Food allergies and eosinophilic gastrointestinal illness

[Eosinophilic gastrointestinal diseases with esophageal involvement: Analysis of 212 patients]

BACKGROUND

Primary eosinophilic gastrointestinal diseases (EGID) are chronic inflammatory disorders of the gastrointestinal tract with unknown etiology. Features, utility, and evolution are still unknown in screening for EGID in adult patients with eosinophilic esophagitis (EoE).

OBJECTIVES

To evaluate the prevalence, characteristics, comorbidities, and evolution of EGID in adults diagnosed with EoE and investigate differences between both groups.

METHODS

Prospective unicenter observational and analytical study. Gastric and duodenal biopsies were obtained during upper baseline endoscopy in all consecutive EoE adult patients evaluated. A colonoscopy with colon biopsies was performed upon persistent diarrhea and normal duodenal biopsies.

RESULTS

212 EoE patients were included. Nine patients (4.3%) also showed significant eosinophilic infiltration in at least one organ within the digestive tract. The most common site affected was the small bowel (78%). Gastrointestinal symptoms (43% vs. 100%, p<0.002) and, more specifically, either abdominal pain or diarrhea (17% vs. 78%, p<0.001), some food sensitizations, and digestive comorbidities (p<0.05) were significantly more common in patients with EGID. Gastrointestinal symptoms were present in 94/212 (44%) patients, of whom 9 (10%) had EGID. Considering only abdominal pain or diarrhea, 20% suffered from it.

CONCLUSIONS

EGID rarely coexist with EoE, even when gastrointestinal symptoms are present. These findings advise against routine gastric, duodenal, or colon biopsies in adult EoE patients with gastrointestinal symptoms. Most of the characteristics of EoE do not change due to having EGID except gastrointestinal symptoms, digestive comorbidities, and sensitizations to some foods. The evolution was generally favorable despite intermittent adherence to treatment, especially maintenance.

Eosinophilic Esophagitis and IgG4: Is There a Relationship?

Our knowledge of the pathophysiology of eosinophilic esophagitis is constantly evolving. There is significant association between eosinophilic esophagitis and atopy; however, multiple studies have refuted the role of IgE in its pathogenesis. Instead, new data have demonstrated an elevated IgG4 level in patients with eosinophilic esophagitis. We review the current understanding of eosinophilic esophagitis pathogenesis and highlight the increasing evidence for the role of IgG4.

Eosinophilic colitis in adults

Eosinophilic colitis (EoC) is a pathological entity associated with abnormal infiltration of colonic mucosa by eosinophilic polynuclear cells (Eo). This is a relatively common pathology in infants and children under 2 years old, but is more rare and has been less studied in adults. EoC can be classified as primary or secondary. Primary EoC is, in the majority of cases, related to an allergic reaction, either IgE-mediated and capable of causing an anaphylactic-type food allergy, or not mediated by IgE and capable of giving rise to food enteropathy. The symptoms for adults with EoC are variable and non-specific, diarrhoea and abdominal pain being the most common signs. There is no histological consensus for the diagnosis of EoC. The presence of over 40 Eo per high-power field (×400) in at least two different colonic segments could be suggested as the criterion for the diagnosis. In adults with primary EoC, skin tests are of limited value and the response to a restrictive diet is less effective than in young children, given that IgE or non-IgE-mediated allergic reactions are rarely identified and EoC generally require medical treatment. There is no consensus on the treatment of EoC, but the potential efficacy of corticosteroids and budesonide has been demonstrated in the vast majority of cases studied.

Eosinophilic Colitis and Clostridioides difficile Sepsis With Rapid Remission After Antimicrobial Treatment; A Rare Coincidence and Its Pathogenic Implications

Eosinophilic colitis is a rare inflammatory disorder of the digestive tract with chronic evolution and unknown pathophysiological mechanisms. The article describes the case of a 64-year old woman with a history of asthma and hypereosinophilia, who presented to a surgical department for persistent abdominal pain in the past 4 months, weight loss and malabsorption. She was diagnosed with eosinophilic colitis based on the colonoscopic result indicating extensive eosinophilic infiltration of the colonic mucosa correlated with the laboratory data and abdominal CT scan results. Following the colonoscopy, the patient developed fever, hypotension and diarrhea and was transferred to an Infectious Diseases Department with a presumptive diagnosis of abdominal sepsis. Treatment with ertapenem was immediately started. Metronidazole was also added due to a PCR positive stool test for Clostridioides difficile toxins encoding-genes. The patient displayed a rapid remission of the fever and of the intestinal complaints following antibiotic therapy and was discharged after 14 days. During a 3 months follow-up, the patient remained asymptomatic with normal values of laboratory parameters except for a persistent hypereosinophilia. The case outlines two distinguishing features: a histopathologic diagnosis of eosinophilic colitis, a rare diagnosis of a patient with chronic abdominal pain and an unexpected and rapid remission of the eosinophilic colitis following the antibiotic treatment and the restoration of the intestinal eubiosis.

Eosinophilic Esophagitis: Existing and Upcoming Therapies in an Age of Emerging Molecular and Personalized Medicine

PURPOSE OF REVIEW

Recent research efforts have spurred great progress in the diagnosis and management of eosinophilic esophagitis (EoE). Nonetheless, challenges remain in addressing disease burden and impairment in the growing EoE population. We highlight work from the Cincinnati Center for Eosinophilic Disorders, the Consortium of Eosinophilic Gastrointestinal Disease Researchers, and others that address these ongoing challenges.

RECENT FINDINGS

New tools for characterizing EoE disease activity include the EoE Histology Scoring System (EoEHSS), endoscopic alternatives, validated patient-reported outcome (PRO) questionnaires, and investigational biomarkers. These diagnostic and monitoring strategies have been complemented by advances in EoE therapy. Treatment modalities have refined the traditional approaches of dietary elimination, swallowed steroids, and proton pump inhibitors (PPI), and biologics offer promise for future treatment. This review summarizes EoE advances in disease management and newly defined EoE endotypes that may serve as the foundation for EoE-personalized medicine.

Eosinophilic Esophagitis in Children: Clinical Findings and Diagnostic Approach

Eosinophilic esophagitis (EoE) is an emerging chronic immune and antigen-mediated clinicopathologic disease. During the last 2 decades, the incidence of this condition in children has increased significantly, thanks to practitioners for creating the awareness and higher use of diagnostic endoscopy. We have analysed paediatric literature on EoE focusing on the epidemiology, pathophysiology, clinical findings and diagnostic approach. EoE is pathogenically related to a Th2 inflammation characterized by a mixed IgE and non-IgEmediated reaction to food and/or environmental agents. This leads to esophageal dysfunction and remodeling accompanied by subepithelial fibrosis. EoE can be presented with several range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or feeding refusal in infants and toddlers, as well as heartburn, dysphagia and food bolus impaction in older children and adults. The diagnostic suspicion is based on the presence of chronic symptoms of esophgeal dysfunction and esophageal eosinophilia characterised histologically by a significant eosinophilic infiltration of the oesophageal mucosa (>15 eosinophils per high powered field). In this review, we will provide an update on clinical presentation and diagnostic approach to EoE in children. We emphasized on the relevant aspects of the new clinical condition termed "PPI responsive esophageal eosinophilia", as entities distinct from EoE and the role of PPI trial in the diagnostic workup, therefore we proposed a new diagnostic algorithm.

Early Infant Risk Factors for Pediatric Eosinophilic Esophagitis

OBJECTIVES

Eosinophilic esophagitis (EoE) is an inflammatory, atopic disease of the esophagus without a clear etiology. Our objective was to identify exposures and conditions in early infancy associated with the development of EoE.

METHODS

A case-control study was performed using the Military Health System Database. Subjects diagnosed with EoE from October 2008 to September 2015 were matched 1:2 on age and sex. Early infant risk factors from the first 6 months of life were investigated.

RESULTS

A total of 1410 cases with EoE were matched to 2820 controls. The median (interquartile range) age at diagnosis of EoE was 4.2 years (2.1-7.2) and 68.7% were boys. Proton pump inhibitors (adjusted odds ratio [aOR], 2.73; 95% confidence interval [CI] 1.93-3.88), histamine-2 receptor antagonists (aOR, 1.64; 95% CI 1.27-2.13), and antibiotics (aOR, 1.31; 95% CI 1.10-1.56) were associated with EoE. Prematurity (aOR, 1.46; 95% CI 1.12-1.89) and early manifestations of atopic disease such as milk protein allergy (aOR, 2.37; 95% CI 1.26-4.44) and eczema (aOR, 1.97; 95% CI 1.64-2.36) were related to increased odds for EoE. Erythema toxicum in infancy was strongly associated with a diagnosis of EoE (aOR 3.52; 95% CI 1.03-12.04). Infants with feeding difficulty (aOR, 1.45; 95% CI 1.18-1.77) and gastroesophageal reflux disease (aOR, 1.79; 96% CI 1.43-2.26) were also at increased risk for EoE.

CONCLUSIONS

Acid-blocking medications and antibiotics during infancy were associated with later diagnosis of EoE. Erythema toxicum neonatorum, an eosinophilic immune phenomenon, was strongly associated with EoE. Identifying early infant risk factors for EoE may help to risk stratify the need for endoscopy.

Clinical Implications of Pediatric Colonic Eosinophilia

OBJECTIVE

Pediatric colonic eosinophilia represents a confounding finding with a wide differential. It is often difficult to determine which children may progress to inflammatory bowel disease (IBD), which have an eosinophilic colitis (EC), and which may have no underlying pathology. There is little guidance for the practitioner on the approach to these patients. To define the clinical presentations of colonic eosinophilia and identify factors which may aid in diagnosis we reviewed patients with colonic eosinophilia and the clinicopathologic factors associated with their diagnoses.

METHODS

An 8-year retrospective chart review of children whose histopathology identified colonic eosinophilia (N = 72) compared to controls with normal biopsies (N = 35).

RESULTS

Patients with colonic eosinophilia had increased eosinophils/high-power field compared to controls (P < 0.001) and had 3 clinical phenotypes. Thirty-six percent had an inflammatory phenotype with elevated erythrocyte sedimentation rate (P < .0001), chronic inflammation on colonic biopsies (P < 0.001), and were diagnosed as having IBD. Thirty-seven percent were diagnosed as having EC, associated with male sex (P < 0.005) and peripheral eosinophilia (P = 0.041). Twenty-one percent had no significant colonic pathology. Forty-three percent of patients had >1 colonoscopy and 68% of these had change from initial diagnoses.

CONCLUSIONS

There are 3 main phenotypes of children with colonic eosinophilia. Signs of chronic systemic inflammation raise suspicion for IBD. Peripheral eosinophilia and male sex are associated with EC. A significant percent of children with colonic eosinophilia do not have colonic disease. Eosinophils/high-power field is not reliable to differentiate etiologies. Repeat colonoscopies may be required to reach final diagnoses.

The colon and terminal ileum in patients with ankylosing spondylitis and controls in Bangladesh: a macroscopic and microscopic study

OBJECTIVE

Little is known about gut lesions in AS patients in a developing country, such as Bangladesh.

METHODS

Full colonoscopy, including the terminal ileum, was performed in 60 AS patients and 20 controls, without diarrhoea, to study macroscopic and microscopic lesions.

RESULTS

In the colon, in 60 AS patients 17 macroscopic lesions were found, of which 11 were in the rectum; only one lesion was found in 20 controls. The prevalence of microscopic lesions in the ascending colon, sigmoid colon and rectum was 51, 44 and 50 in patients, respectively, and 13, 9 and 8 in controls. In the terminal ileum, macroscopic and microscopic lesions were seen in 21/56 and 43/56 AS patients, respectively, and in 1/20 and 9/20 controls. In the AS group, macroscopic (38.5 vs 5%, P < 0.01) and microscopic (76.8 vs 45%, P = 0.009) lesions were more frequent than in controls; no IBD was diagnosed. Findings were comparable in the axial AS group (n = 25) and the mainly peripheral group (n = 35). In AS patients, marked eosinophilic infiltration was observed in the ascending colon and sigmoid colon but not in the rectum, and this infiltration was more than in controls. The colonic mucosa in controls was otherwise comparable with western studies. Anaemia was seen in 18/60 cases. No association was found between anaemia or HLA-B27 status and gut lesions.

CONCLUSION

There was an equal percentage of microscopic lesions in the whole gut in AS cases and healthy controls. Previous helminth invasions might have played a role. Lesions differ significantly between AS and controls only in the ileum; therefore, the ileal lesions might be more disease related than the colonic ones.

Eosinophilic esophagitis phenotypes: Ready for prime time?

Eosinophilic esophagitis (EoE) is one of the most common causes of reflux-like symptoms and feeding problems in children and food impaction and dysphagia in adults with a prevalence of 1:2500. Therapeutic options include diet, use of swallowed corticosteroids, or dilation. In the last several years, recent clinical and translational researches have identified some common and distinctive features, for example, the varying response to diet and medications. As EoE shares some characteristics with both asthma and inflammatory bowel disease, the advances in these fields suggest that various phenotypes may also exist in patients with EoE. Here, we provide a rationale for EoE phenotypes and provide some suggestions for potential phenotypes based on histology, molecular signature, response to therapy or dietary therapy.

Eosinophilic Esophagitis: A Comprehensive Review

Eosinophilic esophagitis (EoE) is an emerging chronic atopic clinical-pathologic disease with an estimated prevalence of 1/1000 similar to the one of Crohn's diseases. Usually, EoE is firstly suspected due to symptoms that are caused by esophageal dysfunction and/or fibrosis. EoE diagnosis is confirmed if the esophageal biopsy shows at least 15 eosinophils per high power field (eos/hpf) as a peak value in one or more of at least four specimens obtained randomly from the esophagus. Most of the patients affected by EoE have other atopic diseases such as allergic rhinitis, asthma, IgE-mediated food allergies, and/or atopic dermatitis. The local inflammation is a T helper type 2 (Th2) flogosis, which most likely is driven by a mixed IgE and non-IgE-mediated reaction to food and/or environmental allergens. Recently published genetic studies showed also that EoE is associated with single nucleotide polymorphism (SNP) on genes which are important in atopic inflammation such as thymic stromal lymphopoietin (TSLP) located close to the Th2 cytokine cluster (IL-4, IL-5, IL-13) on chromosome 5q22. When the EoE diagnosis is made, it is imperative to control the local eosinophilic inflammation not only to give symptomatic relief to the patient but also to prevent complications such as esophageal stricture and food impaction. EoE is treated like many other atopic diseases with a combination of topical steroids and/or food antigen avoidance.

Eosinophilic Gastroenteritis: An Underdiagnosed Condition

BACKGROUND

Eosinophilic gastroenteritis (EOGE) is a rare idiopathic disease characterized by eosinophil-predominant inflammation of the stomach and/or intestines. Our aims are to determine the epidemiology, clinical features and outcomes of EOGE cases in a tertiary-care hospital.

METHODS

Retrospective cohort study of patients with gastrointestinal eosinophilic infiltration from 2004 through 2014. All relevant specimens were reviewed by an expert pathologist. Significant eosinophilic infiltrate was defined as >25 eosinophils/HPF in the stomach or small intestine and >50 eosinophils/HPF in the colon.

RESULTS

Three hundred and sixty-one charts were reviewed and 13 EOGE cases were identified, including nine adults and four pediatric cases. The majority (78 %) of adult cases were females. Clinical presentation was variable; most patients (62 %) had abdominal pain, followed by diarrhea (31 %) and nausea/vomiting (31 %). Atopy and food allergies were present in 54 and 38 % of patients, respectively. Weight loss and failure to thrive were present only in pediatric cases (50 vs 0 %; P = .01). Most EOGE cases (69 %) had peripheral eosinophilia, which was more prominent in patients with ascites compared to patients without ascites (37.3 ± 25.4 vs 9.3 ± 5.4 %; P = .01). Among patients who had long-term follow-up; 30 % had spontaneous remission, 60 % responded to steroids and/or restriction diet, and 10 % had refractory disease.

CONCLUSION

EOGE is an underdiagnosed condition. In contrast to eosinophilic esophagitis; the disease might be female-predominant in adults. High index of clinical suspicion is required for diagnosis. Further studies about the long-term outcomes and the efficacy of restriction diet in adult patients are required.

From genetics to treatment of eosinophilic esophagitis

PURPOSE OF REVIEW

Eosinophilic Esophagitis (EoE) is an emerging chronic atopic disease. Recent advances in understanding its genetic and molecular biology pathogenesis may lead to a better management of the disease

RECENT FINDINGS

EoE is an atopic disease. Most of the patients affected by EoE have other atopic diseases such as allergic rhinitis, asthma, IgE-mediated food allergies and/or atopic dermatitis. The local inflammation is a T helper type 2 (Th2) flogosis, which most likely is driven by a mixed IgE and n-IgE-mediated reaction to food and/or environmental allergens. Epidemiological studies show that EoE is an atopic disease with a strong genetic component. Genetic studies have shown that EoE is associated with single nucleotide polymorphism on genes, which are released by the epithelium and important in atopic inflammation such as thymic stromal lymphopoietin located (TSLP) close to the Th2 cytokine cluster [interleukin (IL)-4, IL-5, IL-13] on chromosome 5q22, Calpain 14, EMSY, and Eotaxin3. When the EoE diagnosis is made, it is imperative to control the local eosinophilic inflammation not only to give symptomatic relief to the patient, but also to prevent complications such as esophageal stricture and food impaction.

SUMMARY

EoE is treated like many other atopic diseases with a combination of topical steroids and/or food antigen avoidance. The new understanding of EoE may lead to more specific and definitive treatments of EoE.

Wheat allergy: diagnosis and management

Triticum aestivum (bread wheat) is the most widely grown crop worldwide. In genetically predisposed individuals, wheat can cause specific immune responses. A food allergy to wheat is characterized by T helper type 2 activation which can result in immunoglobulin E (IgE) and non-IgE mediated reactions. IgE mediated reactions are immediate, are characterized by the presence of wheat-specific IgE antibodies, and can be life-threatening. Non-IgE mediated reactions are characterized by chronic eosinophilic and lymphocytic infiltration of the gastrointestinal tract. IgE mediated responses to wheat can be related to wheat ingestion (food allergy) or wheat inhalation (respiratory allergy). A food allergy to wheat is more common in children and can be associated with a severe reaction such as anaphylaxis and wheat-dependent, exercise-induced anaphylaxis. An inhalation induced IgE mediated wheat allergy can cause baker’s asthma or rhinitis, which are common occupational diseases in workers who have significant repetitive exposure to wheat flour, such as bakers. Non-IgE mediated food allergy reactions to wheat are mainly eosinophilic esophagitis (EoE) or eosinophilic gastritis (EG), which are both characterized by chronic eosinophilic inflammation. EG is a systemic disease, and is associated with severe inflammation that requires oral steroids to resolve. EoE is a less severe disease, which can lead to complications in feeding intolerance and fibrosis. In both EoE and EG, wheat allergy diagnosis is based on both an elimination diet preceded by a tissue biopsy obtained by esophagogastroduodenoscopy in order to show the effectiveness of the diet. Diagnosis of IgE mediated wheat allergy is based on the medical history, the detection of specific IgE to wheat, and oral food challenges. Currently, the main treatment of a wheat allergy is based on avoidance of wheat altogether. However, in the near future immunotherapy may represent a valid way to treat IgE mediated reactions to wheat.

The association of autoimmune diseases with pediatric ulcerative colitis does not influence its disease course

OBJECTIVE

Ulcerative colitis (UC) is a chronic inflammatory condition. Previous reports suggested that UC may have a worse prognosis when associated with auto-immune diseases. We compared characteristics at diagnosis and natural history of the disease between classical ulcerative colitis (CUC) and UC associated with auto-immune diseases (CAI) in children.

MATERIAL AND METHODS

In this study, 67 children followed for UC at Nancy University Hospital between 1993 and 2012 were included: 45 patients in the CUC group and 22 in the CAI group.

RESULTS

Median follow-up was 4.8 years. Median age at diagnosis was 11.6 years in the CAI group and 9.8 years in the CUC group. Time between symptoms onset and diagnosis was broadly similar in the two groups (<3 months) and there were no significant differences regarding biological and histological findings. At 5 years, the need for corticosteroids and azathioprine did not differ between the CAI and the CUC groups. There was also no significant difference between the two groups regarding infliximab use at 1 and 5 years.

CONCLUSIONS

In this pediatric study, CAI had similar characteristics at baseline as CUC. The course of CAI does not seem to be influenced by the presence of concomitant auto-immune diseases.

Eosinophilic Esophagitis and Gastroenteritis

Eosinophilic gastrointestinal disease (EGID) can be classified as eosinophilic esophagitis (EoE) when the eosinophilia is limited to the esophagus or as eosinophilic gastritis (EG) if it is limited to the gastric tract, eosinophilic colitis (EC) if it is limited to the colon, and eosinophilic gastroenteritis (EGE) if the eosinophilia involves one or more parts of the gastrointestinal tract. EoE is by far the most common EGID. It is a well-defined chronic atopic disease due to a T helper type 2 (Th2) inflammation triggered often by food allergens. EoE diagnosis is done if an esophageal biopsy shows at least 15 eosinophils per high power field (eos/hpf). Globally accepted long-term therapies for EoE are the use of swallowed inhaled steroids or food antigen avoidance. The treatment of EoE is done not only to control symptoms but also to prevent complications such as esophageal stricture and food impaction. EGE cause non-specific gastrointestinal (GI) symptoms and are diagnosed if esophagogastroduodenoscopy (EGD)/colonoscopy show eosinophilia in one or more parts of the GI tract. They are rare diseases with an unclear pathogenesis, and they are poorly defined in terms of diagnostic criteria and treatment. Before initiating treatment of any EGE, it is imperative to conduct a differential diagnosis to exclude other causes of hypereosinophilia with GI localization. EGE are often poorly responsive to therapy and there is no commonly accepted long-term treatment. EG has many characteristics similar to EoE, including the fact that it is often due to a food allergen-driven Th2 inflammation; transcriptome analysis however shows that it is more a systemic disease and has a different gene signature than EoE. EC is a benign form of delayed food allergy in infant and is instead a difficult-to-treat severe inflammatory condition in older children and adults. EC in the latter groups can be a manifestation of drug allergy or autoimmune disease. Overall EGE, EC, and EG are rare and are a diagnosis of exclusion until more common causes of eosinophilia have been excluded.

An allergist's perspective to the evaluation of Eosinophilic Esophagitis

Eosinophilic Esophagitis (EoE) is a classic atopic disease as it shares features with other atopic disease on all levels including pathogenesis, genetics, epidemiology, and treatment options. EoE has elements of Th2 pathogenesis with increase levels of Th2 cytokines (IL4, 5, and 13). In addition, it shares atopic genetic risk factors including thymic stromal lymphopoietin (TSLP) loci as a risk factor in genome wide association studies. EoE patients have a higher rate of other atopic disease (asthma, allergic rhinitis and food allergy) compared to the general population indicating their atopic phenotype. Like asthma, atopic dermatitis or food allergy, EoE has increased in the last 20 years. Treatment options include the basic principle of other atopic diseases include using topical steroids or avoidance of the triggers (food or pollen). An allergist provides a critical role as they are experts in the treatment of atopic disease including avoidance strategies.

Effectiveness of dietary allergen exclusion therapy on eosinophilic colitis in Chinese infants and young children ≤ 3 years of age

Eosinophilic colitis is a well recognized clinical entity mainly associated with food allergies. Empiric treatment options include dietary allergen exclusion (extensively hydrolyzed protein formula and elimination diet), anti-allergy medications (antihistamines and leukotriene receptor antagonists) and corticosteroids. We evaluated the effectiveness of dietary antigen exclusion on clinical remission of eosinophilic colitis in infants and young children. We retrospectively reviewed charts of all infants and children ≤3 years of age who were diagnosed with eosinophilic colitis (defined as mucosal eosinophilia ≥20 hpf⁻¹) from 1 January 2011 to 31 December 2013 at a tertiary children’s hospital in China. Forty-nine children were identified with eosinophilic colitis. Elemental formula, simple elimination diet or combination therapy resulted in clinical improvement in 75%, 88.2% and 80% of patients, respectively. In conclusion, eosinophilic colitis in infants and children ≤3 years of age responded well to dietary allergen exclusion.

Immunotherapeutic approaches for the treatment of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a clinical pathologic disease characterized by symptoms of esophageal dysfunction and eosinophilia of the esophagus. When the diagnosis is confirmed, it is important to treat the eosinophilic inflammation not only to control the presenting symptoms, but also to prevent acute and chronic complications. The pathogenesis of EoE is most likely a mixed IgE and non-IgE food-mediated reaction, where Th2 cytokines drive esophageal eosinophilia as in other atopic diseases. Hence, it is not surprising that therapy is based on inflammation control, with steroids (oral or topical) and/or food antigen avoidance. However, these treatment options are not specific, reduce the quality of life of patients and have significant side effects, therefore, there is an ongoing effort to design more specific immunotherapies. In this review, we review standard and immunotherapeutic options for EoE treatment, such as anti-IL-5, anti-TNFα, anti-IgE, anti-CRTH, oral allergy desensitization and environmental immunotherapy.

Non-pulmonary allergic diseases and inflammatory bowel disease: A qualitative review

While the etiological underpinnings of inflammatory bowel disease (IBD) are highly complex, it has been noted that both clinical and pathophysiological similarities exist between IBD and both asthma and non-pulmonary allergic phenomena. In this review, several key points on common biomarkers, pathophysiology, clinical manifestations and nutritional and probiotic interventions for both IBD and non-pulmonary allergic diseases are discussed. Histamine and mast cell activity show common behaviors in both IBD and in certain allergic disorders. IgE also represents a key immunoglobulin involved in both IBD and in certain allergic pathologies, though these links require further study. Probiotics remain a critically important intervention for both IBD subtypes as well as multiple allergic phenomena. Linked clinical phenomena, especially sinonasal disease and IBD, are discussed. In addition, nutritional interventions remain an underutilized and promising therapy for modification of both allergic disorders and IBD. Recommending new mothers breastfeed their infants, and increasing the duration of breastfeeding may also help prevent both IBD and allergic diseases, but requires more investigation. While much remains to be discovered, it is clear that non-pulmonary allergic phenomena are connected to IBD in a myriad number of ways and that the discovery of common immunological pathways may usher in an era of vastly improved treatments for patients.

Rare case of ileal perforation

Ileitis, or inflammation of the ileum, is often caused by Crohn's disease. However, ileitis may be caused by a wide variety of other diseases. These include infectious diseases, spondyloarthropathies, vasculitides, ischemia, neoplasms, medication-induced, eosinophilic enteritis, and others. Eosinophilic enteritis can present as abdominal pain, protein loosing enteropathy, ulcers, intestinal obstruction, intussusception and perforation.Bowel perforation is an uncommon presentation of eosinophilic enteritis. We report a rare case of ileal perforation due to eosinophilic enteritis in a 57 years old female.

Diagnosing eosinophilic colitis: histopathological pattern or nosological entity?

Reports of  "eosinophilic colitis"-raised colonic mucosal eosinophil density in patients with lower gastrointestinal symptoms-have increased markedly over the last fifteen years, though it remains a rarity. There is no consensus over its diagnosis and management, and uncertainty is compounded by the use of the same term to describe an idiopathic increase in colonic eosinophils and an eosinophilic inflammatory reaction to known aetiological agents such as parasites or drugs. In patients with histologically proven colonic eosinophilia, it is important to seek out underlying causes and careful clinicopathological correlation is advised. Because of the variability of eosinophil density in the normal colon, it is recommended that histological reports of colonic eosinophilia include a quantitative morphometric assessment of eosinophil density, preferably across several sites. Few reported cases of "eosinophilic colitis" meet these criteria. As no correlation has been shown between colonic eosinophil density and symptoms in older children or adults, it is suggested that treatment should be directed towards alleviation of symptoms and response to treatment assessed clinically rather than by histological estimates of intramucosal eosinophils.

Eosinophilic gastroenteritis: an update

Eosinophilic gastroenteritis (EGE) is characterized by dense eosinophilic inflammation of one or several digestive tract sections. The symptoms include abdominal pain, weight loss, vomiting and diarrhea. Biopsy samples taken during endoscopic examination allows the diagnosis of the disease. An infiltration of >30 eosinophils per high-power field in at least five high-power fields, exhibiting signs of eosinophilic degranulation and extending to the muscularis mucosa or submucosa are all histological indications of EGE. EGE is traditionally classified into three forms depending on the depth of inflammation in the wall (mucosal, muscular or serosal). This, together with the digestive tract segments involved, determines the clinical presentation. The natural history of EGE includes three different evolutionary patterns, since patients may suffer a single outbreak, a recurrent course or even chronic disease. Corticosteroids are the most frequently used therapy for EGE; dietary treatments should be also considered. Surgery has been limited to solving obstruction and small bowel perforation.

Omalizumab beyond asthma

INTRODUCTION

Omalizumab has been demonstrated to be a successful therapy in the management of asthma through reduction of patient's symptoms and use of inhaled corticosteroids. The effect of omalizumab is achieved by immunoglobulin E (IgE) blockage and other secondary mechanisms resulting from this blockage. Because other diseases have an important IgE mediation in their physiopathology, the question arises as to if omalizumab would be useful in the treatment of other IgE-mediated diseases.

OBJECTIVE

We present an overview of the experimental studies and clinical reports evaluating the use of omalizumab in diseases different to asthma including atopic dermatitis, urticaria, eosinophilic gastrointestinal disorders, idiopathic anaphylaxis, latex allergy, hymenoptera venom allergy, and other IgE diseases.

METHODS

We reviewed the literature using PUBMED, EMBASE, and LILACS for publications which used omalizumab in the treatment of patients with allergic diseases or any other diseases. Complete articles published in English, Spanish or Portuguese were included.

CONCLUSION

There is not enough evidence to support the regular use of omalizumab in IgE diseases other than asthma. However, some experimental and clinical investigations indicate that omalizumab could be a therapeutic option in several allergic diseases like atopic dermatitis, urticaria, and eosinophilic gastrointestinal disorders. More control studies are needed in each IgE disease to evaluate the efficacy and safety of omalizumab in IgE mediated diseases.

Eosinophilic gastroenteritis associated with multiple gastric cancer

Eosinophilic gastroenteritis (EG) is an inflammation of the digestive tract that is characterized by eosinophilic infiltration. There are no specific symptoms, and are related to the layer in which eosinophilic infiltration is observed. A 69-year-old Japanese man presented to our hospital with a history of general malaise, diarrhea, and dysgeusia. Esophagogastroduodenoscopy showed reddish elevated lesions that were edematous all over the gastric mucosa. In addition, three tumors were also observed. The biopsies of the reddish elevated mucosa revealed eosinophilic infiltration and tubular adenocarcinoma from the tumors. Colonoscopy showed abnormal reddish elevated mucosa. The biopsies from the reddish elevated mucosa showed eosinophilic infiltration. From the abdominal contrast computed tomography scan, tumor stain was seen in the anterior wall of the gastric body. No ascites, intestinal wall thickening, or lymph node swelling were found. A slight elevation in the serum immunoglobulin E (IgE), 480 IU/ml, was found from the laboratory test results; other laboratory results were within normal limits including the number of peripheral eosinophils. No specific allergen was found from the multiple antigen simultaneous test and from the skin patch test. The parasitic immunodiagnosis was negative. He was diagnosed with EG associated with gastric cancer and underwent total gastrectomy, regional lymph node dissection with reconstruction by a Roux-en-Y method. He was prescribed prednisolone after the operation and showed a good clinical response. There are many case reports on EG, but none of them were associated with cancer. We encountered a case of EG associated with multiple gastric cancer; the patient underwent total gastrectomy.

Factors contributing to adherence to dietary treatment of eosinophilic gastrointestinal diseases

The purpose of the present study was to identify barriers to dietary adherence found in the treatment of children with eosinophilic gastrointestinal diseases (EGIDs) and food allergy. A prospective study using a self-administered survey to parents of children with EGIDs at a national advocacy meeting was completed. Responses from 45 participants describing children ages 1 to 18 years (69% boys) identified that 63% were adherent to food restrictions. Physicians provided dietary instructions more often than dietitians. Nonadherence was associated with lack of school support (P < 0.027). Access to a dietitian may improve the care of children with EGIDs.

Eosinophilic enteritis confined to an ileostomy site

Eosinophilic enteritis is a rather rare condition that can manifest anywhere from esophagus to rectum. Its description in the literature is sparse, but associations have been made with collagen vascular disease, malignancy, food allergy, parasitic or viral infections, inflammatory bowel disease, and drug sensitivity. We present the case of a 41-year-old male diagnosed with ulcerative colitis who underwent proctocolectomy with ileal pouch anal anastomosis and loop ileostomy formation utilizing Seprafilm®, who later developed eosinophilic enteritis of the loop ileostomy site. This is the first report of eosinophilic enteritis and its possible link to the use of bioabsorbable adhesion barriers.

Eosinophilic colitis: epidemiology, clinical features, and current management

Primary eosinophilic gastrointestinal disorders (EGIDs) represent a spectrum of inflammatory gastrointestinal disorders in which eosinophils infiltrate the gut in the absence of known causes for such tissue eosinophilia. EGIDs can be subgrouped as eosinophilic esophagitis (EE), eosinophilic gastroenteritis (EG), and eosinophilic colitis (EC). The least frequent manifestation of EGIDs is EC. EC is a heterogeneous entity with a bimodal age distribution, presenting with either an acute self-limited bloody diarrhea in otherwise healthy infants or as a more chronic relapsing colitis in young adults. The pathophysiology of primary EC appears related to altered hypersensitivity, principally as a food allergy in infants and T lymphocyte-mediated (i.e. non-IgE associated) in young adults. In adults, symptoms include diarrhea, abdominal pain, and weight loss. Endoscopic changes are generally modest, featuring edema and patchy granularity. Although standardized criteria are not yet established, the diagnosis of EC depends on histopathology that identifies an excess of eosinophils. Therapeutic approaches are based on case reports and small case series, as prospective randomized controlled trials are lacking. Eosinophilic colitis in infants is a rather benign, frequently food-related entity and dietary elimination of the aggressor often resolves the disorder within days. Adolescent or older patients require more aggressive medical management including: glucocorticoids, anti-histamines, leukotriene receptors antagonists as well as novel approaches employing biologics that target interleukin-5 (IL-5) and IgE. This review article summarizes the current knowledge of EC, its epidemiology, clinical manifestations, diagnosis, and treatment.

Histopathologic diagnosis of eosinophilic conditions in the gastrointestinal tract

Eosinophils, a constitutive component of the columnar-lined gastrointestinal tract, play an essential role in allergic responses and parasitic infections. The tissue density of these cells also increases in a variety of conditions of uncertain etiology. With the exception of the esophageal squamous epithelium, in which no eosinophils are normally present, the population of normal eosinophils in the remainder of the luminal gut is poorly defined. Therefore, histopathologists must rely on their subjective judgment to determine when a diagnosis of eosinophilic gastritis, enteritis, or colitis should be rendered. Eosinophilic esophagitis is currently the best defined and most studied eosinophilic condition of the digestive tract; therefore, the confidence in accurate diagnosis is increasing. In contrast, the characteristic clinicopathologic features of eosinophilic conditions affecting other parts of the digestive tract remain somewhat elusive. This review was designed to present pathologists with simple and practical information for the biopsy-based histopathologic diagnosis of eosinophilic esophagitis, gastritis, enteritis, and colitis. It was prepared by critically reviewing more than 200 articles on the topic, along with incorporating evidence accumulated through our own collective experience. We anticipate that by increasing pathologists' confidence in reporting these abnormal but often nameless eosinophilic infiltrates, we can help better define and characterize their significance.

Eosinophilic colitis: university of Minnesota experience and literature review

Eosinophilic colitis is a rare form of primary eosinophilic gastrointestinal disease that is poorly understood. Neonates and young adults are more frequently affected. Clinical presentation is highly variable depending on the depth of inflammatory response (mucosal, transmural, or serosal). The pathophysiology of eosinophilic colitis is unclear but is suspected to be related to a hypersensitivity reaction given its correlation with other atopic disorders and clinical response to corticosteroid therapy. Diagnosis is that of exclusion and differential diagnoses are many because colonic tissue eosinophilia may occur with other colitides (parasitic, drug-induced, inflammatory bowel disease, and various connective tissue disorders). Similar to other eosinophilic gastrointestinal disorders, steroid-based therapy and diet modification achieve very good and durable responses. In this paper, we present our experience with this rare pathology. Five patients (3 pediatric and 2 adults) presented with diarrhea and hematochezia. Mean age at presentation was 26 years. Mean duration of symptoms before pathologic diagnosis was 8 months. Mean eosinophil count per patient was 31 per high-power field. The pediatric patients responded very well to dietary modifications, with no recurrences. The adult patients were treated with steroids and did not respond. Overall mean followup was 22 (range, 2-48) months.

Gastrointestinal manifestations of food allergies

The rates of eosinophilic gastrointestinal disorders appear to be increasing. The most common of these is eosinophilic esophagitis (EoE) which is a clinicopathologic condition consisting of characteristic symptoms and endoscopic features accompanied by a pan-esophageal, acid resistant epithelial eosinophilia of greater than equal to 15 per high power field. Typical symptoms include dysphagia and abdominal pain. Typical endoscopic features include pallor, plaques, furrows, concentric rings. Complications include food impactions and strictures. EoE resolution with food elimination diets provides evidence that EoE is a food-antigen driven process. In vitro and microarray studies have identified specific immunologic factors underlying EoE pathogenesis. Other gastrointestinal manifestations of food intolerances/allergy include food protein induced enterocolitis syndrome.

Eosinophilic colitis: an update on pathophysiology and treatment

BACKGROUND

Primary eosinophilic gastrointestinal disorders, a spectrum of inflammatory conditions, occurs when eosinophils selectively infiltrate the gut in the absence of known causes for such tissue eosinophilia. These may be classified into eosinophilic esophagitis, eosinophilic gastroenteritis and eosinophilic colitis (EC). This review focuses on EC: its pathogenesis, epidemiology, clinical presentation, diagnosis and current approach to treatment.

SOURCES OF DATA

A literature review published in English was performed using Pubmed, Ovid, Google scholar search engines with the following keywords: eosinophilic gastrointestinal disorder, EC, eosinophils, colitis and gastrointestinal.

AREAS OF AGREEMENT

The basis for primary EC appears related to increased sensitivity to allergens, principally as a food allergy in infants and a T lymphocyte-mediated event in adults. Endoscopic changes are generally modest, featuring edema and patchy granularity.

AREAS OF CONTROVERSY

Clear clinical and pathological diagnostic criteria of EC and its management strategy.

GROWING POINTS

Intestinal involvement of EC is primarily mucosal, presenting as a mild self-limited proctitis in infants and self-limited colitis in young adults. Therapeutic approaches based on case reports tend to use either elimination diets to avoid a presumed allergen; agents traditionally used in inflammatory disease or targeted drugs like anti-histamines or leukotriene receptor antagonists.

AREAS TIMELY FOR DEVELOPING RESEARCH

Prospective randomized controlled trials addressing the disease natural history, possible preventive methods and effective medical approach and long-term prognosis are required.

Eosinophilic diseases of the gastrointestinal tract

Eosinophilic gastrointestinal disorders (EGIDs) are a diverse group of disorders whose diagnosis is on the rise and are characterized by symptoms caused by infiltration by eosinophils of the different sections of the digestive tract. Although little is known of their etiology, it seems to be multifactorial. Alteration of the immunological capacity of the digestive mucosa is determined by the exposure of genetically predisposed individuals to potential airborne or food allergens. EGIDs are classified based on the location of the inflammatory response even though their symptoms, prognosis, and treatment vary considerably. Eosinophilic esophagitis is the most widely recognized entity in this family and is characterized by exclusive eosinophilic infiltration of the esophagus. Breakthroughs in understanding its etiopathogeny have been extrapolated to eosinophilic gastroenteritis, a rare disease identified many years ago commonly involving the stomach and small bowel which should be distinguished from hypereosinophilic syndrome. Eosinophilic colitis, which usually affects children, could be considered a specific non-IgE-mediated allergy to food protein. The physiopathological bases of these entities need to be established in order to define specific treatment aimed at preventing and altering their clinical evolution.

Defining eosinophilic colitis in children: insights from a retrospective case series

OBJECTIVES

Although it is a well-described syndrome in infants, eosinophilic colitis is a loosely defined and poorly understood diagnosis in older children. The aims of this case series were to characterise colonic eosinophilia in children and to determine whether it represents a distinct clinicopathological condition.

METHODS

We retrospectively reviewed symptomatic children older than 12 months with the principal diagnosis of colonic eosinophilia who presented between January 2000 and February 2007 (n = 38) and a further 10 children whose colonic biopsies were reported as histologically normal. The eosinophil density in all available gastrointestinal biopsies (n = 620) of these children was determined using a validated quantitative morphometric method. Patients were subdivided according to mean colonic eosinophil levels into 3 groups (marked, moderate, or minimal colonic eosinophilia). The following patient information was obtained and compared among patient groups: symptoms prompting endoscopy, atopic history, outcome, serum C-reactive protein and total immunoglobulin E (IgE) levels, erythrocyte sedimentation rate, blood eosinophil count, and endoscopic findings.

RESULTS

In all 3 patient groups, there was a colonic gradient of decreasing eosinophil density from caecum to rectum. Upper gastrointestinal tract biopsies did not exhibit eosinophilia. Although a significant association (P = 0.03) between abnormal total IgE levels and moderate or severe colonic eosinophilia was found, there was no significant difference (P > 0.05) in other patient characteristics. Furthermore, follow-up data did not show a consistent relation between eosinophil density and progression of symptoms.

CONCLUSIONS

We find no association between "eosinophilic colitis," defined as a histologically demonstrated marked colonic eosinophilia, and symptoms, history of atopy, inflammatory markers, or clinical outcome.

Eosinophilic colitis

Eosinophilic colitis (EC) is a rare form of primary eosinophilic gastrointestinal disease with a bimodal peak of prevalence in neonates and young adults. EC remains a little understood condition in contrast to the increasingly recognized eosinophilic esophagitis. Clinical presentation of EC is highly variable according to mucosal, transmural, or serosal predominance of inflammation. EC has a broad differential diagnosis because colon tissue eosinophilia often occurs in parasitic infection, drug-induced allergic reactions, inflammatory bowel disease, and various connective tissue disorders, which require thorough searching for secondary causes that may be specifically treated with antibiotics or dietary and drug elimination. Like eosinophilic gastrointestinal disease involving other segments of the gastrointestinal tract, EC responds very well to steroids that may be spared by using antihistamines, leukotriene inhibitors and biologics.

The diagnosis of food allergy in children

PURPOSE OF REVIEW

To give an update about the optimal diagnostic work-up for children with suspected food allergy.

RECENT FINDINGS

Food allergy has become a very severe health problem not only for many children and parents, but also for the entire medical and paramedical community. The financial and social costs related to these conditions are increasing, but, contemporarily, basic and clinical research are deeply involved in the search of possible solutions to facilitate the management of these patients.

SUMMARY

Food allergy is defined as an abnormal immunological reaction to food proteins, which causes an adverse clinical reaction. Over 90% of food allergies in childhood are caused by eight foods: cow's milk, hen's egg, soy, peanuts, tree nuts, wheat, fish and shellfish. The evaluation of a child with suspected food allergy includes detailed medical history, physical examination, screening tests and response to elimination diet and to oral food challenge. None of the screening tests, alone or in combination, can definitely diagnose or exclude it. The main principle of food allergy management is avoidance of the offending antigen. An incorrect diagnosis is likely to result in unnecessary dietary restrictions, which, if prolonged, may adversely affect the child's nutritional status and growth.

Is irritable bowel syndrome an inflammatory disorder?

Histopathologic data demonstrate low-grade mucosal inflammation in a subset of patients with irritable bowel syndrome (IBS). This inflammatory infiltrate is mainly represented by increased numbers of T lymphocytes and mast cells lying in the lamina propria. The close apposition of immunocytes to gut nerves supplying the mucosa provides a basis for neuroimmune cross-talk, which may explain gut sensorimotor dysfunction and related symptoms in patients with IBS. A previous gastroenteritis (due to Campylobacter jejuni, Salmonella, Shigella, Escherichia coli, and, likely, viruses) is now an established etiologic factor for IBS (hence, postinfectious IBS). Other putative causes, such as undiagnosed food allergies, genetic abnormalities, stress, or bile acid malabsorption, may also promote and maintain a low-grade mucosal inflammation in IBS. The identification of mucosal inflammation in IBS has pathophysiologic implications and paves the way for novel therapeutic options.