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Laserna‐Mendieta EJ, Navarro P, Casabona‐Francés S, Savarino EV, Amorena E, Pérez‐Martínez I, Guagnozzi D, Blas‐Jhon L, Betoré E, Guardiola‐Arévalo A, Pellegatta G, Krarup AL, Perello A, Barrio J, Gutiérrez‐Junquera C, Teruel Sánchez‐Vegazo C, Fernández‐Fernández S, Naves JE, Oliva S, Rodríguez‐Oballe JA, Carrión S, Espina S, Llorente Barrio M, Masiques‐Mas ML, Dainese R, Feo‐Ortega S, Martín‐Dominguez V, Fernández‐Pacheco J, Pérez‐Fernández MT, Ghisa M, Maniero D, Nantes‐Castillejo Ó, Nicolay‐Maneru J, Suárez A, Maray I, Llerena‐Castro R, Ortega‐Larrodé A, Alcedo J, Granja Navacerrada A, Racca F, Santander C, Arias Á, Lucendo AJ. Swallowed topical corticosteroids for eosinophilic esophagitis: Utilization and real-world efficacy from the EoE CONNECT registry. United European Gastroenterol J 2024; 12:585-595. [PMID: 38284792 PMCID: PMC11176909 DOI: 10.1002/ueg2.12533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/25/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Swallowed topical corticosteroids (tC) are common therapy for patients with eosinophilic esophagitis (EoE). Widely heterogeneous results have occurred due to their active ingredients, formulations and doses. OBJECTIVE To assess the effectiveness of topical corticosteroid therapy for EoE in real-world practice. METHODS Cross-sectional study analysis of the multicentre EoE CONNECT registry. Clinical remission was defined as a decrease of ≥50% in dysphagia symptom scores; histological remission was defined as a peak eosinophil count below 15 per high-power field. The effectiveness in achieving clinico-histological remission (CHR) was compared for the main tC formulations. RESULTS Overall, data on 1456 prescriptions of tC in monotherapy used in 866 individual patients were assessed. Of those, 904 prescriptions with data on formulation were employed for the induction of remission; 234 reduced a previously effective dose for maintenance. Fluticasone propionate formulations dominated the first-line treatment, while budesonide was more common in later therapies. A swallowed nasal drop suspension was the most common formulation of fluticasone propionate. Doses ≥0.8 mg/day provided a 65% CHR rate and were superior to lower doses. Oral viscous solution prepared by a pharmacist was the most common prescription of budesonide; 4 mg/day provided no benefit over 2 mg/day (CHR rated being 72% and 80%, respectively). A multivariate analysis revealed budesonide orodispersible tablets as the most effective therapy (OR 18.9, p < 0.001); use of higher doses (OR 4.3, p = 0.03) and lower symptom scores (OR 0.9, p = 0.01) were also determinants of effectiveness. CONCLUSION Reduced symptom severity, use of high doses, and use of budesonide orodispersible tablets particularly were all independent predictors of tC effectiveness.
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de Bortoli N, Visaggi P, Penagini R, Annibale B, Baiano Svizzero F, Barbara G, Bartolo O, Battaglia E, Di Sabatino A, De Angelis P, Docimo L, Frazzoni M, Furnari M, Iori A, Iovino P, Lenti MV, Marabotto E, Marasco G, Mauro A, Oliva S, Pellegatta G, Pesce M, Privitera AC, Puxeddu I, Racca F, Ribolsi M, Ridolo E, Russo S, Sarnelli G, Tolone S, Zentilin P, Zingone F, Barberio B, Ghisa M, Savarino EV. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis - Definition, Clinical Presentation and Diagnosis. Dig Liver Dis 2024; 56:951-963. [PMID: 38423918 DOI: 10.1016/j.dld.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/26/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic type 2-mediated inflammatory disease of the esophagus that represents the most common eosinophilic gastrointestinal disease. Experts in the field of EoE across Italy (i.e., EoETALY Consensus Group) including gastroenterologists, endoscopists, allergologists/immunologists, and paediatricians conducted a Delphi process to develop updated consensus statements for the management of patients with EoE and update the previous position paper of the Italian Society of Gastroenterology (SIGE) in light of recent evidence. Grading of the strength and quality of the evidence of the recommendations was performed using accepted GRADE criteria. The guideline is divided in two documents: Part 1 includes three chapters, namely 1) definition, epidemiology, and pathogenesis; 2) clinical presentation and natural history, and 3) diagnosis, while Part 2 includes two chapters: 4) treatment and 5) monitoring and follow-up. This document has received the endorsement of three Italian national societies including the SIGE, the Italian Society of Neurogastroenterology and Motility (SINGEM), and the Italian Society of Allergology, Asthma, and Clinical Immunology (SIAAIC). With regards to patients' involvement, these guidelines involved the contribution of members of ESEO Italia, the Italian Association of Families Against EoE.
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Affiliation(s)
- Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome 00189, Italy
| | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Edda Battaglia
- Gastroenterology Unit ASLTO4, Chivasso - Ciriè - Ivrea, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia 27100, Italy; First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Pavia 27100, Italy
| | - Paola De Angelis
- Digestive Endoscopy Unit - Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Iori
- Gastroenterology and Digestive Endoscopy Unit,' Santa Chiara' Hospital, Trento, Italy
| | - Paola Iovino
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi 84084, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia 27100, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia 27100, Italy
| | - Salvatore Oliva
- Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Italy
| | - Gaia Pellegatta
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Marcella Pesce
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | | | - Ilaria Puxeddu
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano - Milan, Italy
| | - Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Erminia Ridolo
- Allergy Unit, Department of Internal Medicine, University Hospital of Parma, Parma, Italy
| | - Salvatore Russo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliera Universitaria of Modena, Modena, Italy
| | - Giovanni Sarnelli
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Campania "Luigi Vanvitelli", Naples 80131, Italy
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, Padua 35128, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, Padua 35128, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, Padua 35128, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, Padua 35128, Italy.
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Navarro P, Feo-Ortega S, Casabona-Francés S, Gutiérrez-Junquera C, Savarino EV, Amorena E, Fernández-Fernández S, Pérez-Martínez I, Oliva S, Barrio J, Masiques-Mas ML, Guardiola-Arévalo A, Guagnozzi D, Racca F, Betoré E, Votto M, Rodríguez-Sánchez A, Barrio ML, Blas-Jhon L, Sánchez-Vegazo CT, García-Morales N, Krarup AL, Dainese R, Martín-Dominguez V, García-Díaz A, Maniero D, Santander C, Arias Á, Laserna-Mendieta EJ, Lucendo AJ. Determinant factors for first-line treatment choice and effectiveness in pediatric eosinophilic esophagitis: an analysis of the EUREOS EoE CONNECT registry. Eur J Pediatr 2024:10.1007/s00431-024-05618-z. [PMID: 38819501 DOI: 10.1007/s00431-024-05618-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/03/2024] [Accepted: 05/17/2024] [Indexed: 06/01/2024]
Abstract
This study compared short-term effectiveness of proton pump inhibitors (PPI), swallowed topical corticosteroids (STC), and dietary therapies in reversing clinical and histological features in pediatric patients with eosinophilic esophagitits (EoE). Determinants for treatment choice and PPI therapy effectiveness were also assessed. A cross-sectional study analysis of patients under 18 years old recruited onto the multicenter EoE CONNECT registry was performed. Clinico-histological response was defined as symptomatic improvement plus a peak eosinophil count below 15 per high-power field after treatment. Effectiveness of first-line options used in monotherapy was compared. Overall, 393 patients (64% adolescents) receiving PPI, STC, or dietary monotherapy to induce EoE remission were identified. PPI was the preferred option (71.5%), despite STC providing the highest clinico-histological response rates (66%) compared to PPI (44%) and diet (42%). Logistic regression identified fibrotic features and recruitment at Italian sites independently associated to first-line STC treatment; age under 12 associated to dietary therapy over other options. Analysis of 262 patients in whom PPI effectiveness was evaluated after median (IQR) 96 (70-145) days showed that this effectiveness was significantly associated with management at pediatric facilities and use of high PPI doses. Among PPI responders, decrease in rings and structures in endoscopy from baseline was documented, with EREFS fibrotic subscore for rings also decreasing among responders (0.27 ± 0.63 vs. 0.05 ± 0.22, p < 0.001). Conclusion: Initial therapy choice for EoE depends on endoscopic phenotype, patient's age, and patients' origin. High PPI doses and treatment in pediatric facilities significantly determined effectiveness, and reversed fibrotic endoscopic features among responders. What is Known: • Proton pump inhibitors are widely used to induce and maintain remission in EoE in real practice, despite other first-line alternative therapies possibly providing higher effectiveness. What is New: • Proton pump inhibitors represent up to two-thirds of first-line monotherapies used to induce EoE remission in pediatric and adolescent patients with EoE. The choice of STC as first-line treatment for EoE was significantly associated with fibrotic features at baseline endoscopy and recruitment in Italian centers; age less than 12 years was associated with dietary therapy. • PPI effectiveness was found to be determined by use of high doses, attendance at pediatric facilities, presenting inflammatory instead of fibrotic or mixed phenotypes, and younger age. Among responders, PPI therapy reversed both inflammatory and fibrotic features of EoE after short-term treatment.
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Affiliation(s)
- Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700, Tomelloso, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Sara Feo-Ortega
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Department of Pediatrics, Hospital General de Tomelloso, Tomelloso, Spain
| | - Sergio Casabona-Francés
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
- Universidad Autónoma de Madrid, Madrid, Spain
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienza Ospedaliera di Padova, Padua, Italy
| | - Edurne Amorena
- Department of Gastroenterology, Hospital Universitario de Navarra, Pamplona, Spain
| | | | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
- Diet, Microbiota and Health Group, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza-University of Rome, Rome, Italy
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | | | - Danila Guagnozzi
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario Vall d'Hebrón, Barcelona, Spain
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano - Milan, Italy
| | - Elena Betoré
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Martina Votto
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia; and Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | | | | | | | - Anne Lund Krarup
- Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Raffaella Dainese
- Department of Gastroenterology, Centre Hospitalier d'Antibes Juan-les Pins, Antibes, France
| | - Verónica Martín-Dominguez
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Alejandro García-Díaz
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
- Research Unit, Hospital General Mancha-Centro, Alcázar de San Juan, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700, Tomelloso, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, 13700, Tomelloso, Spain.
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain.
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain.
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Falk GW, Pesek R. Pharmacologic Management of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:245-264. [PMID: 38575221 DOI: 10.1016/j.iac.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Proton pump inhibitors (PPIs), swallowed topical corticosteroids (STSs), and dupilumab are highly effective therapies for the treatment of eosinophilic esophagitis. Shared decision-making informs the choice of therapy and factors such as ease of use, safety, cost, and efficacy should be addressed. PPIs are the most common medication utilized early in the disease course; however, for nonresponders, STSs are an excellent alternative. Dupilumab is unlikely to replace PPIs or STSs as first-line therapy, except in highly specific circumstances. Identification of novel biologic pathways and the development of small molecules may lead to a wider range of treatment options in the future.
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Affiliation(s)
- Gary W Falk
- Division of Gastroenterology & Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 7th Floor South Pavilion PCAM, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Robbie Pesek
- Division of Allergy and Immunology, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 13 Children's Way, Slot 512-13, Little Rock, AR 72202, USA.
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Nader LS, Epifanio M, Coelho MG, Steinhaus C, Melere M, da Silva CS, Ferreira CT. High prevalence of response to PPI treatment in children and adolescents with eosinophilic esophagitis in southern Brazil. FRONTIERS IN ALLERGY 2024; 5:1346843. [PMID: 38650863 PMCID: PMC11033356 DOI: 10.3389/falgy.2024.1346843] [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: 11/30/2023] [Accepted: 03/21/2024] [Indexed: 04/25/2024] Open
Abstract
Introduction Eosinophilic esophagitis is a newly recognized entity, in which there is significant evidence available that clearly demonstrates the positive impact of PPIs on reducing esophageal eosinophilia in individuals across different age groups, including children, adolescents, and adults. Multiple mechanisms have been proposed to explain how this treatment effect occurs. In Brazil, there seems to be a lack of studies that have prospectively assessed the clinical and therapeutic response rate in pediatric patients with EoE. The objective of this study was to prospectively evaluate the clinical and therapeutic response of pediatric patients with EoE in a medical center located in southern Brazil, by investigating the effectiveness of PPI treatment. Methods This study is a clinical, prospective, open trial that took place in a pediatric hospital located in southern Brazil. The focus of the study was on patients diagnosed with Eosinophilic Esophagitis (EoE) who were given treatment using omeprazole/esomeprazole at a dosage of 1 mg.kg per dose, twice daily, for a period of 8-12 weeks. Following the treatment period, the patients underwent another endoscopy. Patients who exhibited 15 or less eosinophils in the biopsy conducted after the treatment were considered as responders. Results A total of 27 patients was evaluated (74.1% boys). The average age (± standard deviation) was 8 years (±4). Nineteen patients (70.3%) were considered as responders to PPI treatment: 6 patients-22.2%-exhibited a complete response (defined as having 5 or fewer eosinophil per high power field. Additionally, 13 patients-48.1%-demonstrated a partial response, characterized by eosinophil counts exceeding 5 but less than 15 eos/hpf. When comparing the responder and non-responder groups at presentation, a statistical difference was observed in the prevalence of food refusal as a presenting symptom. Food refusal was found to be more prevalent in the non-responder group (87.5% vs. 26.3%, P = 0.008). No differences were observed in terms of atopy history and endoscopic scores. Upon comparing the histological findings from the post-treatment endoscopy of the two groups, it was observed that PPI responders exhibited a greater tendency to decrease basal cell hyperplasia (P = 0.06) and intercellular edema (P = 0.08). Conclusion In this group of pediatric patients with EoE in Southern Brazil most patients showed a high prevalence of histological, endoscopic, and clinical response to PPI treatment. PPIs showed efficacy in Brazilian patients with EoE, most of whom would probably not be able to adequately undergo other treatments. Clinical Trial Registration https://ensaiosclinicos.gov.br/rg/RBR-2ntbth9, identifier (U1111-1301-1842).
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Affiliation(s)
- Luiza Salgado Nader
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Matias Epifanio
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
| | | | - Cintia Steinhaus
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Melina Melere
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Carolina Soares da Silva
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Cristina Targa Ferreira
- Division of Pediatric Gastroenterology Unit, Santa Casa de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Pediatrics, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
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Ugalde-Triviño L, Molina-Jiménez F, H-Vázquez J, Relaño-Rupérez C, Arias-González L, Casabona S, Pérez-Fernández MT, Martín-Domínguez V, Fernández-Pacheco J, Lucendo AJ, Bernardo D, Santander C, Majano P. Circulating immunome fingerprint in eosinophilic esophagitis is associated with clinical response to proton pump inhibitor treatment. Front Immunol 2024; 15:1374611. [PMID: 38646544 PMCID: PMC11026586 DOI: 10.3389/fimmu.2024.1374611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives The aim of the study was to characterize the circulating immunome of patients with EoE before and after proton pump inhibitor (PPI) treatment in order to identify potential non-invasive biomarkers of treatment response. Methods PBMCs from 19 healthy controls and 24 EoE patients were studied using a 39-plex spectral cytometry panel. The plasmacytoid dendritic cell (pDC) population was differentially characterized by spectral cytometry analysis and immunofluorescence assays in esophageal biopsies from 7 healthy controls and 13 EoE patients. Results Interestingly, EoE patients at baseline had lower levels of circulating pDC compared with controls. Before treatment, patients with EoE who responded to PPI therapy had higher levels of circulating pDC and classical monocytes, compared with non-responders. Moreover, following PPI therapy pDC levels were increased in all EoE patients, while normal levels were only restored in PPI-responding patients. Finally, circulating pDC levels inversely correlated with peak eosinophil count and pDC count in esophageal biopsies. The number of tissue pDCs significantly increased during active EoE, being even higher in non-responder patients when compared to responder patients pre-PPI. pDC levels decreased after PPI intake, being further restored almost to control levels in responder patients post-PPI. Conclusions We hereby describe a unique immune fingerprint of EoE patients at diagnosis. Moreover, circulating pDC may be also used as a novel non-invasive biomarker to predict subsequent response to PPI treatment.
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Affiliation(s)
- Lola Ugalde-Triviño
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
| | - Francisca Molina-Jiménez
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
| | - Juan H-Vázquez
- Mucosal Immunology Lab, Unit of Excellence Institute of Biomedicine and Molecular Genetics (IBGM), University of Valladolid and CSIC, Valladolid, Spain
| | - Carlos Relaño-Rupérez
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Bioinformatics Unit, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Laura Arias-González
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Sergio Casabona
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - María Teresa Pérez-Fernández
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Verónica Martín-Domínguez
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Jennifer Fernández-Pacheco
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Alfredo J. Lucendo
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - David Bernardo
- Mucosal Immunology Lab, Unit of Excellence Institute of Biomedicine and Molecular Genetics (IBGM), University of Valladolid and CSIC, Valladolid, Spain
- Centro de Investigaciones Biomedicas en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Cecilio Santander
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Pedro Majano
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Department of Molecular Biology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Cellular Biology, Faculty of Biology, Universidad Complutense de Madrid, Madrid, Spain
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7
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Rodríguez-Alcolado L, Navarro P, Arias-González L, Grueso-Navarro E, Lucendo AJ, Laserna-Mendieta EJ. Proton-Pump Inhibitors in Eosinophilic Esophagitis: A Review Focused on the Role of Pharmacogenetics. Pharmaceutics 2024; 16:487. [PMID: 38675148 PMCID: PMC11054109 DOI: 10.3390/pharmaceutics16040487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Proton-pump inhibitors (PPIs) are the most administered first-line treatment for eosinophilic esophagitis (EoE). However, only around half of EoE patients respond histologically to a double dosage of PPI. In addition, 70% of responders maintain EoE in remission after tapering the PPI dose. In order to avoid endoscopy with biopsies-the only accurate method of assessing PPI response-efforts have been made to identify PPI responder patients. The clinical or endoscopic features and biomarkers evaluated so far, however, have not proven to be sufficient in predicting PPI response. Although new approaches based on omics technologies have uncovered promising biomarkers, the specialized and complex procedures required are difficult to implement in clinical settings. Alternatively, PPI pharmacogenetics based on identifying variations in CYP2C19 and STAT6 genes have shown promising results in EoE, and could easily be performed in most laboratories. Other genetic variations have also been associated with PPI response and may explain those cases not related to CYP2C19 or STAT6. Here, we provide an overview of PPI treatment in EoE and evidence of how genetic variations in CYP2C19 and other genes could affect PPI effectiveness, and also discuss studies evaluating the role of pharmacogenetics in predicting PPI response in patients with EoE.
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Affiliation(s)
- Leticia Rodríguez-Alcolado
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Department of Surgery, Medical and Social Sciences, Universidad de Alcalá, 28805 Alcalá de Henares, Spain
| | - Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Laura Arias-González
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Elena Grueso-Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
| | - Alfredo J. Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Emilio J. Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, 13700 Tomelloso, Spain; (L.R.-A.); (P.N.); (L.A.-G.); (E.G.-N.)
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Instituto de Investigación Sanitaria La Princesa, 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
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8
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Goyal R, Kamboj AK, Snyder DL. Eosinophilic Esophagitis: Clinical Pearls for Primary Care Providers and Gastroenterologists. Mayo Clin Proc 2024; 99:640-648. [PMID: 38569813 DOI: 10.1016/j.mayocp.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/10/2023] [Accepted: 12/28/2023] [Indexed: 04/05/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated esophageal disorder. Given its increasing incidence, it is now a leading cause of dysphagia and food impaction in the United States. Eosinophilic esophagitis is most common in adult White men and has a high concurrence rate with other atopic conditions like allergic rhinitis, bronchial asthma, and eczema. The initial presentation includes symptoms of esophageal dysfunction, classically solid-food dysphagia. Without treatment, inflammation can progress to fibrosis with the formation of strictures, leading to complications such as food impaction. It is a clinicopathologic disease requiring compatible clinical symptoms and histologic evidence of eosinophil-predominant inflammation of the esophageal epithelium with more than 15 eosinophils per high-power field. The mainstay of management includes the 3 d's (diet, drugs, dilation): dietary modifications to eliminate trigger food groups; medications including proton pump inhibitors, swallowed topical glucocorticoids, and dupilumab; and esophageal dilation to manage strictures. Various elimination diets have been found to be effective, including 1-food, 2-food, 4-food, and 6-food elimination diets. Dupilumab, a humanized monoclonal antibody that regulates interleukin 4 and 13 signaling pathways, has shown promising results in clinical trials and was approved by the Food and Drug Administration in 2022 for use in EoE. Symptom alleviation, although important, is not the sole end point of treatment in EoE as persistent inflammation, even in the absence of symptoms, can lead to esophageal fibrosis and stricture formation over time. The chronic nature and high recurrence rates of EoE warrant maintenance therapy in patients with EoE after initial remission is achieved.
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Affiliation(s)
- Rohit Goyal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Amrit K Kamboj
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Diana L Snyder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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9
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Soria-Chacartegui P, Navares-Gómez M, Molina-Jiménez F, Laserna-Mendieta EJ, Arias-González L, Majano P, Casabona S, Lucendo AJ, Abad-Santos F, Santander C, Zubiaur P. Impact of STAT6 Variants on the Response to Proton Pump Inhibitors and Comorbidities in Patients with Eosinophilic Esophagitis. Int J Mol Sci 2024; 25:3685. [PMID: 38612496 PMCID: PMC11011338 DOI: 10.3390/ijms25073685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Proton pump inhibitors (PPIs) are the first-line drug for eosinophilic esophagitis (EoE), although it is estimated that there is a lack of histological remission in 50% of patients. This research aimed to identify pharmacogenetic biomarkers predictive of PPI effectiveness and to study their association with disease features. Peak eosinophil count (PEC) and the endoscopic reference score (EREFS) were determined before and after an eight-week PPI course in 28 EoE patients. The impact of the signal transducer and activator of transcription 6 (STAT6), CYP2C19, CYP3A4, CYP3A5, and ABCB1 genetic variations on baseline PEC and EREFS, their reduction and histological response, and on EoE symptoms and comorbidities was analyzed. PEC reduction was higher in omeprazole-treated patients (92.5%) compared to other PPIs (57.9%, p = 0.003). STAT6 rs12368672 (g.18453G>C) G/G genotype showed higher baseline PEC values compared to G/C and C/C genotypes (83.2 vs. 52.9, p = 0.027). EREFS reduction in STAT6 rs12368672 G/G and G/C genotypes was higher than in the C/C genotype (36.7% vs. -75.0% p = 0.011). However, significance was lost after Bonferroni correction. Heartburn incidence was higher in STAT6 rs167769 (g.27148G>A) G/G patients compared to G/A (54.55% vs. 11.77%, p = 0.030). STAT6 rs12368672G>C and rs167769G>A variants might have a relevant impact on EoE status and PPI response. Further research is warranted to clarify the clinical relevance of these variants.
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Affiliation(s)
- Paula Soria-Chacartegui
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), 28006 Madrid, Spain
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
| | - Marcos Navares-Gómez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), 28006 Madrid, Spain
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
| | - Francisca Molina-Jiménez
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
- Gastroenterology Department, Hospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), 28006 Madrid, Spain
| | - Emilio J. Laserna-Mendieta
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Gastroenterology Department, Hospital General de Tomelloso, 13700 Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
| | - Laura Arias-González
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Gastroenterology Department, Hospital General de Tomelloso, 13700 Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
| | - Pedro Majano
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
- Gastroenterology Department, Hospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Cellular Biology Department, Faculty of Biology, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Sergio Casabona
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
- Gastroenterology Department, Hospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Alfredo J. Lucendo
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Gastroenterology Department, Hospital General de Tomelloso, 13700 Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), 28006 Madrid, Spain
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
- Gastroenterology Department, Hospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), 28006 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Pablo Zubiaur
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Faculty of Medicine, Universidad Autónoma de Madrid (UAM), 28006 Madrid, Spain
- Instituto de Investigación Sanitaria La Princesa (IIS-IP), 28006 Madrid, Spain (A.J.L.)
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10
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de Bortoli N, Visaggi P, Penagini R, Annibale B, Baiano Svizzero F, Barbara G, Bartolo O, Battaglia E, Di Sabatino A, De Angelis P, Docimo L, Frazzoni M, Furnari M, Iori A, Iovino P, Lenti MV, Marabotto E, Marasco G, Mauro A, Oliva S, Pellegatta G, Pesce M, Privitera AC, Puxeddu I, Racca F, Ribolsi M, Ridolo E, Russo S, Sarnelli G, Tolone S, Zentilin P, Zingone F, Barberio B, Ghisa M, Savarino EV. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis-Current Treatment and Monitoring. Dig Liver Dis 2024:S1590-8658(24)00301-3. [PMID: 38521670 DOI: 10.1016/j.dld.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/11/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
The present document constitutes Part 2 of the EoETALY Consensus Statements guideline on the diagnosis and management of eosinophilic esophagitis (EoE) developed by experts in the field of EoE across Italy (i.e., EoETALY Consensus Group). Part 1 was published as a different document, and included three chapters discussing 1) definition, epidemiology, and pathogenesis; 2) clinical presentation and natural history and 3) diagnosis of EoE. The present work provides guidelines on the management of EoE in two final chapters: 4) treatment and 5) monitoring and follow-up, and also includes considerations on knowledge gaps and a proposed research agenda for the coming years. The guideline was developed through a Delphi process, with grading of the strength and quality of the evidence of the recommendations performed according to accepted GRADE criteria.This document has received the endorsement of three Italian national societies including the Italian Society of Gastroenterology (SIGE), the Italian Society of Neurogastroenterology and Motility (SINGEM), and the Italian Society of Allergology, Asthma, and Clinical Immunology (SIAAIC). The guidelines also involved the contribution of members of ESEO Italia, the Italian Association of Families Against EoE.
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Affiliation(s)
- Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, 00189, Rome, Italy
| | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | | | - Edda Battaglia
- Gastroenterology Unit ASLTO4, Chivasso - Ciriè - Ivrea, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, 27100, Pavia, Italy; First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, 27100, Pavia, Italy
| | - Paola De Angelis
- Digestive Endoscopy Unit - Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa,Genoa,Italy, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Iori
- Gastroenterology and Digestive Endoscopy Unit, 'Santa Chiara' Hospital, Trento, Italy
| | - Paola Iovino
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84084, Baronissi, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, 27100, Pavia, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa,Genoa,Italy, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Salvatore Oliva
- Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Italy
| | - Gaia Pellegatta
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy; Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Marcella Pesce
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | | | - Ilaria Puxeddu
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano - Milan, Italy
| | - Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Erminia Ridolo
- Allergy Unit, Department of Internal Medicine, University Hospital of Parma, Parma, Italy
| | - Salvatore Russo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliera Universitaria of Modena, Modena, Italy
| | - Giovanni Sarnelli
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
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11
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Elghoudi A, Zourob D, Al Atrash E, Alshamsi F, Alkatheeri M, Narchi H, Bitar R. Evolving strategies: Enhancements in managing eosinophilic esophagitis in pediatric patients. World J Clin Pediatr 2024; 13:89580. [PMID: 38596434 PMCID: PMC11000055 DOI: 10.5409/wjcp.v13.i1.89580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/26/2023] [Accepted: 01/16/2024] [Indexed: 03/06/2024] Open
Abstract
Eosinophilic esophagitis is a newly recognized disease first described about 50 years ago. The definition, diagnosis, and management have evolved with new published consensus guidelines and newly approved treatment available to pediatricians, enabling a better understanding of this disease and more targeted treatment for patients. We describe the definition, presentation, and diagnosis of eosinophilic esophagitis including management, challenges, and future directions in children. The definition, diagnosis, and management of eosinophilic esophagitis have evolved over the last 50 years. Consensus guidelines and newly approved biologic treatment have enabled pediatricians to better understand this disease and allow for more targeted treatment for patients. We describe the definition, presentation, diagnosis, management, and treatment in addition to the challenges and future directions of eosinophilic esophagitis management in children.
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Affiliation(s)
- Ahmed Elghoudi
- Department of Pediatric, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Doaa Zourob
- Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Eman Al Atrash
- Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Fatima Alshamsi
- Pediatric Residency Program, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Manal Alkatheeri
- Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Hassib Narchi
- College of Medicine and Health Sciences, United Arab Emirates University, Alain, Abu Dhabi, United Arab Emirates
| | - Rana Bitar
- Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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12
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Quinn LA, Burger C, Nguyen B, Arnold MA, Pan Z, Furuta GT, Bauer ME, Menard-Katcher C. Natural Histories and Disease Complications in a Cohort of 151 Children With Gastric or Duodenal Eosinophilia. Am J Gastroenterol 2024:00000434-990000000-00972. [PMID: 38174865 DOI: 10.14309/ajg.0000000000002644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Eosinophilic gastritis (EoG) and duodenitis (EoD) are rare conditions that are poorly understood. Our aim was to describe the natural history of children with varying degrees of gastric or duodenal eosinophilia with respect to disease complications and histologic and endoscopic longitudinal trajectories. METHODS The electronic medical record at a tertiary children's hospital was queried to identify patients with EoG, EoD, or EoG + EoD who were cared for between January 2010 and 2022. Multiple logistic regression was performed to explore associations between baseline features and persistence/recurrence of eosinophilia or complications remote from diagnosis. RESULTS We identified 151 patients: 92 with EoG, 24 with EoD, 12 with EoG + EoD, and 23 with tissue eosinophilia but did not meet histologic criteria for EoG or EoD (low grade). The average age at diagnosis was 10.6 years, and average follow-up was 5.8 years. Twenty-five percent of patients with EoG or EoD had persistence/recurrence of eosinophilia; this was associated with increases in the EoG Endoscopic Reference Score (adjusted odds ratio [aOR] 1.34, confidence interval [CI] 1.03-1.74) on diagnostic endoscopy. Eighteen percent suffered from disease complications, and development of late complications was associated with presenting with a complication (aOR 9.63, CI 1.09-85.20), severity of duodenal endoscopic abnormalities (aOR 8.74, CI 1.67-45.60), and increases in the EoG Endoscopic Reference Score (aOR 1.70, CI 1.11-2.63). DISCUSSION Patients with gastric and duodenal eosinophilia should be followed closely to monitor for recurrence and complications, especially those presenting with endoscopic abnormalities or complications.
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Affiliation(s)
- Laura A Quinn
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cassandra Burger
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Brian Nguyen
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael A Arnold
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Pathology and Laboratory Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Zhaoxing Pan
- Child Health Biostatistics Core, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Maureen E Bauer
- Gastrointestinal Eosinophilic Diseases Program, Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Calies Menard-Katcher
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, Colorado, USA
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13
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Shalem T, Cohen DL, Epstein-Rigbi N, Elizur A, Eindor-Abarbanel A, Broide E, Richter V. Proton pump inhibitors in eosinophilic esophagitis (EoE) related to oral immunotherapy: is it as effective as in other EoE? Eur J Pediatr 2023; 182:5409-5416. [PMID: 37750913 DOI: 10.1007/s00431-023-05228-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/07/2023] [Accepted: 09/17/2023] [Indexed: 09/27/2023]
Abstract
Oral immunotherapy (OIT) may induce eosinophilic esophagitis (EoE). Proton pump inhibitors (PPIs) are an effective treatment for EoE. However, the effect of PPI treatment is not well established in patients with EoE induced by OIT. Our primary aim was to compare the clinical, endoscopic, and histological response rates to PPIs in children with EoE induced by OIT (EoE+OIT) versus EoE patients without OIT (EoE-OIT). The secondary aims are to describe the clinical and histological features of EoE+OIT. Demographic, clinical, endoscopic, and histological findings of patients with EoE in the gastroenterology clinic at Shamir Medical Center between March 2015 and December 2022 were collected. Comparisons were performed between EoE+OIT and EoE-OIT patients. The study included 42 children (74% male, mean age 11.2), of whom 31 had EoE-OIT and 11 had EoE+OIT. There were no significant differences between groups regarding sex, comorbidities, symptoms, or endoscopic and histological characteristics at diagnosis. All 42 children were treated with PPIs after diagnosis with or without diet changes. The rates of any clinical response were 83.9% and 90.1% in the EoE-OIT group and EoE+OIT group, respectively (p = 1.0). The rate of any endoscopic response was 74.2% for EoE-OIT and 81.8% for EoE+OIT (p = 0.54). Histologically, PPIs were even more effective in the EoE+OIT group, where only 18.2% had no histological response at all compared to 51.6% in the EoE-OIT group (p = 0.1). CONCLUSION PPI treatment is as effective in EoE with OIT as it is in EoE due to other etiologies. WHAT IS KNOWN • Proton pump inhibitor (PPI) treatment is effective for achieving clinical response and histologic remission in some patients with eosinophilic esophagitis (EoE). • EoE has also been reported to be triggered by oral immunotherapy (OIT). WHAT IS NEW • PPI treatment in EoE with OIT is as effective as treatment for EoE due to other etiologies.
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Affiliation(s)
- Tzippora Shalem
- The Jecheskiel Sigi Gonczarowski Pediatric Gastroenterology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
| | - Daniel L Cohen
- The Gonczarowski Family Institute of Gastroenterology and Liver Disease, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
| | - Na'ama Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Eindor-Abarbanel
- The Jecheskiel Sigi Gonczarowski Pediatric Gastroenterology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
| | - Efrat Broide
- The Jecheskiel Sigi Gonczarowski Pediatric Gastroenterology Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
- The Gonczarowski Family Institute of Gastroenterology and Liver Disease, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vered Richter
- The Gonczarowski Family Institute of Gastroenterology and Liver Disease, Shamir (Assaf Harofeh) Medical Center, Zerifin, 70300, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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14
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Casabona Francés S, Ruiz de León San Juan A, Sanz García A, Ortega Rabbione GJ, Majano P, Pérez Fernández MT, Lucendo AJ, Santander C. Esophageal biomechanics assessed by impedance planimetry (EndoFLIPTM) in healthy subjects and in patients with eosinophilic esophagitis. Normality values. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:693-699. [PMID: 37449498 DOI: 10.17235/reed.2023.9560/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND active eosinophilic esophagitis is associated with esophageal caliber, distensibility and motility changes that may be reversed with treatment. OBJECTIVES to study esophageal diameter, distensibility and contractility in healthy subjects compared to patients with eosinophilic esophagitis, both before and after treatment. METHODS a quasi-experimental study, EndoFLIP™, was used to analyze the esophageal body and esophago-gastric junction (EGJ) in all three groups, and a program was designed to obtain esophageal diameter, distensibility and contractility values. RESULTS ten healthy volunteers (24-61 years, six men) and nine patients with eosinophilic esophagitis (21-52 years, seven men) were included. The esophagogastric junction distensibility index was 5.07 mm2/Hg in the control subjects, 2.40 mm2/Hg in the subjects with eosinophilic esophagitis before treatment and 2.46 mm2/Hg after treatment. The distensibility plateau was 20.02 mm, 15.43 mm and 17.41 mm, respectively, and the diameter was 21.90 mm, 17.73 mm and 18.30 mm, showing significant differences (p < 0.05), except between control subjects and patients after treatment (p = 0.079). Repetitive antegrade contractions developed in 90 % of control subjects, 66.7 % of eosinophilic esophagitis patients before treatment and 88.9 % of the latter after treatment (p > 0.05). CONCLUSIONS esophago-gastric junction distensibility index, distensibility plateau and diameter values were higher in controls than in patients, although six weeks of treatment seems a short period to observe significant changes in esophageal biomechanics. Repetitive antegrade contractions are the predominant pattern in healthy subjects and eosinophilic esophagitis. We provide normality values for esophageal biomechanics, measured by impedance planimetry in our setting.
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Affiliation(s)
| | | | - Ancor Sanz García
- Unidad de Análisis de Datos, Instituto de Investigación Sanitaria Princesa (IIS-IP)
| | | | - Pedro Majano
- Aparato Digestivo, Hospital Universitario de La Princesa
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15
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Marasco G, Visaggi P, Vassallo M, Fiocca M, Cremon C, Barbaro MR, De Bortoli N, Bellini M, Stanghellini V, Savarino EV, Barbara G. Current and Novel Therapies for Eosinophilic Gastrointestinal Diseases. Int J Mol Sci 2023; 24:15165. [PMID: 37894846 PMCID: PMC10607071 DOI: 10.3390/ijms242015165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023] Open
Abstract
Eosinophilic gastrointestinal diseases (EGIDs) are an emerging group of pathological entities characterized by an eosinophil-predominant infiltration of different tracts of the gut in the absence of secondary causes of eosinophilia. According to the specific tract of the gut involved, EGIDs can be classified into eosinophilic esophagitis (EoE), eosinophilic gastritis (EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC). The epidemiology of EGIDs is evolving rapidly. EoE, once considered a rare disease, now has an incidence and prevalence of 7.7 new cases per 100,000 inhabitants per years and 34.4 cases per 100,000 inhabitants per year, respectively. Fewer data are available regarding non-EoE EGIDs, whose prevalence are estimated to range between 2.1 and 17.6 in 100,000 individuals, depending on age, sex, and ethnicity. Diagnosis requires the presence of suggestive symptoms, endoscopic biopsies showing abnormal values of eosinophils infiltrating the gut, and exclusion of secondary causes of eosinophilia. EoE typically presents with dysphagia and episodes of food bolus impactions, while EoG, EoN, and EoC may all present with abdominal pain and diarrhea, with or without other non-specific symptoms. In addition, although different EGIDs are currently classified as different entities, there may be overlap between different diseases in the same patient. Despite EGIDs being relatively novel pathological entities, the research on possible treatments is rapidly growing. In this regard, several randomized controlled trials are currently ongoing to investigate novel molecules, including ad-hoc steroid formulations, immunosuppressants, and mostly monoclonal antibodies that target the specific molecular mediators of EGIDs. This narrative review provides an up-to-date overview of available and investigational drugs for different EGIDs.
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Affiliation(s)
- Giovanni Marasco
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.M.); (M.V.); (M.F.); (C.C.); (M.R.B.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Risorgimento 36, 56126 Pisa, Italy; (P.V.); (N.D.B.); (M.B.)
| | - Mariagiulia Vassallo
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.M.); (M.V.); (M.F.); (C.C.); (M.R.B.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Miriam Fiocca
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.M.); (M.V.); (M.F.); (C.C.); (M.R.B.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.M.); (M.V.); (M.F.); (C.C.); (M.R.B.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Maria Raffaella Barbaro
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.M.); (M.V.); (M.F.); (C.C.); (M.R.B.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Nicola De Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Risorgimento 36, 56126 Pisa, Italy; (P.V.); (N.D.B.); (M.B.)
| | - Massimo Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Risorgimento 36, 56126 Pisa, Italy; (P.V.); (N.D.B.); (M.B.)
| | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.M.); (M.V.); (M.F.); (C.C.); (M.R.B.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
| | - Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Via Giustiniani 2, 35128 Padua, Italy;
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
| | - Giovanni Barbara
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (G.M.); (M.V.); (M.F.); (C.C.); (M.R.B.); (V.S.)
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti, 9, 40138 Bologna, Italy
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16
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Dutta AK, Jain A, Jearth V, Mahajan R, Panigrahi MK, Sharma V, Goenka MK, Kochhar R, Makharia G, Reddy DN, Kirubakaran R, Ahuja V, Berry N, Bhat N, Dutta U, Ghoshal UC, Jain A, Jalihal U, Jayanthi V, Kumar A, Nijhawan S, Poddar U, Ramesh GN, Singh SP, Zargar S, Bhatia S. Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship. Indian J Gastroenterol 2023; 42:601-628. [PMID: 37698821 DOI: 10.1007/s12664-023-01428-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/10/2023] [Indexed: 09/13/2023]
Abstract
Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.
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Affiliation(s)
- Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College and Hospital, Vellore, 632 004, India.
| | | | - Vaneet Jearth
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ramit Mahajan
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | | | - Vishal Sharma
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | | | | | - Govind Makharia
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | | | - Richard Kirubakaran
- Center of Biostatistics and Evidence Based Medicine, Vellore, 632 004, India
| | - Vineet Ahuja
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Neha Berry
- BLK Institute of Digestive and Liver Disease, New Delhi, 201 012, India
| | - Naresh Bhat
- Aster CMI Hospital, Bengaluru, 560 092, India
| | - Usha Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Uday Chand Ghoshal
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ajay Jain
- Choithram Hospital and Research Center, Indore, 452 014, India
| | | | - V Jayanthi
- Sri Ramachandra Medical College, Chennai, 600 116, India
| | - Ajay Kumar
- Institute of Digestive and Liver Diseases, BLK - Max Superspeciality Hospital, New Delhi, 201 012, India
| | | | - Ujjal Poddar
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | | | - Shivram P Singh
- Kalinga Gastroenterology Foundation, Cuttack, 753 001, India
| | - Showkat Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, 190 011, India
| | - Shobna Bhatia
- Sir H N Reliance Foundation Hospital, Mumbai, 400 004, India
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17
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Molina-Jiménez F, Ugalde-Triviño L, Arias-González L, Relaño-Rupérez C, Casabona S, Pérez-Fernández MT, Martín-Domínguez V, Fernández-Pacheco J, Laserna-Mendieta EJ, Muñoz-Hernández P, Arias-Arias Á, Cano A, Muñoz J, Lucendo AJ, Santander C, Majano P. Proteomic analysis of the esophageal epithelium reveals key features of eosinophilic esophagitis pathophysiology. Allergy 2023; 78:2732-2744. [PMID: 37287363 DOI: 10.1111/all.15779] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic non-IgE-mediated allergic disease of the esophagus. An unbiased proteomics approach was performed to investigate pathophysiological changes in esophageal epithelium. Additionally, an RNAseq-based transcriptomic analysis in paired samples was also carried out. METHODS Total proteins were purified from esophageal endoscopic biopsies in a cohort of adult EoE patients (n = 25) and healthy esophagus controls (n = 10). Differentially accumulated (DA) proteins in EoE patients compared to control tissues were characterized to identify altered biological processes and signaling pathways. Results were also compared with a quantitative proteome dataset of the human esophageal mucosa. Next, results were contrasted with those obtained after RNAseq analysis in paired samples. Finally, we matched up protein expression with two EoE-specific mRNA panels (EDP and Eso-EoE panel). RESULTS A total of 1667 proteins were identified, of which 363 were DA in EoE. RNA sequencing in paired samples identified 1993 differentially expressed (DE) genes. Total RNA and protein levels positively correlated, especially in DE mRNA-proteins pairs. Pathway analysis of these proteins in EoE showed alterations in immune and inflammatory responses for the upregulated proteins, and in epithelial differentiation, cornification and keratinization in those downregulated. Interestingly, a set of DA proteins, including eosinophil-related and secreted proteins, were not detected at the mRNA level. Protein expression positively correlated with EDP and Eso-EoE, and corresponded with the most abundant proteins of the human esophageal proteome. CONCLUSIONS We unraveled for the first time key proteomic features involved in EoE pathogenesis. An integrative analysis of transcriptomic and proteomic datasets provides a deeper insight than transcriptomic alone into understanding complex disease mechanisms.
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Affiliation(s)
- Francisca Molina-Jiménez
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
| | - Lola Ugalde-Triviño
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
| | - Laura Arias-González
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Carlos Relaño-Rupérez
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
| | - Sergio Casabona
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - María Teresa Pérez-Fernández
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Verónica Martín-Domínguez
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Jennifer Fernández-Pacheco
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Emilio José Laserna-Mendieta
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real, Spain
- Clinical Laboratory, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Ángel Arias-Arias
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Research Unit, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | - Ainara Cano
- Food Research, AZTI, Basque Research and Technology Alliance (BRTA), Parque Tecnológico de Bizkaia, Derio, Spain
| | - Javier Muñoz
- Cell Signalling and Clinical Proteomics Group, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Ikerbasque, Basque Foundation for Science, Bilbao, Spain
| | - Alfredo J Lucendo
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Cecilio Santander
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Pedro Majano
- Molecular Biology Unit, Hospital Universitario de la Princesa, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Cellular Biology, Faculty of Biology, Universidad Complutense de Madrid, Madrid, Spain
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18
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Attwood SE. Multiple inflammatory mechanisms in eosinophilic oesophagitis make it unlikely that single pathway inhibition by monoclonal biological therapies would succeed. Gut 2023; 72:1806-1807. [PMID: 37640444 DOI: 10.1136/gutjnl-2023-330590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
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19
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Zhang X, Zhang N, Wang Z. Eosinophilic esophagitis and esophageal microbiota. Front Cell Infect Microbiol 2023; 13:1206343. [PMID: 37600943 PMCID: PMC10434796 DOI: 10.3389/fcimb.2023.1206343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is an antigen-mediated chronic inflammatory disease of the esophagus, the prevalence of which has steadily increased in recent years. The pathogenesis of EoE is not yet well-defined; however, recent studies have demonstrated that the esophageal microbiota is an essential regulator of physiological and pathological processes of EoE. Currently, research on EoE and microbiota is an emerging field of study that is receiving increasing attention. Here, we review existing EoE-related esophageal microbiota studies to explore the potential mechanisms underlying esophageal microbiota-mediated EoE. The esophageal microbiome is altered in patients with EoE. Although α diversity is usually not significantly different, an increase in Haemophilus and a decrease in Firmicutes were observed in EoE patients. The role of microbiota in initiating and perpetuating inflammation is not fully understood. Current evidence suggests that the penetration of microbiota leads to the activation of epithelial cells as well as innate and adaptive immune cells, with the subsequent release of cytokines, leading to immune responses and inflammation. The involvement of toll-like receptors in EoE also supports the potential role of the microbiota in the progression of this disease. While EoE-induced inflammation can also lead to alterations in the local microbiome. Moreover, dietary modifications, proton pump inhibitors, and corticosteroids can modulate the esophageal microbiota; however, definitive conclusions about the alterations of microbes after treatment cannot be drawn. These findings provide promising avenues for future studies.
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Affiliation(s)
- Xiaohan Zhang
- Microbiota Division, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Medical School, Nankai University, Tianjin, China
| | - Nana Zhang
- Microbiota Division, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zikai Wang
- Microbiota Division, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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20
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Henriksen SD, Hansen SK, Heinesen M, Terkelsen JH, Hollænder M, Bredal K, Melgaard D, Krarup AL. The phenotype of adults with complicated eosinophilic esophagitis is dominated by a 5-year longer diagnostic delay: A population-based study of the DanEoE cohort. JGH Open 2023; 7:553-558. [PMID: 37649863 PMCID: PMC10463020 DOI: 10.1002/jgh3.12947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 06/04/2023] [Accepted: 07/05/2023] [Indexed: 09/01/2023]
Abstract
Background and Aim The DanEoE is a previously described population- and register-based cohort of 236 adult patients with eosinophilic esophagitis (EoE) in a well-defined Danish region with a population of 580 000 and free medical treatment. The aim of the study was to compare the phenotype and treatment response between EoE patients with complications to patients without complications at diagnosis. Methods A retrospective cross-sectional study of the DanEoE cohort's 236 adult EoE patients diagnosed between 2007 and 2017 in the North Denmark Region. Patients were divided into a group who had had complications (dilated or food bolus obstruction [FBO]) before or at the diagnosis, and a group without. Results At the diagnostic endoscopy, 61% had never had a complication, and 39% had either had FBO (n = 77) or been dilated (n = 15). The complicated group had the same mean age at symptom debut (37 [SD = 16] vs 37 [SD = 17] years, P = 1.0), but were diagnosed significantly later with a resulting longer diagnostic delay (13 [SD = 13] vs 7.9 [SD = 11] years, P = 0.01). Almost half of all patients were never treated to symptomatic remission (uncomplicated 40%, complicated 49%). The histological remission was not secured in the majority (uncomplicated 68%, complicated 70%). Despite this, <15% of patients with previous FBO experienced this after the diagnosis. Conclusion In the population-based DanEoE cohort, results indicated that the complicated EoE phenotype was a patient with a 5-year longer diagnostic delay. In the current study, the complication status did not predict the treatment response.
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Affiliation(s)
- Stine D Henriksen
- Department of Gastrointestinal SurgeryAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Clinical Cancer Research CenterAalborg University HospitalAalborgDenmark
| | - Stine K Hansen
- Department of Gastroenterology and HepatologyAalborg University HospitalAalborgDenmark
| | - Mia Heinesen
- Department of Emergency Medicine and Trauma CenterAalborg University HospitalAalborgDenmark
| | - Jacob H Terkelsen
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of Emergency Medicine and Trauma CenterAalborg University HospitalAalborgDenmark
| | - Martin Hollænder
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of Emergency Medicine and Trauma CenterAalborg University HospitalAalborgDenmark
| | - Kasper Bredal
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of Emergency Medicine and Trauma CenterAalborg University HospitalAalborgDenmark
| | - Dorte Melgaard
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- North Denmark Regional HospitalHjørringDenmark
- Mech‐Sense, Department of Gastroenterology and HepatologyAalborg University HospitalAalborgDenmark
| | - Anne L Krarup
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of Gastroenterology and HepatologyAalborg University HospitalAalborgDenmark
- Department of Emergency Medicine and Trauma CenterAalborg University HospitalAalborgDenmark
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21
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Melgaard D, Hansen AB, Pedersen C, Sandholm E, Hansen TB, Frandsen LT, Krarup AL. An improved guideline adherence and PPI efficacy has been accompanied by a decrease in diagnostic delay, and strictures before diagnosis of eosinophilic esophagitis in the North Denmark Region - a retrospective registry study of the DanEoE cohorts. Clin Res Hepatol Gastroenterol 2023; 47:102159. [PMID: 37307949 DOI: 10.1016/j.clinre.2023.102159] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND In the North Denmark Region an increased awareness of eosinophilic esophagitis (EoE) was observed after 2011 where a regional biopsy guideline was implemented. This resulted in an increased awareness of EoE and a 50-fold increase in the incidence of EoE patients between 2007-2017. AIMS The aims of this study were to examine the progress in diagnostic delay, complications, PPI treatment, and follow up since 2017 in Danish patients with eosinophilic esophagitis. MATERIALS AND METHODS This was a retrospective registry- and population-based cohort study (DanEoE2 cohort) including 346 adult patients with esophageal eosinophilia diagnosed between 2018-2021 in the North Denmark Region. The DanEoE2 cohort included all possible EoE patients by using the Danish Patho-histology registry based on the SNOMED-system. The data was analyzed and compared to the DanEoE cohort (2007-2017). RESULTS The diagnostic delay of EoE patients diagnosed between 2018-2021 in the North Denmark Region had decreased with a median of 1.5 years (5.5 (2.0;12) years versus 4.0 (1.0;12) years, p=0.03). Strictures before diagnosis had decreased 8.4 % (11.6% versus 3.2%, p=0.003). The number of patients started on high-dose PPI increased (56% versus 88%, p<0.001). An intensified awareness regarding national guidelines and follow-up was observed as an increase in the number of histological follow up (67% versus 74%, p=0.05). CONCLUSIONS Comparisons of the DanEoE cohorts showed a decrease in diagnostic delay, a decrease in stricture formation before diagnosis, and an improved guideline adherence after 2017. Future studies are needed to assess if symptomatic or histological remission on PPI treatment is more capable of predicting a patient's risk of developing complications.
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Affiliation(s)
- Dorte Melgaard
- MechSense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Hobrovej 18-22, Aalborg 9000, Denmark; Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, Aalborg 9000, Denmark
| | - Amalie Byrholdt Hansen
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, Aalborg 9000, Denmark
| | - Camilla Pedersen
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, Aalborg 9000, Denmark
| | - Elise Sandholm
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, Aalborg 9000, Denmark
| | - Tanja Bech Hansen
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, Aalborg 9000, Denmark
| | - Line Tegtmeier Frandsen
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Hobrovej 18-22, Aalborg 9000, Denmark
| | - Anne Lund Krarup
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, Aalborg 9000, Denmark; Department of Gastroenterology and Hepatology, Aalborg University Hospital, Hobrovej 18-22, Aalborg 9000, Denmark; Department of Emergency Medicine and Trauma Center, Aalborg University Hospital, Hobrovej 18-22, Aalborg 9000, Denmark.
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22
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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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23
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Molina-Infante J, Mata-Romero P, Martín-Holgado D. New approaches to diet therapy for eosinophilic esophagitis. Curr Opin Gastroenterol 2023; 39:315-319. [PMID: 37097832 DOI: 10.1097/mog.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
PURPOSE OF REVIEW An empiric step-up (2-4-6) elimination diet remains the most common dietary approach in clinical practice when treating eosinophilic esophagitis (EoE). However, research in this field has fallen behind pharmacological therapy. This review aims to summarize novel approaches to dietary therapy for EoE. RECENT FINDINGS A first prospective multicenter study in 41 pediatric patients (mean age 9 years) has evaluated the efficacy of a cow's milk elimination diet. This dietary approach led to histological remission in 51% of patients, albeit a caveat is that up to 80% of patients were receiving concomitant therapy with proton pump inhibitors. In a series of 18 adult patients with documented milk-induced EoE, ingestión of 400 ml of sterilized milk (boiled for up to 20 min) daily for 8 weeks did not induce histologic relapse in two-thirds of patients. SUMMARY Milk elimination diet is effective in one-half of pediatric EoE patients and should likely be the first choice in children with EoE (within a step-up dietary approach). Promising data on tolerance of sterilized milk in adults with milk-induced EoE (66%) merit further replication in children, which may radically improve quality of life for patients and their caregivers.
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Affiliation(s)
- Javier Molina-Infante
- Department of Gastroenterology, Hospital Universitario de Cáceres, Cáceres
- Centro de Investigacion Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Pilar Mata-Romero
- Department of Gastroenterology, Hospital Universitario de Cáceres, Cáceres
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Leiman DA, Kamal AN, Otaki F, Bredenoord AJ, Dellon ES, Falk GW, Fernandez-Becker NQ, Gonsalves N, Hirano I, Katzka DA, Peterson K, Yadlapati R, Kathpalia P. Quality Indicators for the Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol 2023; 118:1091-1095. [PMID: 36599135 PMCID: PMC10392038 DOI: 10.14309/ajg.0000000000002138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/21/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Despite best practice recommendations for managing eosinophilic esophagitis (EoE), variation in care exists. METHODS We used established methodology for quality indicator development to identify metrics to define quality for the treatment of EoE. RESULTS Among 29 proposed quality indicator statements, 9 (31%) were adopted as highly valid across all categories. Two (22%) of these statements were identified as having existing or suspected quality gaps. DISCUSSION We identified highly valid EoE quality indicators for adult gastroenterologists, which can be used for quality improvement with resulting benefits for patient outcomes.
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Affiliation(s)
- David A. Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Afrin N. Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Albert J. Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania, USA
| | - Nielsen Q. Fernandez-Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David A. Katzka
- Division of Gastroenterology, Columbia University Medical Center, New York, New York, USA
| | | | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
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25
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Miehlke S, Arnim UV, Schlag C, Labenz J, Madisch A. [Treatment of eosinophilic esophagitis - advancements and perspectives]. Laryngorhinootologie 2023; 102:339-348. [PMID: 37141876 DOI: 10.1055/a-1861-7152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
In recent years significant progress has been made in the treatment of eosinophilic esophagitis (EoE), especially in the area of topical corticosteroids. Novel EoE-specific formulations have been developed and first approvals have been obtained for induction and maintenance of remission in adult EoE patients with the orodispersible budesonide tablet in Germany and other European and non-EU countries. A novel budesonide oral suspension is currently under priority review by the FDA for first approval in the U.S. In contrast, the scientific evidence on the efficacy of proton pump inhibitors remains limited. Moreover, new biologicals have been identified which showed promising results in phase 2 trials and are now being studied in phase 3. This article aims to summarize and discuss recent advances and perspectives in the treatment of EoE.
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Affiliation(s)
- Stephan Miehlke
- Magen-Darm-Zentrum, Facharztzentrum Eppendorf, Hamburg, Germany
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology and Infectious diseases, Universitätsklinikum Magdeburg AöR, Magdeburg, Germany
| | - Christoph Schlag
- Second medical department, Klinikum rechts der Isar der Technischen Universität München, Munchen, Germany
| | - Joachim Labenz
- Medizinische Klinik, Ev. Jung-Stilling Krankenhaus, Siegen, Germany
| | - Ahmed Madisch
- Department of Internal Medicine, Siloah Hospital, Hannover, Germany
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26
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Proton Pump Inhibitor Therapy in Pediatric Eosinophilic Esophagitis: Predictive Factors and Long-Term Step-Down Efficacy. J Pediatr Gastroenterol Nutr 2023; 76:191-198. [PMID: 36416845 DOI: 10.1097/mpg.0000000000003660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the short- and long-term efficacy of proton pump inhibitor (PPI) therapy for pediatric eosinophilic esophagitis (EoE) in real-world practice with a step-down strategy, and to evaluate factors predictive of PPI responsiveness. METHODS We collected data regarding the efficacy of PPIs during this cross-sectional analysis of the prospective nationwide RENESE registry. Children with EoE treated with PPI monotherapy were included. Histological remission was defined as a peak eosinophilic count of <15 eosinophils (eos)/high-power field (hpf). Factors associated with PPI responsiveness were identified using multivariate logistic regression analysis. RESULTS After induction therapy, histological and clinico-histological remission were observed in 51.4% (n = 346) and 46.5% of children, respectively. Normal endoscopic appearance of the esophagus was associated with a higher possibility [odds ratio (OR), 9.20; 95% confidence interval (CI), 2.10-40.16], and fibrostenotic phenotype was associated with a lower possibility (OR, 0.36; 95% CI, 0.18-0.74) of histological remission. Long-term therapy with a step-down strategy effectively maintained histological remission in 68.5% and 85.3% of children at 7 months (n = 108) and 16 months (n = 34), respectively. Complete initial histological remission (≤5 eos/hpf) was associated with a higher possibility of sustained histological remission (OR, 5.08; 95% CI, 1.75-14.68). Adverse events were infrequent and mild. CONCLUSIONS We confirmed the efficacy of PPIs for a large cohort of children with EoE with sustained histological remission using a step-down strategy. Children with fibrostenotic phenotypes are less likely to respond to induction therapy. Furthermore, patients with complete initial histological remission are more likely to experience long-term histological remission.
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27
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Visaggi P, Baiano Svizzero F, Savarino E. Food elimination diets in eosinophilic esophagitis: Practical tips in current management and future directions. Best Pract Res Clin Gastroenterol 2023; 62-63:101825. [PMID: 37094908 DOI: 10.1016/j.bpg.2023.101825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/16/2023] [Indexed: 04/26/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, antigen-mediated disease of the esophagus characterized by symptoms of esophageal dysfunction and an eosinophil-predominant inflammation. Seminal reports identified the role of food allergens in the pathogenesis of the disease by demonstrating that food avoidance could lead to the resolution of esophageal eosinophilia in EoE patients. Although pharmacological treatments for EoE are increasingly being investigated, the exclusion of trigger foods from the diet still represents a valuable option for patients to achieve and maintain disease remission without drugs. Food elimination diets are variegated, and one size does not fit all. Accordingly, before starting any elimination diet, patients' characteristics should be thoroughly evaluated, and a rigorous management plan should be defined. This review provides practical tips and considerations to succeed in the management of EoE patients undergoing food elimination diets, as well as recent advances and future perspectives on food avoidance strategies.
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Affiliation(s)
- Pierfrancesco Visaggi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.
| | - Federica Baiano Svizzero
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
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28
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Mechanisms and clinical management of eosinophilic oesophagitis: an overview. Nat Rev Gastroenterol Hepatol 2023; 20:101-119. [PMID: 36253463 DOI: 10.1038/s41575-022-00691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/03/2023]
Abstract
Since the first description of eosinophilic oesophagitis (EoE) less than three decades ago, we have observed a striking increase in the number of patients diagnosed with EoE and the understanding of its clinical and immunopathogenic background. Nonetheless, a plethora of open questions await elucidation. In this Review, we discuss the current state of knowledge regarding the underlying mechanisms, particularly environmental factors and their interaction with genetic susceptibility. Subsequently, we discuss how to translate these factors into the diagnostic and therapeutic management of this chronic, immune-mediated disorder. Finally, we dissect the still long list of unmet needs, such as reasons for and handling refractory EoE and atypical clinical presentations. These open questions can guide us through future research steps and potentially foster reconsideration of the diagnostic guidelines of EoE.
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29
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Alexander JA, Ravi K, Symrk TC, Wu TT, Lavey CJ, Geno D, Johnson AJ, Lennon RJ, Collins MH, Dellon ES, Katzka DA. Use of the Esophageal Sponge in Directing Food Reintroduction in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2023; 21:299-306.e3. [PMID: 35697266 DOI: 10.1016/j.cgh.2022.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/18/2022] [Accepted: 05/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND & AIMS Dietary therapy is successful in eosinophilic esophagitis (EoE) but requires multiple upper endoscopies. The aim of this study was to determine if food reintroduction in EoE can be directed by minimally-invasive esophageal sponge cytology. METHODS In this prospective non-blinded trial, 22 responders to 6-food elimination diets underwent sequential food reintroduction guided by esophageal sponge cytology. Foods were reintroduced followed by unsedated esophageal sponge cytology assessment. A food trigger was defined by sponge cytology peak eosinophil count of ≥15 eos/high-powered field (hpf). Symptoms (EoE symptom activity index [EEsAI]), endoscopic score (EoE endoscopic reference score [EREFS]), and biopsy histology (peak eosinophil count) were collected pre-dietary therapy and post-dietary therapy, and then 4 weeks post food reintroduction. RESULTS The EEsAI and EREFS were similar post-dietary therapy to post-food reintroduction: 12.0 (interquartile range [IQR], 0.0-27.0) vs 16.5 (IQR, 9.0-28.8) (P = .265) and 1.5 (IQR, 0.2-3.0) vs 1.0 (IQR, 0.0-2.0) (P = .185). However, the peak eosinophil count was increased post-food reintroduction compared with post-dietary therapy: 20.0 (IQR, 5.0-51.5) vs 2.0 (IQR, 1.0-4.0) (P < .001), suggesting a failure of identification of all food triggers. The peak eosinophil count was lower post-food reintroduction compared with pre-dietary therapy: 20.0 (IQR, 5.0-51.5) vs 52.0 (IQR, 30.8-76.2) (P = .008). At the post food reintroduction evaluation, sponge cytology and biopsy histology were in agreement in 59% (13/22) of cases using a cutoff of <15 eos/hpf and 68% (15/22) of cases using a cutoff of <6 eos/hpf. CONCLUSIONS In the first study to evaluate a non-endoscopic technique in the clinical management of EoE, the esophageal sponge was moderately successful at guiding food reintroduction in EoE dietary responders in the outpatient setting. CLINICALTRIALS gov, Number NCT02599558.
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Affiliation(s)
- Jeffrey A Alexander
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Karthik Ravi
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Thomas C Symrk
- Department of Pathology, Mayo Clinic, Rochester, Minnesota
| | - Tsung-The Wu
- Department of Pathology, Mayo Clinic, Rochester, Minnesota
| | - Crystal J Lavey
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Debra Geno
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Alyssa J Johnson
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ryan J Lennon
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Evan S Dellon
- Department of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina
| | - David A Katzka
- Department of Gastroenterology, Columbia University Medical Center, New York, New York
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30
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Kinoshita Y, Yahata S, Oouchi S. Eosinophilic Gastrointestinal Diseases: The Pathogenesis, Diagnosis, and Treatment. Intern Med 2023; 62:1-10. [PMID: 34670903 PMCID: PMC9876718 DOI: 10.2169/internalmedicine.8417-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic gastrointestinal diseases are delayed-type chronic allergic disorders that show gastrointestinal eosinophil dense infiltration, with an exaggerated Th2-type immune reaction considered to be an important mechanism. These diseases can be roughly divided into two types: eosinophilic esophagitis, mainly found in young and middle-aged men, and eosinophilic gastroenteritis, which is found in both genders equally. A diagnosis of eosinophilic esophagitis is suspected when characteristic endoscopic findings, including longitudinal furrows and rings, are noted. However, characteristic endoscopic abnormalities are rarely found in cases with eosinophilic gastroenteritis, so multiple biopsy sampling from the apparently normal gastrointestinal mucosal surface is important for making an accurate diagnosis. The administration of systemic glucocorticoid is the standard treatment for eosinophilic gastroenteritis, while acid inhibitors and topical glucocorticoid swallowing therapy are effective for eosinophilic esophagitis. Anti-cytokine therapies for eosinophilic gastrointestinal diseases are currently under development.
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Affiliation(s)
- Yoshikazu Kinoshita
- Department of Medicine, Hyogo-Brain and Heart Center at Himeji, Japan
- Department of Medicine, Steel Memorial Hirohata Hospital, Japan
| | - Shinsuke Yahata
- Department of Medicine, Steel Memorial Hirohata Hospital, Japan
| | - Sachiko Oouchi
- Department of Medicine, Steel Memorial Hirohata Hospital, Japan
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31
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Assessment of Esophageal Motility in Patients With Eosinophilic Esophagitis: A Scoping Review. J Clin Gastroenterol 2023; 57:10-30. [PMID: 36504227 DOI: 10.1097/mcg.0000000000001792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/08/2022] [Indexed: 12/15/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated condition causing esophageal symptoms, particularly dysphagia. Despite the important progress in the treatment of EoE, a significant proportion of patients continue to report symptoms that negatively impact quality of life. Esophageal manometry is used to assess motility and function, but is not routinely used in EoE. We aimed to systematically review and describe current literature evaluating esophageal manometry in EoE. Forty-eight studies meeting the criteria were identified, describing 802 patients. Using standard water swallow protocols, the proportion of abnormalities detected was not dissimilar to other populations, apart from disorders of esophago-gastric outflow, which were found in 5%. Twelve studies described pretreatment and posttreatment manometry, with motility normalization after pharmacological therapy reported in 20%. Early, brief panesophageal pressurization was described in a number of studies and was more prevalent in the few studies utilizing additional provocation testing. Reports in the literature regarding temporal relationships between manometric findings and symptoms are variable. Esophageal manometry may be capable of detecting clinically relevant changes to esophageal function in EoE. Possible mechanisms are altered neuromuscular function because of secretory products of EoE and/or fibroinflammatory processes, manifesting as pressurization because of altered esophageal compliance. Some changes may be reversible with therapy. Drawing strong conclusions from the literature is difficult, with bias toward case reports and retrospective observation. Adaptations to assessment protocols to include provocation testing may provide more robust evaluation and detect clinically relevant, subtle changes in esophageal function, earlier within the patient pathway.
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32
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Montoro-Huguet MA. Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus. Nutrients 2022; 14:nu14224819. [PMID: 36432505 PMCID: PMC9697263 DOI: 10.3390/nu14224819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/06/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett's esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.
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Affiliation(s)
- Miguel A. Montoro-Huguet
- Unit of Gastroenterology, Hepatology & Nutrition, University Hospital San Jorge, 22005 Huesca, Spain;
- Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain
- Aragón Health Sciences Institute (IACS), 50009 Zaragoza, Spain
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33
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Schreiner P, Safroneeva E, Schoepfer A, Greuter T, Biedermann L, Schlag C, Labenz J, Auth MKH, Bredenoord AJ, Chang JW, Bonis PA, Rothenberg ME, Collins MH, Hirano I, Gupta SK, Katzka DA, Dellon ES, Straumann A, Furuta GT, Gonsalves N. Management of eosinophilic esophagitis associated food impaction in Europe and the United States. Dis Esophagus 2022; 35:6516224. [PMID: 35088073 DOI: 10.1093/dote/doac003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is the most common cause of esophageal food impaction (EFI). Approaches to management of EFI due to EoE have not been well characterized. We conducted a web-based survey to understand approaches to management of EFI due to EoE among endoscopists. Questions focused on management of patients from presentation to post-endoscopy follow-up. The survey was administered to a list of eligible candidates provided by societies of gastroenterology. A total of 308 endoscopists completed the questionnaire. The majority (83%) practiced in Europe and treated adults (78%). Most agreed patients should be advised to seek emergency care (66%) within 1 to 2 hours (41% agreement). There was agreement that medications to induce vomiting should be avoided (84%) and that blood tests or imaging studies were usually not required before endoscopy. By contrast, there was more variability in the type of sedation recommended and the need for endotracheal intubation, especially when comparing more experienced with less experienced EoE-endoscopists. Overall, fewer than half (43%) respondents recommended obtaining esophageal biopsies during the initial endoscopy. However, there were significant differences in the proportion who recommended biopsies based on level of EoE-experience (25, 52, 77%, P < 0.001; less vs. moderate vs. very experienced) and comparing pediatric and adult endoscopists (32, vs. 79%, P < 0.001; adult vs. pediatric). There exists heterogeneity among endoscopists in recommendations to manage EFI in patients with EoE. These findings support development of clinical guidelines and new studies to clarify the rationale for best practices. Key summary: Established knowledge-The optimal management of patients with esophageal food impaction due to eosinophilic esophagitis from presentation at the emergency department to postendoscopy care is unclear. New findings-Considerable recommendation variation exists in the management of EFI in patients with EoE. Our findings provide a rationale for the creation of consensus practice guidelines and further study into best practices.
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Affiliation(s)
- Philipp Schreiner
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Luc Biedermann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Schlag
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Joachim Labenz
- Department of Medicine, Diakonie Hospital Jung- Stilling, Siegen, Germany
| | - Marcus K H Auth
- Alder Hey Children's NHS Foundation Trust and University of Liverpool, Liverpool, UK
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Peter A Bonis
- Division of Gastroenterology, Tufts University School of Medicine, Boston, MA, USA
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University/Community Health Network, Indianapolis, IN, USA
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Alex Straumann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado and Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
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Characterization of Eosinophilic Esophagitis From the European Pediatric Eosinophilic Esophagitis Registry (pEEr) of ESPGHAN. J Pediatr Gastroenterol Nutr 2022; 75:325-333. [PMID: 35706095 DOI: 10.1097/mpg.0000000000003530] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Few pediatric data on phenotypic aspects of eosinophilic esophagitis (EoE) are available. The pEEr registry was developed to prospectively characterize children with EoE from Europe and Israel. METHODS pEEr is an ongoing prospective registry enrolling children with esophageal eosinophilia (≥15 eos/HPF). Anonymized data were collected from 19 pediatric centers. Data regarding demographics, clinical manifestations, endoscopy, histology, and therapies were collected. RESULTS A total of 582 subjects (61% male) were analyzed. The median age at diagnosis was 10.5 years [interquartile range (IQR): 5.7-17.7], whereas the age at symptom onset was 9.2 years (IQR: 4.3-16.4), resulting in a median diagnostic delay of 1.2 years (IQR: 0.7-2.3). The diagnostic delay was longer below age <6 years. Shorter diagnostic delays were associated with the presence of food allergy or a family history for EoE. Symptoms varied by age with dysphagia and food impaction more common in adolescents, while vomiting and failure to thrive more common in younger children ( P < 0.001). Among endoscopic findings, esophageal rings were more common in adolescents, whereas exudates were more frequent in younger children( P < 0.001). Patients who responded to proton pump inhibitors (PPIs) were more likely to be older, males, and less often presented severe endoscopic findings. Patients unresponsive to PPIs received topical steroids (40%), elimination diet (41%), or a combined therapy (19%). CONCLUSIONS EoE findings vary according to age in pediatric EoE. Young children are commonly characterized by non-specific symptoms, atopic dermatitis, food allergy, and inflammatory endoscopic lesions. Adolescents usually have dysphagia or food impaction, fibrostenotic lesions, and a better PPI response.
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Facchin S, Calgaro M, Pandolfo M, Caldart F, Ghisa M, Vitulo N, Savarino EV. Editorial: non-invasive testing for EoE-does microbiome testing hold the key? Authors' reply. Aliment Pharmacol Ther 2022; 56:729-730. [PMID: 35879893 DOI: 10.1111/apt.17144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Sonia Facchin
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University Hospital of Padua, Padua, Italy
| | - Matteo Calgaro
- Department of Biotechnology, University of Verona, Verona, Italy
| | - Mattia Pandolfo
- Department of Biotechnology, University of Verona, Verona, Italy
| | - Federico Caldart
- Department of Medicine, Gastroenterology Unit, University of Verona, Verona, Italy
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University Hospital of Padua, Padua, Italy.,Department of Oncological Gastrointestinal Surgery, Gastroenterology Unit, S. Maria del Prato Hospital, Feltre, Italy
| | - Nicola Vitulo
- Department of Biotechnology, University of Verona, Verona, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University Hospital of Padua, Padua, Italy
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Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R, Morris D, Epstein J, Novelli MR, Hunter H, Cordell A, Hall S, Hayat JO, Kapur K, Moore AR, Read C, Sami SS, Turner PJ, Trudgill NJ. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022; 71:1459-1487. [PMID: 35606089 PMCID: PMC9279848 DOI: 10.1136/gutjnl-2022-327326] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE. METHODS The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance. RESULTS Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research. CONCLUSIONS These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.
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Affiliation(s)
- Anjan Dhar
- Gastroenterology, Darlington Memorial Hospital, Darlington, UK .,Teesside University, Middlesbrough, UK
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea University, Swansea, UK,Department of Gastroenterology, University Hospital Llandough, Llandough, UK
| | | | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
| | - Jason M Dunn
- Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
| | - Rami Sweis
- Research Department of Tissue and Energy, Division of Surgery & Interventional Science, University College London, London, UK
| | - Danielle Morris
- Department of Gastroenterology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Hannah Hunter
- Department of Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Amanda Cordell
- Trustee & Chair, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sharon Hall
- Department of Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Jamal O Hayat
- Gastroenterology, St George's Healthcare NHS Trust, London, UK
| | - Kapil Kapur
- Gastroenterology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Andrew Robert Moore
- Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Carol Read
- Medical advisor/Patient advocate, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sarmed S Sami
- Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul J Turner
- National Heart and Lung Institute Section of Allergy and Clinical Immunology, London, UK,Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
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Lucendo AJ, Molina-Infante J. Current treatment options and long-term outcomes in patients with eosinophilic esophagitis. Expert Rev Clin Immunol 2022; 18:859-872. [PMID: 35770955 DOI: 10.1080/1744666x.2022.2096591] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Dietary and pharmacological (proton pump inhibitors, swallowed topical corticosteroids) therapies are effective for induction of clinical and histological remission of eosinophilic esophagitis. However, data evaluating their long-term efficacy and safety is limited. AREAS COVERED Since eosinophilic esophagitis is chronic, clinical, endoscopic, and histological features usually recur when successful treatments are stopped. In untreated patients, persistent esophageal eosinophilic inflammation may progress to fibrostenosis over time, giving place to strictures and narrow-caliber esophagi. This article comprehensively reviews available data on long-term maintenance of eosinophilic esophagitis with pharmacological and dietary treatment. It also discusses limitations re: available literature and outlines data gaps on adherence to therapy and monitoring disease activity in the long-term. EXPERT OPINION Evidence indicates that long-term maintenance therapy may decrease the risk of esophageal stricture, food bolus impaction, and need for dilation in patients with eosinophilic esophagitis. Further knowledge on eosinophilic esophagitis phenotypes is needed to ascertain who will benefit best from sustained therapy. Unanswered questions include an adequate definition for sustained remission, best strategies for maintenance drugs and diets, enhancement of treatment adherence, and proper monitoring for long-term surveillance.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Javier Molina-Infante
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de Caceres, Caceres, Spain
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Muñoz FV, Almeida PH, Carrión-Jaramillo E, Montalvo AV. Clinical Features of Eosinophilic Esophagitis: A Single Center Experience in Ecuador. Pediatr Gastroenterol Hepatol Nutr 2022; 25:293-299. [PMID: 35903492 PMCID: PMC9284109 DOI: 10.5223/pghn.2022.25.4.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/19/2022] [Accepted: 05/19/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Data on eosinophilic esophagitis (EoE) in South America is scarce. Moreover, no studies are available in Ecuador. We evaluated the clinical, endoscopic, and histological characteristics of Ecuadorian children with EoE. METHODS Medical records of 2,711 children who underwent upper gastrointestinal endoscopy (UGE) between 2009 and 2020 at Hospital Metropolitano de Quito, Ecuador were reviewed. Esophageal mucosal biopsies were obtained from 72 patients and the features of 35 children with EoE were described. EoE was diagnosed when there were more than 15 eosinophils in the esophagus, per high power field. RESULTS EoE was diagnosed in 35 children (9.4±4.5 years) with a male predominance (74%). Abdominal pain (51.4%) and vomiting (31.4%) were dominant symptoms. A history of allergic diseases was noted in 47.1% of the children, which mainly included allergic rhinitis (37.1%) and atopic dermatitis (11.4%). The most common endoscopic findings were furrowing (82.9%) and edema (74.3%). All patients were initially treated with proton-pump inhibitors (PPIs). Those who did not respond to PPIs received steroids (5.7%) and diet therapy (5.7%), and five patients were referred to an allergist. Clinical and histological resolution was observed in 65% of the patients who underwent a second UGE after 6-8 weeks of PPI. CONCLUSION Our study describes the clinical features of pediatric EoE in Ecuador. This is the first retrospective study in Ecuador that describes the clinical, endoscopic, and histological manifestations of EoE in a small pediatric population. Almost half of the children who underwent a biopsy had EoE.
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Affiliation(s)
| | | | | | - Andrea Vásconez Montalvo
- Department of Pediatrics, Hospital Metropolitano, Universidad Internacional del Ecuador, Quito, Ecuador
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Strauss AL, Falk GW. Refractory eosinophilic esophagitis: what to do when the patient has not responded to proton pump inhibitors, steroids and diet. Curr Opin Gastroenterol 2022; 38:395-401. [PMID: 35762699 PMCID: PMC9552275 DOI: 10.1097/mog.0000000000000842] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Management for patients with refractory eosinophilic esophagitis (EoE) remains a clinical challenge. This review aims to define refractory EoE, explore rates and reasons for nonresponse, and discuss the evidence that informs the approach to these patients. RECENT FINDINGS Many patients will fail first-line therapies for EoE. Longer duration of therapy can increase response rates, and initial nonresponders may respond to alternative first-line therapies. There are ongoing clinical trials evaluating novel therapeutics that hold promise for the future of EoE management. Increasingly, there is recognition of the contribution of oesophageal hypervigilance, symptom-specific anxiety, abnormal motility and oesophageal remodelling to ongoing clinical symptoms in patients with EoE. SUMMARY For refractory EoE, clinicians should first assess for adherence to treatment, adequate dosing and correct administration. Extending initial trials of therapy or switching to an alternative first-line therapy can increase rates of remission. Patients who are refractory to first-line therapy can consider elemental diets, combination therapy or clinical trials of new therapeutic agents. Patients with histologic remission but ongoing symptoms should be evaluated for fibrostenotic disease with EGD, barium esophagram or the functional luminal imaging probe (FLIP) and should be assessed for the possibility of oesophageal hypervigilance.
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Affiliation(s)
- Alexandra L Strauss
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Dhar A, Haboubi H, Auth M, Attwood S. Eosinophilic oesophagitis: improving diagnosis and therapy - reducing the burden of repeated endoscopy. Frontline Gastroenterol 2022; 13:e51-e56. [PMID: 35812023 PMCID: PMC9234720 DOI: 10.1136/flgastro-2022-102118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/17/2022] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic oesophagitis is now being diagnosed more often, although there continues to be a significant delay in the recognition of the condition in primary care, and among patients presenting with food bolus obstruction to other specialities like Ears, Nose and Throat and Accident & Emergency. The diagnosis requires endoscopy and biopsy, with six biopsies taken from at least two different areas of the oesophagus. The diagnostic threshold is > 15 eosinophils/high power field or 0.3 mm2. Dietary management although effective is often difficult to carry out due to poor adherence by patients and the need for a specialist dietitian and repeated biopsies. Orodispersible budesonide is very effective for inducing remission and maintaining it long term, with fewer biopsies. Newer targeted biological agents are promising in the treatment of patients who have not responded to conventional treatments. Dilatation of strictures in this condition is safe.
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Affiliation(s)
- Anjan Dhar
- Gastroenterology, County Durham & Darlington NHS Foundation Trust & Teesside University, Bishop Auckland, UK
| | - Hasan Haboubi
- Gastroenterology, Cardiff and Vale NHS Trust, Cardiff, UK
| | - Marcus Auth
- Paediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust & Liverpool University, Liverpool, UK
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Savarino V, Antonioli L, Fornai M, Marabotto E, Demarzo MG, Zingone F, Ghisa M, Barberio B, Zentilin P, Ribolsi M, Savarino E. An update of pharmacology, efficacy, and safety of vonoprazan in acid-related disorders. Expert Rev Gastroenterol Hepatol 2022; 16:401-410. [PMID: 34550866 DOI: 10.1080/17474124.2021.1984878] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Patients with acid-related disorders (ARDs) of the upper digestive tract remain highly prevalent and need to be continuously investigated to improve their management. AREAS COVERED This review provides a summary of the most recent advancements in the treatment of ARDs with particular focus on the new drugs available to overcome the unmet needs of traditional therapies. EXPERT OPINION Proton pump inhibitors remain the best therapy in treating ARDs, but a consistent proportion of these patients continues to present mucosal lesions or to experience symptoms despite treatment. These cases pertain mainly to the most severe forms of erosive esophagitis or to non-erosive reflux disease. Also, the increasing rate of patients with H. pylori infection not responding to eradication therapy represents a difficult clinical condition. The recent advent of a new class of antisecretory drugs, such as the potassium competitive acid blockers and, among them the most studied vonoprazan, which are characterized by a better pharmacological profile than PPIs (rapid onset of action, longer lasting acid suppression, control of nocturnal acidity), has the potential to overcome the above-mentioned unmet needs. More research should be done to assess their efficacy in Western populations and their safety in patients treated in the long term.
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Affiliation(s)
- Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Luca Antonioli
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Matteo Fornai
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Maria Giulia Demarzo
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Mentore Ribolsi
- Gastroenterology Unit, Departmental Faculty of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Rome, Italy
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Formulations of Topical Steroids in Eosinophilic Esophagitis-Current Treatment and Emerging Possibilities. J Clin Med 2022; 11:jcm11051454. [PMID: 35268544 PMCID: PMC8910832 DOI: 10.3390/jcm11051454] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterised by eosinophilic inflammation and esophageal dysfunction symptoms. The recommended first-line treatment options are proton pump inhibitors and swallowed topical steroids (STS). However, current recommendations regarding STS are based on relatively few studies employing various doses and formulations. Our aim was to review the STS formulations currently used in the treatment of eosinophilic esophagitis, to demonstrate in a practical way the variety of exiting application methods, and to present emerging options for STS delivery to the esophagus. After the literature review, we established that the three most commonly used STS formulations include mist from an inhaler, viscous suspensions compounded with vehicles for oral use, and a recently introduced proprietary medication in the form of orodispersible tablets. Several drug delivery technologies with potential use in EoE are under investigation. To ensure optimal adherence, the choice of formulation should be based on efficacy, patient preferences and experience of the clinician, as well as current recommendations. Further studies are needed to compare the efficacy and acceptability of existing STS types, and to develop new, well-tolerated and effective drug formulations.
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Lam AY, Ma C, Lee JK, Bredenoord AJ. Eosinophilic esophagitis: New molecules, better life? Curr Opin Pharmacol 2022; 63:102183. [PMID: 35176546 DOI: 10.1016/j.coph.2022.102183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 11/03/2022]
Abstract
Eosinophilic esophagitis (EoE) is an antigen-mediated chronic T helper type 2 (Th2)-associated inflammatory disorder that has emerged in the last three decades as an increasingly common cause of esophageal symptoms. Despite rising incidence and prevalence, there are currently no approved therapies for EoE in the United States and only one oral topical corticosteroid approved in Europe and Canada. Current management relies on labor- and endoscopy-intensive dietary elimination, proton-pump inhibitors (PPIs) with only moderate efficacy, and use of inhaled or nebulized topical corticosteroids designed for asthma and limited by accessibility. Fortunately, progress in elucidating the underlying pathophysiology of EoE has led to the development of new therapies derived from molecular targets necessary for disease pathogenesis. We summarize established and emerging medical therapies for EoE, with a focus on new treatments with specific molecular targets that are likely to change EoE management paradigms in the next decade.
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Affiliation(s)
- Angela Y Lam
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA, USA
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA, USA; Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, the Netherlands.
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Lucendo AJ, Santander C, Savarino E, Guagnozzi D, Pérez-Martínez I, Perelló A, Guardiola-Arévalo A, Barrio J, Elena Betoré-Glaria M, Gutiérrez-Junquera C, Ciriza de los Ríos C, Racca F, Fernández-Fernández S, Blas-Jhon L, Lund Krarup A, de la Riva S, Naves JE, Carrión S, Rodríguez Oballe JA, García-Morales N, Tamarit-Sebastián S, Navarro P, Arias Á, Laserna-Mendieta EJ, Casabona-Francés S, Pérez-Fernández T, Llerena Castro R, Ghisa M, Manie D, Pellegatta G, Suárez A, Alcedo J, Gil Simón P, Teresa Palomeque M, Asensio T, Granja-Navacerrada A, de Mendoza Guena LH, Rodríguez Sánchez A, Masiques Mas L, Dainese R, Feo-Ortega S. EoE CONNECT, the European Registry of Clinical, Environmental, and Genetic Determinants in Eosinophilic Esophagitis: rationale, design, and study protocol of a large-scale epidemiological study in Europe. Therap Adv Gastroenterol 2022; 15:17562848221074204. [PMID: 35126668 PMCID: PMC8814964 DOI: 10.1177/17562848221074204] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/27/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The growing prevalence of eosinophilic esophagitis (EoE) represents a considerable burden to patients and health care systems. Optimizing cost-effective management and identifying mechanisms for disease onset and progression are required. However, the paucity of large patient cohorts and heterogeneity of practice hinder the defining of optimal management of EoE. METHODS EoE CONNECT is an ongoing, prospective registry study initiated in 2016 and currently managed by EUREOS, the European Consortium for Eosinophilic Diseases of the Gastrointestinal Tract. Patients are managed and treated by their responsible specialists independently. Data recorded using a web-based system include demographic and clinical variables; patient allergies; environmental, intrapartum, and early life exposures; and family background. Symptoms are structurally assessed at every visit; endoscopic features and histological findings are recorded for each examination. Prospective treatment data are registered sequentially, with new sequences created each time a different treatment (active principle, formulation, or dose) is administered to a patient. EoE CONNECT database is actively monitored to ensure the highest data accuracy and the highest scientific and ethical standards. RESULTS EoE CONNECT is currently being conducted at 39 centers in Europe and enrolls patients of all ages with EoE. In its aim to increase knowledge, to date EoE CONNECT has provided evidence on the effectiveness of first- and second-line therapies for EoE in clinical practice, the ability of proton pump inhibitors to induce disease remission, and factors associated with improved response. Drug effects to reverse fibrous remodeling and endoscopic features of fibrosis in EoE have also been assessed. CONCLUSION This prospective registry study will provide important information on the epidemiological and clinical aspects of EoE and evidence as to the real-world and long-term effectiveness and safety of therapy. These data will potentially be a vital benchmark for planning future EoE health care services in Europe.
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Affiliation(s)
| | - Cecilio Santander
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain,Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain,Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Università di Padova, Padova, Italy
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Vall d’Hebron, Barcelona, Spain,Digestive System Research Unit, Unitat de Fisiología I Fisiopatología Digestiva, Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Viladecans, Barcelona, Spain
| | - Antonio Guardiola-Arévalo
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain; Instituto de Investigación Sanitaria La Paz (IdiPAZ), Madrid, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | - Constanza Ciriza de los Ríos
- Department of Gastroenterology, Hospital Clínico San Carlos, Universidad Complutense, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Sonia Fernández-Fernández
- Pediatric Gastroenterology, Hepatology and Nutrition, University Hospital Severo Ochoa, Leganés, Spain
| | - Leonardo Blas-Jhon
- Department of Gastroenterology, University Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - Anne Lund Krarup
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Acute Medicine and Trauma Care, Aalborg University Hospital, Aalborg, Denmark,Faculty of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Susana de la Riva
- Department of Gastroenterology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan E. Naves
- Gastroenterology Unit, Hospital Universitari Germans Trias i Pujol, CIBERehd, Badalona, Spain
| | - Silvia Carrión
- Gastrointestinal Motility Laboratory, Department of Surgery, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Juan Armando Rodríguez Oballe
- Department of Gastroenterology, University Hospital Santa María and University Hospital Arnau de Vilanova, Lleida, Spain
| | | | - Sonsoles Tamarit-Sebastián
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Ángel Arias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain,Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain,Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain
| | - Emilio J. Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain,Clinical Laboratory, Hospital Universitario de La Princesa, Madrid, Spain
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45
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Franciosi JP, Mougey EB, Dellon ES, Gutierrez-Junquera C, Fernandez-Fernandez S, Venkatesh RD, Gupta SK. Proton Pump Inhibitor Therapy for Eosinophilic Esophagitis: History, Mechanisms, Efficacy, and Future Directions. J Asthma Allergy 2022; 15:281-302. [PMID: 35250281 PMCID: PMC8892718 DOI: 10.2147/jaa.s274524] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/14/2022] [Indexed: 12/11/2022] Open
Abstract
Over the past decade, the role of proton pump inhibitor (PPI) medication has evolved from a diagnostic tool for Eosinophilic Esophagitis (EoE), by excluding patients with PPI responsive esophageal eosinophilia (PPI-REE), to a therapy for EoE. This transition resulted from the Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the Appraisal of Guidelines for Research and Evaluation II (AGREE) Conference to support PPI therapy for EoE in children and adults. Additional recent advances have suggested a role for genetic variations that might impact response to PPI therapy for EoE. This review article will explore a brief background of EoE, the evolution of PPI therapy for EoE and its proposed mechanisms, efficacy and safety in children and adults, and considerations for future PPI precision medicine in patients with EoE.
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Affiliation(s)
- James P Franciosi
- Division of Gastroenterology, Nemours Children’s Hospital, Orlando, FL, USA
- College of Medicine, University of Central Florida, Orlando, FL, USA
- Correspondence: James P Franciosi, Division of Gastroenterology, Nemours Children’s Hospital, 6535 Nemours Parkway, Orlando, FL, 32827, USA, Email
| | - Edward B Mougey
- Center for Pharmacogenomics and Translational Research, Nemours Children’s Health System, Jacksonville, FL, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carolina Gutierrez-Junquera
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro-Majadahonda, Autonomous University of Madrid, Madrid, Spain
| | | | - Rajitha D Venkatesh
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine and Community Health Network, Indianapolis, IN, USA
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46
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Tamarit-Sebastian S, Ferrer-Soler FM, Lucendo AJ. Current options and investigational drugs for the treatment of eosinophilic esophagitis. Expert Opin Investig Drugs 2022; 31:193-210. [DOI: 10.1080/13543784.2022.2033207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sonsoles Tamarit-Sebastian
- Department of Gastroenterology, Hospital General de Tomelloso
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM)
| | - Francisco Miguel Ferrer-Soler
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM)
- Hospital Pharmacy, Hospital General de Tomelloso
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM)
- Hospital Pharmacy, Hospital General de Tomelloso
- Instituto de Investigación Sanitaria Princesa (IIS-IP)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)
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47
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Feo-Ortega S, Lucendo AJ. Evidence-based treatments for eosinophilic esophagitis: insights for the clinician. Therap Adv Gastroenterol 2022; 15:17562848211068665. [PMID: 35069803 PMCID: PMC8777364 DOI: 10.1177/17562848211068665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/03/2021] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. Left untreated, EoE progresses to fibrous remodeling and stricture formation that impairs quality of life. Therefore, EoE requires either repeated treatments or maintenance therapy. Current guidelines recommend swallowed topical corticosteroids (STCs), proton-pump inhibitors (PPIs), or dietary intervention as initial options to induce and maintain long-term disease remission. Impractical exclusive elemental diets and suboptimal allergy testing-directed food avoidance paved the way for empirical elimination diets. These are moderately effective and highly reproducible in inducing EoE remission and allow for identification of specific food triggers. Step-up strategies, including two- and four-food rather than six-food elimination diets, should be considered as initial approaches for dietary treatment in patients of all ages, as they reduce the need for endoscopic procedures, shorten diagnostic processing time, and avoid unnecessary restrictions. Formulations of STC originally designed for asthma therapy are suboptimal for EoE treatment, with new effervescent orodispersible tablets and viscose formulations designed to coat the esophageal mucosa providing increased effectiveness at reduced doses. The anti-inflammatory effects of PPI in EoE are independent from gastric acid secretion inhibition; despite evidence from observational research, PPIs are the most commonly prescribed first-line therapy for EoE due to their accessibility, low cost, and safety profile. Double doses of PPI only induce remission in half of EoE patients, irrespective of the drug used or patients' age. Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving EoE remission. Most responders effectively maintain long-term remission with standard PPI doses. Finally, endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. This article provides a state-of-the-art review and updated discussion of current therapies and newly developed options for EoE.
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Affiliation(s)
- Sara Feo-Ortega
- Pediatric Gastroenterology Unit, Hospital
General de Tomelloso, Tomelloso, Spain, and Instituto de Investigación
Sanitaria de Castilla-La Mancha (IDISCAM)
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Yang K, Luo RH, Sun YL. Recurrent abdominal pain, peritoneal effusion, and eosinophilia in a boy aged 17 years. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:1169-1173. [PMID: 34753550 DOI: 10.7499/j.issn.1008-8830.2107109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A boy, aged 17 years, was admitted again due to abdominal pain, diarrhea, and eosinophilia for 3 years, which worsened for 3 days. Three years ago, the boy suffered from abdominal pain and diarrhea after eating yogurt; color Doppler ultrasound showed a large amount of peritoneal effusion, and routine blood test, bone marrow cell morphology, and ascites histological examination showed a large number of eosinophils. Three days ago, he was admitted again due to abdominal pain and diarrhea. The gastrointestinal endoscopy showed eosinophil infiltration in the angle of stomach. The boy was diagnosed with eosinophilic gastrointestinal disease (eosinophilic gastroenteritis). He was improved after the treatment with glucocorticoids and dietary avoidance, and no recurrence was observed during the one-year follow-up. It is concluded that for children who attend the hospital due to gastrointestinal symptoms such as abdominal pain and diarrhea, if there is an increase in peripheral blood eosinophils, it is necessary to consider the possibility of eosinophilic gastrointestinal disease, and eosinophil infiltration and abnormal eosinophil count in gastrointestinal tissue based on endoscopic biopsy may be the key to diagnosis.
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Affiliation(s)
- Kun Yang
- Department of Pediatrics,Tai'an City Central Hospital, Tai'an, Shandong 271000, China
| | - Rong-Hua Luo
- Department of Pediatrics,Tai'an City Central Hospital, Tai'an, Shandong 271000, China
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49
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Navarro P, Laserna-Mendieta EJ, Guagnozzi D, Casabona S, Perelló A, Savarino E, de la Riva S, Olalla JM, Ghisa M, Serrano-Moya N, Alcolea-Valero C, Ortega-Rabbione G, Majano P, Santander C, Arias Á, Lucendo AJ. Proton pump inhibitor therapy reverses endoscopic features of fibrosis in eosinophilic esophagitis. Dig Liver Dis 2021; 53:1479-1485. [PMID: 34120859 DOI: 10.1016/j.dld.2021.05.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/15/2021] [Accepted: 05/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-standing inflammation leads to esophageal remodeling with stricture formation in patients with eosinophilic esophagitis (EoE). The ability of proton pump inhibitors (PPI) to reverse endoscopic features of fibrosis is still unknown. OBJECTIVE To investigate the effect of a short course of PPI treatment in reducing endoscopic findings indicative of esophageal fibrosis in EoE patients. METHODS Cross-sectional analysis of the EoE CONNECT registry. Patients who received PPI to induce EoE remission were evaluated. Endoscopic features were graded using the EoE Endoscopic Reference Score (EREFS), with rings and strictures indicating fibrosis. Results were compared to those from patients treated with swallowed topic corticosteroids (STC). RESULTS Clinico-histological remission was achieved in 83/166 adult patients treated with PPI (50%) and in 65/79 (82%) treated with STC; among responders, 60 (36%) and 57 (72%) patients respectively achieved deep histological remission (<5 eosinophils/hpf). At baseline, mean±SD EREFS was lower in patients treated with PPI compared to those who received STC (p < 0.001). Short term treatment significantly reduced EREFS scores in patients treated either with PPI or STC as well as rings and strictures. Among patients treated with PPI, deep histological remission (<5 eosinophils/hpf) provided further reduction in total EREFS score. CONCLUSION Effective PPI therapy for EoE significantly reduced endoscopic esophageal fibrosis in the short term.
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Affiliation(s)
- Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Clinical Laboratory, Hospital Universitario de La Princesa, Madrid, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Sergio Casabona
- Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Viladecans, Barcelona, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Università di Padova, Padova, Italy
| | | | - José María Olalla
- Department of Gastroenterology Clinica Universidad de Navarra, Pamplona, Spain
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, Università di Padova, Padova, Italy
| | | | | | - Guillermo Ortega-Rabbione
- Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Data Analysis Unit, Health Research Institute Hospital Universitario de la Princesa, Madrid, Spain
| | - Pedro Majano
- Research Unit, Hospital Universitario La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Cecilio Santander
- Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ángel Arias
- Research Unit, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad. Real, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
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50
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Oliva S, Dellon ES. Reversal of fibrosis in eosinophilic esophagitis: Another feather in the PPI cap? Dig Liver Dis 2021; 53:1476-1478. [PMID: 34531128 DOI: 10.1016/j.dld.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/26/2021] [Accepted: 08/10/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy.
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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