Eosinophilic oesophagitis in patients presenting with dysphagia--a prospective analysis

Endoscopic Features of Eosinophilic Esophagitis

Edema, rings, exudates, furrows, and strictures (EREFS) represent the major endoscopic features of eosinophilic esophagitis (EoE). The Endoscopic Reference System (EREFS) grading system is easy to learn and apply during daily clinical practice in the diagnosis and follow-up of EoE patients. When endoscopy is performed by an EoE-experienced physician, the EREFS criteria will identify the majority of EoE patients. The EREFS score from the area of greatest involvement of the esophagus should be reported. The EREFS grading system was formally validated as an endoscopy score and several randomized placebo-controlled trials have shown responsiveness of the EREFS score to therapeutic interventions.

Artificial Intelligence Tools for the Diagnosis of Eosinophilic Esophagitis in Adults Reporting Dysphagia: Development, External Validation, and Software Creation for Point-of-Care Use

BACKGROUND

Despite increased awareness of eosinophilic esophagitis (EoE), the diagnostic delay has remained stable over the past 3 decades. There is a need to improve the diagnostic performance and optimize resources allocation in the setting of EoE.

OBJECTIVE

We developed and validated 2 point-of-care machine learning (ML) tools to predict a diagnosis of EoE before histology results during office visits.

METHODS

We conducted a multicenter study in 3 European tertiary referral centers for EoE. We built predictive ML models using retrospectively extracted clinical and esophagogastroduodenoscopy (EGDS) data collected from 273 EoE and 55 non-EoE dysphagia patients. We validated the models on an independent cohort of 93 consecutive patients with dysphagia undergoing EGDS with biopsies at 2 different centers. Models' performance was assessed by area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV). The models were integrated into a point-of-care software package.

RESULTS

The model trained on clinical data alone showed an AUC of 0.90 and a sensitivity, specificity, PPV, and NPV of 0.90, 0.75, 0.80, and 0.87, respectively, for the diagnosis of EoE in the external validation cohort. The model trained on a combination of clinical and endoscopic data showed an AUC of 0.94, and a sensitivity, specificity, PPV, and NPV of 0.94, 0.68, 0.77, and 0.91, respectively, in the external validation cohort.

CONCLUSION

Our software-integrated models (https://webapplicationing.shinyapps.io/PointOfCare-EoE/) can be used at point-of-care to improve the diagnostic workup of EoE and optimize resources allocation.

Retrospective cohort study: Effect of age as a barrier to diagnosis of eosinophilic oesophagitis

BACKGROUND

Prior work suggests eosinophilic oesophagitis (EoE) is rare in those aged over 65 years. However, elderly patients with EoE experience a substantial diagnostic delay from symptom onset to diagnosis.

AIMS

To assess if age predicted whether oesophageal biopsies were obtained in patients with EoE symptoms, what clinical features predict EoE in the elderly, and if EoE phenotype differs between elderly and non-elderly patients.

METHODS

We conducted a retrospective cohort study utilising the University of North Carolina (UNC) electronic medical record, EoE clinicopathologic database and UNC endoscopy software from July 2008 to April 2021. A sample of 193 elderly and non-elderly patients with dysphagia, chest pain and/or heartburn were assembled. Patients with EoE were newly diagnosed per contemporaneous guidelines. Patient demographics, clinical characteristics and procedural data were extracted. Summary statistics, bivariate and multivariate analyses were performed.

RESULTS

Of 193 patients, we included 91 elderly (47%) and 102 non-elderly (53%). Age independently predicted the odds of biopsies (adjusted odds ratio (aOR): 0.44 elderly vs. non-elderly; 95% CI: 0.21-0.92). Endoscopic features of EoE, but not symptoms, were more common in elderly than non-EoE elderly patients. Elderly patients with EoE differed from non-elderly only by time to diagnosis (aOR per year of symptoms preceding diagnosis: 1.08, 95% CI: 1.04-1.11).

CONCLUSIONS

Elderly patients with EoE have <50% the odds of oesophageal biopsies. There were no significant differences between elderly and non-elderly EoE patients, although endoscopic features helped discriminate the two groups. Our findings suggest that older age represents a barrier to EoE diagnosis.

Diagnosis of Eosinophilic Esophagitis at the Time of Esophageal Food Impaction

BACKGROUND

Esophageal food impactions (EFI) often precede a diagnosis of eosinophilic esophagitis (EOE). Current guidelines suggest obtaining esophageal biopsies upon suspicion of EOE, treating with proton pump inhibitor (PPI), and repeating esophagogastroduodenoscopy (EGD). This study was conducted to determine provider practice patterns with these mentioned recommendations at the time of EFI.

METHODS

In this retrospective study, key outcomes were the proportion of patients who had EOE mucosal biopsies, EOE diagnosis, PPI initiation, and recommendations and completions of repeat EGD. Differences in outcomes among age, sex, race, off-hours time of procedure, and trainee involvement were examined. EOE diagnosis predictors were explored with logistic regression.

RESULTS

Twenty-nine percent of the patients had esophageal biopsies taken at the time of index EGD (iEGD). Sixteen patients were diagnosed with EOE at the time of index EFI, while fourteen patients were diagnosed on subsequent EGDs. Among those diagnosed with EOE at iEGD, 94% were placed on PPI. Of patients with confirmed EOE on index biopsy, 63% of patients were recommended repeat EGD, of which 50% completed it within 90 days. Older age was protective of EOE diagnosis while no GERD history and endoscopist suspicion of EOE predicted diagnosis of EOE.

CONCLUSIONS

Endoscopists uncommonly take biopsies at the time of EFI, which may delay diagnosis and treatment of EOE.

Linked color imaging improves the diagnostic accuracy of eosinophilic esophagitis

Objectives

To assess the usefulness of linked color imaging (LCI), a recently developed image‐enhanced endoscopy technique, in the endoscopic diagnosis of eosinophilic esophagitis (EoE).

Methods

Thirty white light images (WLIs) and 30 WLI+LCI images collected from patients with and without EoE were randomly and blindly reviewed by 10 endoscopists, including four experts (Exs) and six non‐Exs. Edema, ring, exudate furrows, and strictures were rated on the adjusted EoE endoscopic reference score; the diagnosis of EoE was assessed. Using the kappa value, inter‐ and intra‐observer agreements were analyzed among endoscopists.

Results

WLI+LCI images had a higher diagnostic accuracy for EoE than WLIs (0.85 vs. 0.70, respectively), especially in non‐Exs or endoscopists with no experience with EoE patients. Inter‐observer agreement for WLI+LCI images statistically surpassed WLIs for furrows (kappa, 0.73 vs. 0.67, respectively; p = 0.0013), stricture (kappa, 0.51 vs. 0.39, respectively; p = 0.0072), and diagnosis (kappa, 0.67 vs. 0.57, respectively; p < 0.0001) of EoE. The increase in inter‐observer agreement in WLI+LCI images allowed for a reduction in the differences between the Exs and non‐Ex endoscopists. Intra‐observer agreement for WLI+LCI images surpassed WLIs for a ring (kappa, 0.62 vs. 0.43, p = 0.0052), and a similar trend was found in exudates, furrows, and diagnosis irrespective of the Exs or non‐Exs.

Conclusions

LCI can contribute to the improvement of the endoscopic diagnosis for EoE, with “moderate” to “substantial” consistency, by enhancing the visibility of abnormal findings, leading to reduced diagnostic disparities among endoscopists.

Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference

Endoscopy plays a critical role in caring for and evaluating the patient with eosinophilic esophagitis (EoE). Endoscopy is essential for diagnosis, assessment of response to therapy, treatment of esophageal strictures, and ongoing monitoring of patients in histologic remission. To date, less-invasive testing for identifying or grading EoE severity has not been established, whereas diagnostic endoscopy as integral to both remains the criterion standard. Therapeutic endoscopy in patients with adverse events of EoE may also be required. In particular, dilation may be essential to treat and attenuate progression of the disease in select patients to minimize further fibrosis and stricture formation. Using a modified Delphi consensus process, a group of 20 expert clinicians and investigators in EoE were assembled to provide guidance for the use of endoscopy in EoE. Through an iterative process, the group achieved consensus on 20 statements yielding comprehensive advice on tissue-sampling standards, gross assessment of disease activity, use and performance of endoscopic dilation, and monitoring of disease, despite an absence of high-quality evidence. Key areas of controversy were identified when discussions yielded an inability to reach agreement on the merit of a statement. We expect that with ongoing research, higher-quality evidence will be obtained to enable creation of a guideline for these issues. We further anticipate that forthcoming expert-generated and agreed-on statements will provide valuable practice advice on the role and use of endoscopy in patients with EoE.

Eosinophilic Esophagitis: Cytokines Expression and Fibrotic Markers in Comparison to Celiac Disease

Introduction: Eosinophilic esophagitis (EoE) is now recognized as the main inflammatory condition that leads to fibrosis, unlike other chronic inflammatory gastrointestinal diseases, such as celiac disease. The aim of our study is to characterize the collagen deposition and cytokine expression involved in the fibrogenic response in patients affected by EoE in comparison to celiac disease. Materials and Methods: Consecutive patients with a clinical suspicion of untreated EoE or active celiac disease were enrolled. In the control group, patients with negative upper endoscopy were included. Total RNA was isolated from biopsy specimens using a commercial kit (SV Total RNA Isolation System, Promega Italia Srl). Quantitative real-time PCR (qRT-PCR) was performed in triplicate using a StepOne™ Real-Time PCR instrument (Thermo Fisher Scientific, Monza, Italy). mRNA encoding for inflammatory molecules: interleukin 4 (IL-4), interleukin 5 (IL-5), interleukin 13 (IL-13), and fibrotic markers: transforming growth factor beta 1 (TGF-β), mitogen-activated protein kinase kinase kinase 7 (MAP3K7), serpin family E member 1 (SERPINE1), were quantified using TaqMan Gene Expression Assays (Applied Biosystems). RESULTS. In EoE, the qPCR analysis showed an increase in all the inflammatory cytokines. Both IL-5 and Il-3 mRNA expression resulted in a statistically significant increase in oesophageal mucosa with respect to the celiac duodenum, while no differences were present in IL-4 expression. TGF-β expression was similar to the controls in the mid esophagus but reduced in the distal EoE esophagus (RQ: 0.46 ± 0.1). MAP3K7 expression was reduced in the mid esophagus (RQ: 0.59 ± 0.3) and increased in the distal esophagus (RQ: 1.75 ± 0.6). In turn, the expression of SERPINE1 was increased in both segments and was higher in the mid than in the distal esophagus (RQ: 5.25 ± 3.9, 1.92 ± 0.9, respectively). Collagen deposition was greater in the distal esophagus compared to the mid esophagus [18.1% ± 8 vs. 1.3% ± 1; p = 0.008]. Conclusions: The present study confirms the esophageal fibrotic involution involving the distal esophagus and shows that the inflammatory pathway in EoE is peculiar to this disease and different from other chronic inflammatory gastrointestinal disorders such as celiac disease.

Primary eosinophilic gastrointestinal disorders and allergy: Clinical and therapeutic implications

Primary eosinophilic gastrointestinal disorders (EGID) are increasingly prevalent, immune‐mediated, chronic conditions which primarily affect pediatric and young adult patients, leading to substantial disease burden, and poor quality of life. EGID may either involve single portions of the gastrointestinal tract (i.e., esophagus, stomach, small bowel, and colon) or a combination. Their strong association with allergic disorders has been recently recognized, and although their shared pathophysiological basis remains partly elusive, this feature greatly impacts the diagnostic and treatment work‐up. We herein critically discuss the current knowledge on the association of EGID and allergic disorders, including atopic dermatitis, allergic rhinitis, allergic asthma, and food or drug allergy. In particular, we reviewed the literature focusing on their epidemiology, pathophysiological basis and mechanisms, and diagnostic strategies. Finally, we discuss the currently ongoing clinical trials targeting EGID and allergic diseases, including, among others the monoclonal antibodies dupilumab, mepolizumab, benralizumab, and lirentelimab.

Incidence and evolution of foreign body impaction in the upper gastrointestinal tract and its relationship with eosionophilic oesophagitis

BACKGROUND

Foreign body impaction is a frequent indication of urgent endoscopy. One of the reasons for impaction is eosinophilic oesophagitis (EE). To analyse characteristics of oesophageal foreign body impactions and their relationship with eosinophilic oesophagitis.

METHODS

In this retrospective study, urgent endoscopies in a tertiary care centre were analysed. We included all urgent endoscopies due to bolus and foreign body impactions performed between September 1^st 2018 and September 1^st 2020. We reviewed clinical data of all patients who were diagnosed with EE and compared it to impactions that were due to other motives. The mean follow-up time was 18.7 months.

RESULTS

693 urgent endoscopy procedures were performed. 239 (34%) of these were due to foreign body ingestion. Mean age of the patients was 63 years old and 135 (63%) were men. EE was diagnosed in 36 (17%) patients. The factors associated with EE were age, to be younger than 50 years (OR, 7.3; 95% CI, 1.1-48.4; P=0.04), asthma/rhinitis/atopic dermatitis (OR, 8.9; 95% CI, 2.3-35.3; P= 0.002), findings in the endoscopy as trachealization (OR, 9.7; 95% CI, 1.3-70.9; P= 0.03) and psychotropic/ calcium channel blocker drugs (OR, 0.09; 95% CI, 0.009-0.9; P= 0.04). 15 (7%) patients died. In 6 of them death was impaction-related. None patients with EE died.

CONCLUSIONS

Foreign body impaction in the upper gastrointestinal tract due to EE is a frequent cause of urgent endoscopy. Being under 50 years of age, having asthma/rhinitis/atopic dermatitis, trachealization on the esophagus and not taking psychotropic/calcium channel blocker drugs are factors associated with the diagnosis of EE. Mortality in the follow-up of patients without EE is important.

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

BACKGROUND/OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Esophageal Food Impaction: A Retrospective Chart Review

Background

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

Methods

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

Results

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

Conclusion

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

Esophagitis in Cats and Dogs

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

Utility of Routine Esophageal Biopsies in Patients With Refractory Reflux Symptoms

INTRODUCTION

This study aimed to assess the diagnostic yield of routine esophageal biopsies in patients with refractory reflux symptoms.

METHODS

We prospectively enrolled consecutive patients referred for upper endoscopy and collected histological, clinical, and endoscopic data.

RESULTS

Of the 301 included patients, 14 (4.7%) patients met the clinicopathological diagnostic definition of eosinophilic esophagitis. Presence of dysphagia, food bolus impaction, atopic background, and typical endoscopic features were the factors with the strongest association and diagnostic accuracy for eosinophilic esophagitis. The diagnostic yield in patients lacking symptoms of dysphagia or endoscopic features was negligible (0% and 1.9%, respectively).

DISCUSSION

Routine esophageal biopsy sampling in patients with refractory reflux symptoms has a low diagnostic yield. Esophageal biopsies should only be obtained in patients with refractory reflux symptoms who also present with dysphagia (see Visual abstract, Supplementary Digital Content 2, http://links.lww.com/AJG/B792).

[Approach of Dysphagia]

Dysphagia has been reported to be relatively common and seems to be increased in Korea. Dysphagia can be classified as oropharyngeal dysphagia or esophageal dysphagia. In patients with swallowing difficulties, it is important to determine whether the dysphagia is oropharyngeal or esophageal. Patients with orophayngeal dysphagia are likely to develop aspiration and aspiration pneumonia, so accurate diagnosis should be made in the early stages of complaining of swallowing difficulties. Patients with orophayngeal dysphagia complained difficulty initiating a swallow. Swallowing may be accompanied by coughing, choking, nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx. Patients with esophageal dysphagia complained difficulty swallowing several seconds after initiating a swallow and a sensation of food getting stuck in the esophagus. Esophageal dysphagia should be characterized by analyzing whether foods that cause swallowing difficulties are solid, liquids or both, whether symptoms are progressive or intermittent, how severe, and associated symptoms, such as weight loss, heartburn, or regurgitation. The approach to diagnostic testing to determine the cause of esophageal dysphagia is based upon the medical history. If esophageal motility disorder is suspected, barium esophagogram is performed first, and upper endoscopy is performed first if structural abnormalities are suspected. If an upper endoscopy shows normal findings, but the esophagus is still suspected of mechanical obstruction, a barium esophagogram is performed. Esophageal manometry should be performed in patients with swallowing difficulties who are suspected of esophageal motility disorder or have normal findings in upper endoscopy.

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

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

Eosinophilic Esophagitis: Etiology and Therapy

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

Validation of the diagnosis of eosinophilic esophagitis based on histopathology reports in Sweden

BACKGROUND

Eosinophilic esophagitis (EoE) is a relatively new diagnosis, where until recently a specific international classification of disease code was missing. One way to identify patients with EoE is to use histopathology codes. We validated the clinicopathological EoE diagnosis based on histopathology reports and patient charts to establish these data sources as the basis for a nationwide EoE patient cohort.

METHODS

Through the Epidemiology Strengthened by histoPathology Reports in Sweden (ESPRESSO) study, we randomly selected 165 patients from five Swedish health care regions with a histopathologic diagnosis of EoE. Patients were assigned a histopathology diagnosis of EoE if they had ≥15 eosinophils per high-power field or, in the absence of eosinophil quantification, the pathologist interpreted the biopsy as consistent with EoE. Patient charts were scrutinized to see if the other diagnostic criteria were fulfilled. Of the 131 received patient charts, 111 (85%) had sufficient information to be included in the study.

RESULTS

Of the 111 validated patients, 99 had EoE, corresponding to a positive predictive value of 89% (95% confidence interval = 82-94%). Dysphagia was the most common symptom (n = 78, 70%), followed by food impaction (n = 64, 58%) and feeding difficulties (n = 37, 33%). Twelve patients had coexisting asthma (11%) and 16 allergic rhinitis (14%). Seventeen patients underwent esophageal dilatation (15%), of which seven had more than one dilatation. Ninety-seven (87%) patients had a proton-pump inhibitor treatment ≤2 years before or after the diagnosis. Forty-two patients (38%) had been prescribed inhalation steroids and 64 (58%) had undergone esophageal radiology.

CONCLUSION

Histopathology reports from the ESPRESSO cohort with esophageal eosinophilic inflammation are suggestive of EoE.

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

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

Management of Eosinophilic Esophagitis: Dietary and Nondietary Approaches

Eosinophilic esophagitis (EoE) is an allergen-driven chronic inflammatory condition, characterized by symptoms related to esophageal dysfunction and confirmed histologically by esophageal mucosal eosinophilia. Since its first description in the 1990s, the incidence and prevalence of EoE have been on the rise. It is known to affect all ages of various ethnic backgrounds and both sexes; however, it is most seen in White males. Children with EoE often present with abdominal pain, nausea, vomiting, and failure to thrive, whereas adults with EoE typically present with dysphagia and food impaction. Diagnosis of EoE requires histologic confirmation of elevated esophageal eosinophils in a symptomatic patient, and only after secondary causes have been excluded. Because EoE is a chronic and progressively fibrostenotic disease, treatment goals include resolution of symptoms, induction and maintenance of disease remission, and prevention and possibly reversal of fibrostenotic complications, while minimizing treatment-related adverse effects and improving quality of life. Treatment strategies include the "3 D's"-drugs, diet, and dilation. Standard drug therapies include proton-pump inhibitors and topical corticosteroids. Dietary therapies include elemental diet, allergy testing-directed elimination diet, and empiric elimination diets. Endoscopic esophageal dilation for EoE strictures can alleviate esophageal symptoms but has no effect on mucosal inflammation. Recent progress in EoE research has made possible evidence-based clinical guidelines. Ongoing pharmacologic trials show promise for novel biologic agents in the treatment of refractory EoE.

Esophageal foreign bodies: observational cohort study and factors associated with recurrent impaction

BACKGROUND AND AIM

Esophageal foreign bodies, including food bolus impaction, represent a common clinical problem. The prevalence of underlying esophageal disease depends on study design and degree of suspicion of a structural or functional esophageal abnormality. Aim of this study was to analyze factors associated with recurrent impaction.

METHODS

The prospectively collected database at a University Hospital and Swallowing Center was reviewed from January 2012 to June 2019 to identify all patients admitted for esophageal foreign bodies. Patients who underwent an emergency endoscopic procedure represented the final study sample. Patient characteristics, including history of previous esophageal foreign bodies, and type of endoscopic procedure were collected.

RESULTS

Sixty-five patients, 41 males and 24 females with a median age of 59 years, underwent emergency endoscopy for esophageal foreign bodies during the study period. Food bolus was the most common foreign body (n = 43, 66%). Flexible endoscopy was successful in retrieving or pushing the foreign bodies in the stomach in 91% of patients. In 54% of patients, impaction was secondary to an underlying esophageal disorder, which was previously unrecognized in half of them. Recurrent impaction was more common in patients with esophageal disease (P < 0.011). Surgical therapy was required in 4 patients (6.1%).

CONCLUSIONS

Food bolus impaction is a common sentinel event in patients with underlying esophageal disease and is associated with recurrent impaction. Diagnostic endoscopy with biopsies should possibly be performed at the first episode of impaction. Patients with negative biopsies should undergo barium swallow study and high-resolution esophageal manometry.

Outcomes of delayed endoscopic management for esophageal soft food impactions

BACKGROUND AND AIMS

Food impactions are a common reason for emergent upper endoscopy. Current guidelines call for urgent upper endoscopy (within 24 hours) for food impactions without complete esophageal obstruction and emergent endoscopy (within 6 hours) for those with complete esophageal obstruction. Multiple adverse events can arise from esophageal foreign bodies. Cases with longer delays from symptom onset to presentation have been associated with higher rates of surgical intervention. However, data on esophageal soft food impactions are scant. We set out to determine differences in outcomes for food impactions undergoing intervention within 12 hours versus over 12 hours of symptom onset.

METHODS

A retrospective review of medical records was conducted to identify patients who presented to our hospital with an esophageal soft food impaction and underwent an EGD between January 2010 and January 2018. Patients were divided into 2 groups based on the timing from symptom onset to EGD. An EGD within 12 hours was considered an early intervention and over 12 hours was considered a delayed intervention. Patients who had ingested bones or hard objects were not included. Primary outcomes studied were rates of aspiration, admission, local esophageal adverse events, and 30-day all-cause mortality.

RESULTS

We identified 110 patients with a soft food impaction who underwent an EGD. Forty- two patients had an early intervention and 68 a delayed intervention. There were no differences in basic demographics and comorbidities. Additionally, there were no differences in rates of local esophageal adverse events, aspiration, admission, or 30-day mortality. Multivariate analysis revealed endoscopic accessory use was associated with increased odds of local esophageal adverse events (odds ratio, 6.37; P = .01).

CONCLUSIONS

The overall rates of serious adverse events in esophageal soft food impactions are low. Delayed intervention is not associated with increased adverse events or 30-day mortality compared with early intervention. However, accessory use is associated with higher adverse event rates.

Eosinophilic Esophagitis Is Rarely Continually Symptomatic 10 Years After an Initial Treatment Course in Adults

INTRODUCTION

Despite its initial description over 25 years ago, there is little known about the course of eosinophilic esophagitis (EoE) after an initial course of medical or dietary treatment. We aim to assess the long-term symptomology and quality of life (QoL) metrics in patients 10 years after initial treatment for eosinophilic esophagitis.

METHODS

Inclusion criteria: single center study of EoE patients diagnosed over 10 years ago with completion of an 18-question structured telephone interview. A cohort of patient's prospectively underwent an esophageal barium exam, esophageal sponge cytology, and evaluation by a esophagologist at greater than 10 years' time since original diagnosis.

RESULTS

A total of 54 patients were included in the study. The average age at follow-up was 55.0, with the majority male (64.8%). At the original diagnosis, 62.9% and 37.0% were initially treated with topical steroids and a proton pump inhibitor (PPI), respectively,compared to 59.3% and 7.4% after 10 years, and 7.4% of patients reported a history of dilatations. Only 11.8% noted avoidance of trigger foods, with 62.7% noting an unlimited diet without caution. QoL decrease secondary to EoE was noted to be trivial to minimal in 56.9% of patients, mild in 19.6%, moderate in 15.7% and severe in 7.8%. In the prospective follow-up cohort, the results of telephone survey results matched the direct physician-obtained interview in 88% of cases.

CONCLUSION

Ten years after diagnosis, treated EoE is rarely continually symptomatic, requires mainly PPI-based therapies and is associated with a minimal decrease in QoL scores.

Retrospective Analysis of Eosinophilic Esophagitis in Patients with Refractory Gastroesophageal Reflux Disease

Introduction

Eosinophilic esophagitis (EoE) is not a common differential diagnosis in patients with longstanding refractory gastroesophageal reflux disease (GERD). The aim of this retrospective analysis was to assess the prevalence of EoE in patients with refractory GERD.

Methods

This retrospective analysis was performed in the Gastroenterology Department of a tertiary care institute in Karachi, Pakistan. Records of esophagogastroduodenoscopy (EGD) with esophageal biopsy from January 2016 till December 2018 were included.

Results

There were 16 (7.7%) patients of refractory GERD diagnosed with EoE. There were more females than males (5:3). The median age was 58 years (range: 41-63 years). Dysphagia was the chief complaint leading to EGD followed by food impaction and heartburn. The median duration of symptoms was 46.5 months (range: 22-65 months). Erosive esophagitis, white plaques, and friability are common endoscopic findings; however, strictures are also not uncommon.

Conclusion

Eosinophilic esophagitis is not uncommon in patients with refractory GERD. It may present with dysphagia, heartburn, and food impaction. Old patients with longstanding GERD, positive for atopy, not responding to gastric acid inhibitors must be considered for EoE screening via EGD and esophageal biopsy.

Acute intramucosal dissection in eosinophilic esophagitis

Acute intramucosal dissection of the esophagus (IED) is a rare complication of eosinophilic esophagitis (EoE). Only few of such IED cases have been described in the literature. We report the case of a 32-year-old man with a 4-months diagnosis of EoE who was referred to the Emergency Department complaining of dysphagia, epigastric pain and fever and who was diagnosed, after an urgent endoscopy, an IED. After careful evaluation and multidisciplinary assessment the patient was managed conservatively, with specific medical therapy-high-dose proton pump inhibitors, swallowed steroid, broad-spectrum antibiotic-and, after a period of absolute fasting, a diet regimen based on "six food elimination diet" with a stepwise increase of food consistency. The patient experienced a rapid and complete relief of symptoms, paralleled by a progressive healing of IED with no recurrence over a 6-month follow-up period. In EoE patients with a high clinical suspicion of an acute IED, we suggest an early execution of chest CT and a contrast esophagography, avoiding potentially dangerous endoscopic procedures in the acute phase that can contribute to enlargement of the dissection, or progression to perforation. Once the diagnosis of IED is confirmed, even in the presence of a contained perforation, a conservative treatment with a multidisciplinary management should always be considered.

The evolution of treatment and complications of esophageal food impaction

Background

Esophageal food impaction is relatively common and increasing over time. Treatment ranges from medications to invasive endoscopic therapies. The endoscopic push technique has been advised against in favor of endoscopic retrieval for safety concerns. We sought to assess use patterns and safety of treatments for food impaction in a population-based retrospective review.

Methods

A database of recorded esophageal food impactions in Olmsted County, MN, USA, from 1975-2011 was reviewed for patient demographics, treatment, and complications.

Results

A total of 645 impactions occurred, with increasing incidence over time, peaking at 23.2 per year (2000-2004). Medications (almost exclusively glucagon) were successful in relieving impactions 34.5% of the time when trialed. Urgent endoscopy was common (74.0%), as was the need for endoscopic therapy (67.1%). Endoscopic therapy increased over time, with the endoscopic push technique becoming most common. Esophageal complications (deep mucosal injury or perforation) increased over time but remained rare (peak 11%). There was no difference in complications between push and retrieval techniques.

Conclusions

The endoscopic push technique is safe in comparison to endoscopic retrieval in esophageal food impactions. While complications surrounding impaction have increased, they remain rare. Medication trials are reasonable, as long as they do not delay endoscopy, and may prevent the need for emergent endoscopy in one-third of cases.

Eosinophilic Esophagitis: Review and Update

Background: Eosinophilic esophagitis (EoE) was first described in the 1990s, showing an increasing incidence and prevalence since then, being the leading cause of food impaction and the major cause of dysphagia. Probably, in a few years, EoE may no longer be considered a rare disease. Methods: This article discusses new aspects of the pathogenesis, symptoms, diagnosis, and treatment of EoE according to the last published guidelines. Results: The epidemiological studies indicate a multifactorial origin for EoE, where environmental and genetic factors take part. EoE affects both children and adults and it is frequently associated with atopic disease and IgE-mediated food allergies. In patients undergoing oral immunotherapy for desensitization from IgE-mediated food allergy the risk of developing EoE is 2.72%. Barrier dysfunction and T-helper 2 inflammation is considered to be pathogenetically important factors. There are different patterns of clinical presentation varying with age and can be masked by adaptation habits. Besides, symptoms do not usually correlate with histologic disease activity. The diagnostic criteria for EoE has evolved but mainly requires symptoms of esophageal dysfunction with histologic evidence of a peak value of at least 15 eosinophils per high-power field. Endoscopies have to be repeated in order to diagnose, monitor, and treat EoE. Treatment of EoE can be started either by drugs (PPIs and topical corticosteroids) or elimination diets. The multistage step-up elimination diet management approach of EoE is promising. Endoscopic dilation is used for patients with severe dysphagia/food impaction with inadequate response to anti-inflammatory treatment. Conclusions: Research in recent years has contributed to a better understanding of EoE's pathogenesis, genetic background, natural history, allergy workup, standardization in assessment of disease activity, evaluation of minimally invasive diagnostic tools, and new therapeutic approaches. However, several unmet needs are to be solved urgently, as finding a non-invasive disease-monitoring methods and biomarkers for routine practice, the development or new therapies, novel food allergy testing to detect triggering foods, drug, and doses required for initial therapy and safety issues with long-term maintenance therapy, amongst others. Besides, multidisciplinary management units of EoE, involving gastroenterologists, pediatricians, allergists, pathologists, dietitians, and ENT specialists are needed.

Food impaction: etiology over 35 years and association with eosinophilic esophagitis

With the emergence of eosinophilic esophagitis (EoE) as a common cause of food impaction (FI) and a presumed increase in incidence of EoE in the population, the effect on the incidence of FI has not been well described. The aim of this study is to describe the incidence of FI and endoscopic findings in these patients and the association with EoE. A population-based retrospective chart review of the Rochester Epidemiology Project database was performed to identify all patients within Olmsted County that presented with FI from 1976 to 2012. A review of all endoscopic findings, biopsy results, and demographic data was performed. 497 patients were identified with FI from 1976 to 2012. The overall incidence of FI has changed from 1976 to 2012 (Fig. 1) (P < 0.001). The peak incidence of 17.12 per 100,000 people occurred in the time period 1995 to 2000. Both the incidence of comorbid gastroesophageal reflux disease (GERD) and proton pump inhibitor (PPI) use increased over the time period of the study (P < 0.001 for both). Of these patients, 188 (46.7%) had no abnormalities on their endoscopy. The most common endoscopic finding was stricture in 71 (17.6%) patients followed closely by Schatzki's ring in 68 (16.9%) patients. 139 patients had biopsies performed within 2 years of FI and 50 (36.0%) of those were diagnosed with EoE. We present for the first time the changing incidence of FI over the last 35 years in a population-based setting. We also demonstrate the rise of EoE as an important clinical consideration in patients with FI.

A Prospective Study of Eosinophilic Esophagitis and the Expression of Tight Junction Proteins in Patients with Gastroesophageal Reflux Disease Symptoms

Background/Aims

Eosinophilic esophagitis (EoE) is often erroneously diagnosed as gastroesophageal reflux disease (GERD). The aim of this study is to investigate the prevalence of EoE and the expression of tight junction (TJ) proteins in patients with GERD symptoms.

Methods

One hundred patients with GERD symptoms and 10 healthy controls were prospectively studied. Sixty-two patients had symptoms refractory to proton pump inhibitors (PPI). All patients underwent esophageal biopsy. Patients were diagnosed with EoE if the number of eosinophil granulocytes per high-power field was ≥15. Immunohistochemical analysis of TJ proteins (claudin-1, claudin-4, occludin, and zonula occludin-1 [ZO-1]) was performed.

Results

EoE was diagnosed in six of 100 patients (6%) with GERD symptoms and in six patients (9.7%) of 62 patients with PPI-refractory GERD. Only one had typical EoE endoscopic findings. The proportion of ZO-1-positive cells was significantly lower in the lower than in the middle esophagus (56.0%±14.0% vs 66.0%±11.5%, p＜0.05). There were no significant correlations between TJ protein expression and GERD symptoms.

Conclusions

The prevalence of EoE among patients with PPI-refractory GERD is approximately 10%. Regardless of endoscopic findings, esophageal biopsy is crucial in diagnosing EoE. The disruption of ZO-1 expression in the lower esophagus is significantly associated with GERD symptoms.

Diagnostic yield in the evaluation of dysphagia: experience at a single tertiary care center

Evaluation of dysphagia typically starts with esophagogastroduodenoscopy (EGD); further testing is pursued if this is negative. When no mucosal, structural, or motor esophageal disorders are identified with persisting symptoms, functional dysphagia is considered. We evaluated outcomes in patients undergoing EGD for dysphagia, and estimated prevalence of functional dysphagia. The endoscopy database at single tertiary care center was interrogated to identify EGDs performed for an indication of 'dysphagia' over a 12-month period (2008-09). Electronic medical records were reviewed over the next 8 years to assess if an etiology was identified. Data were analyzed to assess the diagnostic yield of endoscopy and subsequent tests in the evaluation of dysphagia. Of 5486 EGDs, 822 (15.0%) were performed for dysphagia in 694 patients (58.4 ± 0.6 year, range: 18-95 year, 55.8% female). Of these, 529 (76.2%) had EGD findings that explained dysphagia; another 22 (3.2%) had findings on histopathology. Of the remainder 143 patients (20.6%) with normal index EGD, 38 (26.6%) patients underwent barium esophagram with 15 (39.5%) having abnormal studies. 19 patients (13.3%) underwent esophageal high resolution manometry with 12 (63.2%) being abnormal, and 7 had a mechanism for dysphagia on alternate testing. A repeat EGD was abnormal in 6 patients, while 45 patients were lost to follow-up. 42 patients had complete resolution of symptoms despite normal endoscopy, of which 30 were treated empirically with a proton pump inhibitor (PPI). Only 16 patients had no findings on evaluation, and had continued dysphagia symptoms, representing true functional dysphagia in 2.3% of all dysphagia patients and 11.2% of patients with normal EGD. Endoscopy remains the test with the highest yield (over 75%) for a diagnosis in patients presenting with dysphagia; secondary tests are useful when endoscopy does not provide a diagnosis. Benign strictures and GERD-related etiologies are leading causes; PPI therapy is useful even when testing is negative. Functional dysphagia is extremely rare, accounting for <2.5% of all dysphagia.

Eosinophilic esophagitis in Japan: Focus on response to acid suppressive therapy

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by esophageal dysfunction and dense eosinophilic infiltration of esophageal epithelium. According to clinical consensus and guidelines published in 2011, esophageal eosinophilia was classified into two entities based on response to proton pump inhibitor (PPI) administration: EoE and PPI-responsive esophageal eosinophilia (PPI-REE). We have performed a series of investigations to determine whether EoE is actually different from PPI-REE. Consistent with Western reports, more than half of our examined patients with symptomatic esophageal eosinophilia suggestive of EoE achieved histological remission with single PPI therapy. Furthermore, our comparisons of clinical, endoscopic, and histopathological findings between patients with EoE and those with PPI-REE revealed nearly no differences between them. We also compared gene expression profiles in mucosal biopsy specimens between those groups and found that microarray findings obtained from PPI-REE patients substantially overlapped with those from EoE patients, suggesting that both represent the same condition or are variations of a single disease. In addition, we have noted that more than half of EoE patients who show resistance to a PPI therapy respond to vonoprazan, a novel potassium-competitive acid blocker that has been shown to provide more potent and sustained suppression of gastric acid secretion than PPIs. Our results indicate that PPI-REE may constitute a subtype of EoE. Based on novel evidence including results obtained in our studies, the most recently updated guidelines have included responders to PPI therapy within the spectrum of EoE, abandoning the term PPI-REE.

Diagnostic Trends and Clinical Characteristics of Eosinophilic Esophagitis: A Korean, Single-center Database Study

Background/Aims

The prevalence of eosinophilic esophagitis (EoE) is reportedly increasing in Western countries. However, its prevalence in Korea remains unknown. We investigated the diagnostic trends and clinical characteristics of EoE in Korea.

Methods

Using an endoscopic database maintained at a tertiary care center, we retrospectively reviewed the biopsy reports regarding 18 399 biopsy specimens collected from all patients who underwent esophagogastroduodenoscopy and esophageal biopsy at this facility between 2006 and 2014. The presence of more than 15 eosinophils per high-power field with symptoms related to esophageal dysfunction was considered to indicate EoE.

Results

A total of 37 patients (male:female ratio, 29:8; mean age, 44.0 ± 13.0 years) were diagnosed with EoE. These patients presented with dysphagia (21.6%), epigastric pain (21.6%), heartburn (24.3%), and other symptoms (32.4%). Typical endoscopic appearance of EoE was noted in 33 cases (89.1%) and included linear furrows in 24 cases (64.8%), ringed esophagus in 10 cases (27.0%), and white exudates in 11 cases (29.7%). The median eosinophilic count was 25 per high-power field (interquartile range, 20-70). Notable histopathological findings included eosinophilic microabscesses in 21 cases (56.7%). The diagnosis rate of EoE was found to have increased from 2006 and to 2014 (P-value ＜ 0.001 by the Cochran-Armitage trend test).

Conclusions

The number of patients with EoE appears to have increased significantly over the 9-year period investigated, while the number of endoscopic investigations increased only marginally. Greater awareness of EoE and the role of esophageal biopsies should be considered.

Prevalence of Eosinophilic Esophagitis in Adult Patients with Upper Gastrointestinal Symptoms in a Locality in Upper Egypt

BACKGROUND/AIMS

Eosinophilic esophagitis (EoE) is gaining importance in the diagnosis of upper gastrointestinal (UGI) symptoms. Diagnosis is based on the clinical presentation of esophageal dysfunction and pathological findings in the absence of other causes of tissue eosinophilia. Our study was designed to evaluate EoE prevalence in patients with UGI symptoms in our locality (El-Minia, Egypt).

METHODS

This single-center, cross-sectional study recruited all patients with UGI symptoms who agreed for endoscopic evaluation. Esophageal biopsy samples were obtained and histological evaluation for the presence of eosinophils was performed for every patient. EoE was defined when at least 15 eosinophils were present in a single high-power field, in the absence of other causes of esophageal eosinophilia.

RESULTS

Between 2013 and 2015, 218 of 476 adult patients with UGI symptoms underwent upper endoscopy after giving consent. Among the 218 patients, only 4 (1.87%) had the diagnosis of EoE based on the presence of eosinophils in esophageal biopsies and exclusion of other causes of esophageal eosinophilia. Three patients with EoE presented mainly with dysphagia (75%) and/or other UGI symptoms, such as heartburn.

CONCLUSIONS

We observed a low prevalence of EoE in our locality. The diagnosis of EoE should be considered in patients with dysphagia and/or heartburn.

Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia

BACKGROUND AND AIMS

Our aim is to review the literature and provide guidelines for the assessment of uninvestigated dysphagia.

METHODS

A systematic literature search identified studies on dysphagia. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Statements were discussed and revised via small group meetings, teleconferences, and a web-based platform until consensus was reached by the full group.

RESULTS

The consensus includes 13 statements focused on the role of strategies for the assessment of esophageal dysphagia. In patients presenting with dysphagia, oropharyngeal dysphagia should be identified promptly because of the risk of aspiration. For patients with esophageal dysphagia, history can be used to help differentiate structural from motility disorders and to elicit alarm features. An empiric trial of proton pump inhibitor therapy should be limited to four weeks in patients with esophageal dysphagia who have reflux symptoms and no additional alarm features. For patients with persistent dysphagia, endoscopy, including esophageal biopsy, was recommended over barium esophagram for the assessment of structural and mucosal esophageal disease. Barium esophagram may be useful when the availability of endoscopy is limited. Esophageal manometry was recommended for diagnosis of esophageal motility disorders, and high-resolution was recommended over conventional manometry.

CONCLUSIONS

Once oropharyngeal dysphagia is ruled out, patients with symptoms of esophageal dysphagia should be assessed by history and physical examination, followed by endoscopy to identify structural and inflammatory lesions. If these are ruled out, then manometry is recommended for the diagnosis of esophageal dysmotility.

New Developments in the Diagnosis, Therapy, and Monitoring of Eosinophilic Esophagitis

PURPOSE OF REVIEW

Eosinophilic esophagitis (EoE) has transformed over the past two decades from a little-known entity to a significant cause of morbidity in the adult and pediatric population. We reviewed the most recent advancements in the diagnosis, therapy, and long-term monitoring of EoE.

RECENT FINDINGS

Based on clinical, endoscopic, histologic, immunologic, and genetic similarities, there is growing consensus to move away from distinguishing proton pump inhibitor responsive esophageal eosinophilia as an entity distinct from EoE. An increasing number of studies have identified duration of untreated disease as an important determinant of esophageal stricture formation. New approaches to the empiric elimination diet including one, two, four, and step-up protocols were developed to reduce the need for repeated endoscopies during reintroduction of food triggers. Topical steroids remain the mainstay of medical therapy but newer formulations are under development to optimize esophageal delivery. Novel, disease activity monitoring techniques are being evaluated that assess esophageal inflammatory activity without the need for endoscopy. Understanding of EoE has increased remarkably from the first identification of the disease. The underlying pathogenesis continues to be explored leading to shifts in diagnostic criteria as well as novel therapeutic targets. Innovative methods to monitor disease are under investigation and more research is needed to understand the natural history of EoE.

Eosinophilic Esophagitis: Incidence and Prevalence

Eosinophilic esophagitis (EoE) is a rapidly emerging allergy-mediated condition encountered frequently in clinical practice. It presents with failure to thrive, nausea, and vomiting in children and is a common reason for dysphagia and food impaction in adults. Several institution-based and population-based studies have reported the frequency of EoE over the past few years. The incidence and prevalence of EoE vary depending on the method of data collection. In population-based studies using national registries, the incidence appears to be increasing, currently estimated to be approximately 10 cases/100,000 persons annually, whereas the prevalence is reported between 10 and 57 cases/100,000 persons.

Endoscopic and Radiologic Findings in Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) was first described by Landis in 1978. The disease is characterized by esophageal symptoms, primarily dysphagia in adult patients, and esophageal eosinophilic infiltration. The disease is associated with characteristic endoscopic findings, including edema, rings, furrows, exudates, and strictures. The typical radiographic findings of this disorder are rings, strictures, and small-caliber esophagus. The endoscopic and radiographic findings of EoE are the topic of this review.

Epidemiology and Natural History of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) has emerged over the past 2 decades as a major cause of upper gastrointestinal morbidity. Over this time, the epidemiology of EoE has also rapidly evolved. EoE has transformed from a rare case-reportable condition to disease that is commonly encountered in the gastroenterology clinic, hospital emergency room, and endoscopy suite. The incidence and prevalence are increasing at rates that outpace increased disease recognition. Current incidence estimates range from 5 to 10 cases per 100,000, and current prevalence estimates range from 0.5 to 1 case per 1000. We review the data and potential reasons behind this increase, examine risk factors, and identify important areas for research into disease etiology. The article also discusses the progression of EoE from an inflammatory to fibrostenotic phenotype. An accurate view of the natural history of EoE is central to discussions with patients regarding disease prognosis and decisions about long-term use of medical, endoscopic, and diet therapies. Progressive remodelling appears to be gradual, but not universal, and the duration of untreated disease is the best predictor of stricture risk. Ultimately, prospective, long-term outcome studies focusing on multiple aspects of disease activity are needed to fully understand the natural history of EoE.

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

Eosinophilic esophagitis (EoE) has arisen as a common disorder in current clinical and endoscopic gastroenterology practice. Areas covered: A comprehensive review of the literature to summarize and update different aspects related with the use of endoscopy in the diagnostic workout and treatment of pediatric and adult EoE patients is conducted. Expert commentary: Endoscopic features in EoE are frequently subtle, so were inadverted in some initial reports of the disease. Literature has described a wide number of EoE-associated features, systematized in the EREFS classification, which standardized the grade and severity of exudates, rings, edema, furrows, and strictures. The insufficient reliability of these features to predict eosinophilic inflammation still makes biopsies essential in diagnosing or monitoring EoE. EoE causes half of the food impactions requiring endoscopy; food impaction leads to EoE diagnosis in up to half of cases. Long term consequences of EoE include esophageal remodeling leading to strictures and narrowing, thus impairing symptoms and needs dilation. Recognizing the risks from dilation in EoE required carrying out a safe technique to avoid the high complication rate reported in the early literature. Endoscopic dilation should be considered in patients with esophageal narrowing and dysphagia/food impaction unresponsive to diet or drugs-based anti-inflammatory treatment.

The Prevalence of Biopsy-Proven Eosinophilic Esophagitis in Hispanics Undergoing Endoscopy Is Infrequent Compared to Caucasians: A Cross-Sectional Study

INTRODUCTION

The prevalence of eosinophilic esophagitis (EoE), a chronic, immune-mediated, clinicopathologic, inflammatory disorder, has been well described in the pediatric and adult Caucasian population but not as well studied in the Hispanic population. The major aims of this study are to determine the prevalence and gene expression profile of EoE in these populations.

METHODS

This is a retrospective cohort study of patients from two institutions predominantly serving a Hispanic population. Patients included at Los Angeles County Hospital (LACH) had an esophagogastroduodenoscopy (EGD) and esophageal biopsies performed for evaluation of dysphagia and/or food impaction, while patients included from the University Hospital Medical Center of El Paso (UHMCEP) had an EGD and esophageal biopsies performed for any appropriate clinical indication. Gene expression analysis which has been shown to accurately diagnose EOE in Caucasians was performed for 9 patients at UHMCEP to determine its accuracy in Hispanics.

RESULTS

At LACH, 234 patients were included in the study of whom 155 (66.3%) were Hispanic and 22 (9.4%) were Caucasian. 3.2% of the Hispanic patients and 9.1% of the Caucasian patients were diagnosed with EOE with threefold difference. At UHMCEP 1700 patients were included of whom 1350 (79.4%) were Hispanic and 179 (10.5%) were Caucasian. 0.96% of the Hispanic patients and 7.26% of the Caucasian patients were diagnosed with EOE with a sevenfold difference. Gene expression accurately diagnosed EOE in a small number of both Hispanics and Caucasians who underwent analysis.

CONCLUSIONS

Hispanic patients at LAC and UMHCEP had a significantly lower prevalence of EOE as compared to Caucasians at these two institutions and a lower prevalence as compared to Caucasians with EOE previously reported in the literature. Gene expression analysis, which has previously been shown to accurately diagnose EOE in Caucasian patients, accurately diagnosed EOE in a small sample of this Hispanic population. Based on this similar gene expression, other factors such as environmental, ethnic, and cultural causes should be investigated to explain the markedly lower prevalence of EOE in Hispanics.

Eosinophilic esophagitis. The North against the South? A bio-economic-social mechanistic approach and clinical implications

Eosinophilic esophagitis is a chronic antigen-mediated disease characterized by esophageal symptoms, esophageal eosinophilia, and the absence of response to proton pump inhibitors. It is the most frequent cause of dysphagia and food impaction in adults. Its incidence and prevalence is very high in the developed countries (USA, Europe, Australia), where its connotation is that of an emerging epidemic. While studies have been published with large case series in the developed countries, those published in Latin America are small or consist of isolated case reports. The differences in the prevalence of the disease between the developed and developing regions are unknown. Genetic or racial causes have been cited. Nevertheless, the epidemic nature of the disease suggests that environmental causes are the most powerful. Based on the published hypotheses, as well as on epidemiologic studies, the present review discusses some of the possible causes of the disparity in the prevalence of eosinophilic esophagitis between the two types of countries. The 'hygiene hypothesis' is reviewed, together with the possible relation of Helicobacter pylori, intestinal parasites, and modifications of the esophageal microbiota in patients with eosinophilic esophagitis. In reference to studies conducted in the United States, the clinical behavior and progression of eosinophilic esophagitis in Hispanics is reviewed and a possible predominant phenotype in Mexican and other Latin American patients is discussed. Finally, based on the above, an algorithm for studying the disease in the Latin American countries is proposed.

Systematic review with meta-analysis: endoscopic dilation is highly effective and safe in children and adults with eosinophilic oesophagitis

BACKGROUND

Oesophageal dilation is frequently used as an adjunct treatment to alleviate symptoms that develop from fibrostenotic remodelling in eosinophilic oesophagitis (EoE). Earlier reports described an increased risk of complications associated with dilation.

AIM

Perform a systematic review and meta-analysis to assess the efficacy and safety of endoscopic dilation in children and adults with EoE.

METHODS

Professional librarians searched MEDLINE, EMBASE, the Cochrane library, Scopus, and Web of Science for articles in any language describing studies of dilation in EoE through December 2016. Studies were selected and data were abstracted independently and in duplicate. Random effects modelling was used to generate summary estimates for clinical improvement and complications (haemorrhage, perforation, hospitalisation, and death).

RESULTS

The search resulted in 3495 references, of which 27 studies were included in the final analysis. The studies described 845 EoE patients, including 87 paediatric patients, who underwent a total of 1820 oesophageal dilations. The median number of dilations was 3 (range: 1-35). Clinical improvement occurred in 95% of patients (95% CI: 90%-98%, I² : 10%, 17 studies). Perforation occurred in 0.38% (95% CI: 0.18%-0.85%, I² : 0%, 27 studies), haemorrhage in 0.05% (95% CI: 0%-0.3%, I² : 0%, 18 studies), and hospitalisation in 0.67% (95% CI: 0.3%-1.1%, I² : 44%, 24 studies). No deaths occurred (95% CI: 0%-0.2% I² : 0%, 25 studies).

CONCLUSIONS

Endoscopic dilation is consistently effective in children and adults with EoE, resulting in improvement in 95% of patients with very low rates (<1%) of major complications.

Multi-morbidities of allergic rhinitis in adults: European Academy of Allergy and Clinical Immunology Task Force Report

This report has been prepared by the European Academy of Allergy and Clinical Immunology Task Force on Allergic Rhinitis (AR) comorbidities. The aim of this multidisciplinary European consensus document is to highlight the role of multimorbidities in the definition, classification, mechanisms, recommendations for diagnosis and treatment of AR, and to define the needs in this neglected area by a literature review. AR is a systemic allergic disease and is generally associated with numerous multi-morbid disorders, including asthma, eczema, food allergies, eosinophilic oesophagitis (EoE), conjunctivitis, chronic middle ear effusions, rhinosinusitis, adenoid hypertrophy, olfaction disorders, obstructive sleep apnea, disordered sleep and consequent behavioural and educational effects. This report provides up-to-date usable information to: (1) improve the knowledge and skills of allergists, so as to ultimately improve the overall quality of patient care; (2) to increase interest in this area; and (3) to present a unique contribution to the field of upper inflammatory disease.

Association between atopic manifestations and eosinophilic esophagitis: A systematic review and meta-analysis

BACKGROUND

Eosinophilic esophagitis (EoE) has repeatedly been associated with atopic manifestations, which are reported more frequently in these patients than in the general population.

OBJECTIVE

To systematically assess the evidence and strength of the associations between EoE and atopy.

METHODS

We performed a systematic search of the MEDLINE, EMBASE, and SCOPUS databases for case-control studies comparing the frequency of atopic diatheses among patients with EoE and control subjects representing the general population without EoE. Using random-effects meta-analyses, we calculated summary estimates, including 95% confidence intervals (CIs), for bronchial asthma, atopic rhinitis, and eczema. Publication bias risks were assessed by means of funnel plot analysis and specific statistical tests.

RESULTS

Of the 2,954 references identified, data were collected from 21 studies, including a total of 53,542 patients with EoE and 54,759 controls. The criteria for defining a diagnosis of atopy in patients with EoE or controls was not structurally considered in most of the studies. Overall, allergic rhinitis was significantly more common among patients with EoE compared with control subjects (odds ratio [OR], 5.09; 95% CI, 2.91-8.90; I² = 86.7%) as were bronchial asthma (OR, 3.01; 95% CI, 1.96-4.62; I² = 84.5%) and eczema (OR, 2.85; 95% CI, 1.87-4.34; I² = 57.1%). Food allergies and other atopic conditions were also assessed. No significant publication bias was found for studies dealing with allergic rhinitis and eczema in EoE.

CONCLUSION

Despite pointing to a significant association between atopy and EoE, most of the studies provided no normalized diagnostic criteria for atopy. Further research should provide clear and standardized definitions of such conditions.

TRIAL REGISTRATION

www.crd.york.ac.uk/PROSPERO Trial Identifier: CRD42016036161.

Eosinophilic esophagitis: Update in diagnosis and management. Position paper by the Italian Society of Gastroenterology and Gastrointestinal Endoscopy (SIGE)

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus characterized by symptoms related to esophageal dysfunction, as well as significant esophageal eosinophilia. The entity exists worldwide but has been most extensively studied in Western countries. However, a wide range of symptoms has been noticed such as chest pain or gastro-esophageal reflux disease-like symptoms. Upper gastro-intestinal endoscopy and esophageal biopsies are crucial for the diagnosis. Endoscopy might be normal or reveal typical patterns such as rings, furrows, exudates, edema, and stricture. Two to four biopsies should be performed both in the distal and in the proximal esophagus, and 15 eosinophils per high power field within the esophageal epithelium are the minimal threshold to diagnose eosinophilic esophagitis. Allergy testing is recommended, although its impact to orient treatment remains to be demonstrated. Eosinophilic esophagitis treatment includes medical treatment, diet and endoscopic dilation. Proton pump inhibitors are the first-line therapy as up to 50% of patients respond well to proton pump inhibitors irrespective of objective evidence of GERD. Topical viscous corticosteroids or elimination diet are the treatment of choice in case of unresponsiveness to proton pump inhibitors.