially males, who present with dysphagia, reflux symptoms, vomiting, abdominal pain, or failure to thrive should be considered for endoscopy to establish the diagnosis of eosinophilic esophagitis.

Critical role for adaptive T cell immunity in experimental eosinophilic esophagitis in mice

We have previously developed a murine model of allergen-induced eosinophilic esophagitis (EE), characterized by intraepithelial eosinophils, extracellular granule deposition, and epithelial cell hyperplasia, features that mimic the pathophysiological changes observed in individuals with various forms of EE. We now test the hypothesis that adaptive T cell immunity is critical in initiating experimental EE. We first demonstrate that EE induction is associated with an increase in lymphocyte subpopulations (B+, CD4+, and CD8+ cells) in the esophagus. We induced experimental EE in wild-type and various lymphocyte subpopulation-deficient mice by intranasal allergen sensitization. Eosinophil levels and epithelial cell proliferation were determined by performing antimajor basic protein and antiproliferation cell nuclear antigen immunohistochemical analysis. Eosinophil accumulation in the esophagus was ablated completely in RAG1 gene-deficient mice, but no role for B cells or antigen-specific antibodies was found, as B cell-deficient (IgH6) mice developed unabated, experimental EE. In addition, T cell-deficient (forkhead box N1-/-) mice were protected from the induction of experimental EE. CD8alpha-deficient mice developed unaltered, experimental EE, and CD4-deficient mice were only protected moderately from disease induction. Taken together, these studies indicate a role for CD4+ and CD4- cell populations in EE pathogenesis and demonstrate that experimental allergen-induced EE is dependent on adaptive T cell immunity.