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Van-Londoño I, Ramírez-Giraldo C, Martínez Echeverri JC, Villany-Sarmiento JJ, Fino-Velásquez LM. Eosinophilic enterocolitis in duodenum, ileum, and colon: A case report. Heliyon 2024; 10:e26885. [PMID: 38468951 PMCID: PMC10925976 DOI: 10.1016/j.heliyon.2024.e26885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024] Open
Abstract
Eosinophilic gastroenteritis (EGE) is a rare disease which mainly consists of an abnormal eosinophile infiltration of the gastrointestinal tract. It's classified according to its location: eosinophilic esophagitis, eosinophilic gastritis, eosinophilic enteritis (including duodenum, jejunum and/or ileum) and eosinophilic colitis and degree of infiltration (mucosal, muscular, serosal). Depending on eosinophile concentration, type of EGE and the patient's condition it may manifest with different clinical presentations such as functional dyspepsia, abdominal pain, irritability, hypoproteinemia, diarrhea, anemia, among others. Few research has been done on such an uncommon pathology to the extent that treatment evidence is mostly limited to small case series. This case study reports an infrequent presentation of EGE in the small and large intestine as an undifferentiated gastrointestinal disease and successful corticoid management given to the patient in order to further broaden knowledge on this subject and facilitate an established clinical conduct for the treating physician.
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Affiliation(s)
| | - Camilo Ramírez-Giraldo
- Universidad del Rosario, Bogotá, Colombia
- Hospital Universitario Mayor – Méderi, Bogotá, Colombia
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2
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Šaban J, Milošević V. A rare case of eosinophilic esophagitis and eosinophilic subserosal gastroenteritis with ascites. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:851-853. [PMID: 31530531 DOI: 10.5152/tjg.2019.18680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jovana Šaban
- Center for Hematology, Clinic of Internal Medicine, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Velimir Milošević
- Department of Gastroenterohepatology, Clinic of Internal Medicine, Clinical Center of Montenegro, Podgorica, Montenegro
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Cavalli E, Brusaferro A, Pieri ES, Cozzali R, Farinelli E, De' Angelis GL, Esposito S. Eosinophilic esophagitis in children: doubts and future perspectives. J Transl Med 2019; 17:262. [PMID: 31399124 PMCID: PMC6688237 DOI: 10.1186/s12967-019-2014-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/04/2019] [Indexed: 01/07/2023] Open
Abstract
Background Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disorder and represents the leading cause of food impaction. The pathogenesis of EoE is the result of an interplay between genetic, environmental and host immune system factors. New therapeutic approaches for EoE have been proposed. In this manuscript we review the current evidence regarding EoE management in pediatric age, with a particular focus on new findings related to the efficacy and safety of monoclonal antibodies. Main body Conventional therapies have failed in treating some patients with EoE, which then requires aggressive procedures such as esophageal dilatation. The most effective available medical therapy for EoE is swallowed topic corticosteroids (fluticasone propionate and budesonide), which have two main drawbacks: they are related to well-known adverse effects (especially in the paediatric population), and there are not enough long-term data to confirm that they are able to reverse the remodelling process of the esophageal mucosa, which is the major cause of EoE symptoms (including dysphagia, abdominal pain, nausea, obstruction, perforation and vomiting). The monoclonal antibodies appear to be an interesting therapeutic approach. However, the studies conducted until now have shown substantial histological improvement not coupled with significant clinical improvements and no significant relationship between a decreasing number of eosinophils and clinical symptoms, highlighting the importance in the pathogenesis of EoE of cells such as T-helper cells, mast cells, B cells, epithelial cells and natural killer cells. Conclusions Monoclonal antibodies targeting a signal involved in the pathogenesis of EoE may not break the complex self-propagating inflammatory activation responsible for perpetuation of the inflammatory response and the development of symptoms and complications. We speculate that combined biological therapies targeting more than one molecule or cell may provide better results, with conventional therapies potentially enhancing the effects of antibodies. However, further studies should aim to find the best therapeutic approach to target the cells involved in the remodelling process and to reverse the histological changes in this complex clinical condition.
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Affiliation(s)
- Elena Cavalli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Andrea Brusaferro
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Elena Sofia Pieri
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Rita Cozzali
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Edoardo Farinelli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Gian Luigi De' Angelis
- Gastroenterology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy.
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Gomez Torrijos E, Gonzalez-Mendiola R, Alvarado M, Avila R, Prieto-Garcia A, Valbuena T, Borja J, Infante S, Lopez MP, Marchan E, Prieto P, Moro M, Rosado A, Saiz V, Somoza ML, Uriel O, Vazquez A, Mur P, Poza-Guedes P, Bartra J. Eosinophilic Esophagitis: Review and Update. Front Med (Lausanne) 2018; 5:247. [PMID: 30364207 PMCID: PMC6192373 DOI: 10.3389/fmed.2018.00247] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/15/2018] [Indexed: 12/13/2022] Open
Abstract
Background: Eosinophilic esophagitis (EoE) was first described in the 1990s, showing an increasing incidence and prevalence since then, being the leading cause of food impaction and the major cause of dysphagia. Probably, in a few years, EoE may no longer be considered a rare disease. Methods: This article discusses new aspects of the pathogenesis, symptoms, diagnosis, and treatment of EoE according to the last published guidelines. Results: The epidemiological studies indicate a multifactorial origin for EoE, where environmental and genetic factors take part. EoE affects both children and adults and it is frequently associated with atopic disease and IgE-mediated food allergies. In patients undergoing oral immunotherapy for desensitization from IgE-mediated food allergy the risk of developing EoE is 2.72%. Barrier dysfunction and T-helper 2 inflammation is considered to be pathogenetically important factors. There are different patterns of clinical presentation varying with age and can be masked by adaptation habits. Besides, symptoms do not usually correlate with histologic disease activity. The diagnostic criteria for EoE has evolved but mainly requires symptoms of esophageal dysfunction with histologic evidence of a peak value of at least 15 eosinophils per high-power field. Endoscopies have to be repeated in order to diagnose, monitor, and treat EoE. Treatment of EoE can be started either by drugs (PPIs and topical corticosteroids) or elimination diets. The multistage step-up elimination diet management approach of EoE is promising. Endoscopic dilation is used for patients with severe dysphagia/food impaction with inadequate response to anti-inflammatory treatment. Conclusions: Research in recent years has contributed to a better understanding of EoE's pathogenesis, genetic background, natural history, allergy workup, standardization in assessment of disease activity, evaluation of minimally invasive diagnostic tools, and new therapeutic approaches. However, several unmet needs are to be solved urgently, as finding a non-invasive disease-monitoring methods and biomarkers for routine practice, the development or new therapies, novel food allergy testing to detect triggering foods, drug, and doses required for initial therapy and safety issues with long-term maintenance therapy, amongst others. Besides, multidisciplinary management units of EoE, involving gastroenterologists, pediatricians, allergists, pathologists, dietitians, and ENT specialists are needed.
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Affiliation(s)
| | | | | | - Robledo Avila
- Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | - Jesus Borja
- Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | | | - M. Pilar Lopez
- Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | | | - Mar Moro
- Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - Ana Rosado
- Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - Vanessa Saiz
- Hospital UniversitarioReina Sofía de Córdoba, Cordoba, Spain
| | | | - Olga Uriel
- Hospital Universitario de Araba, Vitoria-Gasteiz, Spain
| | - Angelina Vazquez
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Pilar Mur
- Hospital Santa Barbara, Puertollano, Spain
| | - Paloma Poza-Guedes
- Allergy Section, Hospital Universitario de La Laguna, San Cristóbal de La Laguna, Spain
| | - Joan Bartra
- Allergy Section, Pneumology Department, Hospital Clínic Universitat de Barcelona, Barcelona, Spain
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Munoz-Persy M, Lucendo AJ. Treatment of eosinophilic esophagitis in the pediatric patient: an evidence-based approach. Eur J Pediatr 2018; 177:649-663. [PMID: 29549437 DOI: 10.1007/s00431-018-3129-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 12/19/2022]
Abstract
UNLABELLED Eosinophilic esophagitis (EoE) is a unique form of non-IgE-mediated food allergy characterized by esophageal eosinophilic infiltration that commonly causes dysphagia and food impaction in children and adolescents. Assessing the efficacy of dietary restrictions or drug therapies to achieve clinical and histologic resolution of EoE through randomized controlled trials and meta-analyses has resulted in new evidence-based guidelines. Avoiding food triggers is the only therapy targeting the cause of the disease. None of the currently available food allergy tests adequately predict food triggers for EoE. Exclusively feeding with an amino acid-based elemental diet and empiric six-food elimination diet (avoiding the six foods most commonly related with food allergy) has consistently provided the best cure rates, but their high level of restriction and need for multiple endoscopies are deterrents for implementation. Simpler and less restrictive empirical methods, like a four-food (milk, gluten-containing cereals, egg, legumes) or a two-food (milk and gluten) elimination diet, show encouraging results. Proton pump inhibitors are currently a first-line treatment, achieving histological remission and improvement of symptoms in 54.1 and 64.9% of pediatric EoE patients, respectively. The efficacy of topical corticosteroids in EoE assessed in several trials and summarized in meta-analyses indicates that budesonide and fluticasone propionate are significantly superior to placebos, both in decreasing eosinophil mucosal infiltration and in relieving symptoms. Owing to differences in drug delivery, viscous budesonide formulas seem to be the best pharmacological therapy for EoE. CONCLUSION Applying evidence-based therapies and a practical management algorithm provide an effective control of EoE. What is Known: • Eosinophilic esophagitis (EoE) now constitutes the main cause of dysphagia and food impaction in children, adolescents, and young adults. • Its chronic course and frequent progression to subepithelial fibrosis leading to strictures and narrow-caliber esophagus indicate the need for treatment. What is New: • Therapeutic goals in children with EoE include resolution of esophageal symptoms, to cure esophageal inflammation (mucosal healing) and restore a proper esophageal caliber in case of fibrostenotic endoscopic findings. Avoiding iatrogenic drug effects and nutritional deficiencies, as well as maintaining an adequate quality of life, is also essential. • Novel evidence-based guidelines, endorsed by several European scientific societies, incorporate recent advances in knowledge from several randomized controlled trials and systematic reviews to provide the best standard of care to pediatric patients, by following simple management algorithms.
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Affiliation(s)
- Mery Munoz-Persy
- Department of Pediatrics, Hospital General de Tomelloso, Tomelloso, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n, 13700 Tomelloso, Ciudad Real, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
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Philpott H, Dougherty MK, Reed CC, Caldwell M, Kirk D, Torpy DJ, Dellon ES. Systematic review: adrenal insufficiency secondary to swallowed topical corticosteroids in eosinophilic oesophagitis. Aliment Pharmacol Ther 2018; 47:1071-1078. [PMID: 29508432 PMCID: PMC5867261 DOI: 10.1111/apt.14573] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/05/2018] [Accepted: 01/27/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Swallowed topical corticosteroids are prescribed for eosinophilic oesophagitis (EoE), but there is a theoretical risk of adrenal insufficiency from their use. AIMS To determine if the use of topical corticosteroids to treat EoE is associated with the development of adrenal insufficiency. METHOD We conducted a systematic review of the published literature from January 1, 1950 to April 1, 2017 using Pubmed, Embase, Web of Science and Cochrane Central. Studies and meeting abstracts were included that described patients with EoE who received swallowed topical corticosteroids and any investigation for adrenal insufficiency. RESULTS The search revealed 1610 unique publications, and 17 met inclusion criteria. There were 7 randomised controlled trials (RCTs), 6 prospective observational studies, 3 retrospective observational studies, and 1 case report. Cortisol measurements were performed on 596 individuals with EoE who received topical corticosteroids. Adrenal testing was abnormal, as defined by each study, in 94/596 patients (crude rate of 15.8%). Only 2 studies were considered to have a low risk of bias, being randomised controlled trials that estimated adrenal insufficiency in the active treatment and placebo groups, before and after treatment. None of the seven randomised controlled trials demonstrated statistically significantly different rates of adrenal insufficiency between topical corticosteroid and placebo over treatment intervals of 2-12 weeks. CONCLUSION Topical corticosteroids were associated with adrenal insufficiency in a minority of patients. Most cases came from uncontrolled observational studies, with widely varying definitions of adrenal insufficiency. Longer follow-up and larger controlled studies are needed to quantify the risk of adrenal insufficiency with maintenance topical corticosteroid therapy in EoE.
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Affiliation(s)
- Hamish Philpott
- Northern Adelaide Local Health Network (NALHN), Department of Gastroenterology Lyell McEwin and Modbury Hospitals, University of Adelaide, South Australia
| | - Michael K. Dougherty
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Craig C. Reed
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Marie Caldwell
- Division of Endocrinology and Metabolism, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Deepa Kirk
- Division of Endocrinology and Metabolism, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David J. Torpy
- Department of Endocrinology, Royal Adelaide Hospital, University of Adelaide, South Australia
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Di Pede C, Mantovani ME, Del Felice A, Masiero S. Dysphagia in the elderly: focus on rehabilitation strategies. Aging Clin Exp Res 2016; 28:607-17. [PMID: 26589905 DOI: 10.1007/s40520-015-0481-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 10/17/2015] [Indexed: 11/25/2022]
Abstract
Prevalence of oropharyngeal dysphagia among the elderly is high, but underestimated and underdiagnosed. It may give raise to relevant complications impacting on morbidity, hospital length of stay and health care costs. Dysphagia evaluation and management is a multidisciplinary task; it includes a detailed history taking, clinical and instrumental exams, and identification of the risk of aspiration. Long-standing individual abilities and impairments determine the goals of an ad hoc rehabilitation program. Currently there are no standard algorithmic approaches for the management of dysphagia in the elderly. Education of health professionals on early diagnosis and improvement of therapeutic strategies are mainstays to allow maximal recovery potential in this population. This narrative review summarizes the current rehabilitation approaches for dysphagia in the elderly. The aim is to inform the treating health care professionals, whether caring physician, physical medicine doctor, speech/swallowing therapist or nurse, on the state-of-the-art and stimulate discussion in the scientific community.
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Affiliation(s)
- C Di Pede
- Rehabilitation Unit, Department of Neurosciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - M E Mantovani
- Rehabilitation Unit, Department of Neurosciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - A Del Felice
- Rehabilitation Unit, Department of Neurosciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - S Masiero
- Rehabilitation Unit, Department of Neurosciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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Lucendo AJ. Meta-Analysis-Based Guidance for Dietary Management in Eosinophilic Esophagitis. Curr Gastroenterol Rep 2016; 17:464. [PMID: 26292666 DOI: 10.1007/s11894-015-0464-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is a prevalent chronic esophageal disorder, triggered and maintained by immunologically mediated responses against dietary antigens. EoE represents the most recent form of food allergy, and its control by avoiding offending foods has increasingly appeared as a therapeutic alternative to achieve and maintain remission. Dietary therapies have proved equally effective in pediatric and adult EoE patients, among whom various types of interventions to eliminate or reduce food antigens exposure have been evaluated. A recent meta-analysis showed elemental diet as the most effective option to induce disease remission, but with a limited application in clinical practice. Inconsistency and wide variability in results from skin allergy testing-directed food restriction contributed to dissatisfaction with implementation of this option, which subsequently was displaced by empiric elimination of common food allergens. Such empiric elimination of common food allergens is now recognized as the best alternative for dietary treatment, with moderate-to-high efficiency and reproducible results. This review provides evidence-based insights into the dietary management of EoE.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos, s/n., 13700, Tomelloso, Ciudad Real, Spain,
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