Oesophageal eosinophilic infiltration in patients with noncardiac chest pain

The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis - Definition, Clinical Presentation and Diagnosis

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.

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

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.

Eosinophilic Esophagitis with Angina Pectoris

Eosinophilic esophagitis (EoE) is an immune or antigen-mediated chronic inflammatory esophageal disorder that is relatively rare in Asian countries. The main symptoms of EoE are dysphagia and food impaction. Although chest pain is a symptom of EoE, it is also a symptom of coronary heart disease. This paper reports a case of EoE with angina pectoris in a 45-year-old male who was referred to the authors' hospital for chest pain. He was diagnosed with angina pectoris because of mild stenosis in the left coronary artery on coronary angiography. On the other hand, the symptoms did not improve with angina medication therapy. Therefore, he underwent a chest CT scan, which revealed esophageal thickening. Esophagogastroduodenoscopy was performed. His endoscopic findings showed linear furrows with edema, and >90 eosinophils existed per high-power field on the histology findings. He was diagnosed with EoE. Through additional examinations, he was also diagnosed with asthma. The patient was treated with a proton pump inhibitor and a fluticasone inhaler. His symptoms and abnormal endoscopic findings disappeared after eight weeks of treatment. This case shows that physicians should consider the possibility of the symptoms for EoE when unexplained chest pain persists.

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.

Eosinophilic esophagitis: definition, epidemiology and quality of life

Eosinophilic esophagitis (EoE) is a clinicopathological disease defined by symptoms of esophageal dysfunction and ≥15 eosinophils/HPF after excluding other causes of esophageal eosinophilia. Increasing attention has been paid by clinicians and researchers after its first description in 1978. Many consensuses and guidelines have been issued over the years, as gastroenterologists did not reach an agreement on EoE definition, especially regarding the controversial responsiveness to proton pump inhibitor (PPI) therapy. Of note, recent evidence suggests that the incidence and prevalence of EoE have been increasing through the years: many risk factors have been advocated as possible reasons for this, although further studies are needed. In this brief review, we will first cover the history of EoE in the literature, with a focus on its varying definition throughout the years. Then, we will discuss EoE epidemiology, emphasizing potential risk factors explaining its increasing incidence and prevalence. Last, we will deal with the quality of life of adult and pediatric patients with EoE.

Diagnosis and Management of Functional Chest Pain in the Rome IV Era

Functional chest pain accounts for about a third of the patients with noncardiac chest pain. It is a very common functional esophageal disorder that remains even today a management challenge to the practicing physician. Based on the definition offered by the Rome IV criteria, diagnosis of functional chest pain requires a negative workup of noncardiac chest pain patients that includes, proton pump inhibitor test or empirical proton pump inhibitor trial, endoscopy with esophageal mucosal biopsies, reflux testing, and esophageal manometry. The mainstay of treatment are neuromodulators that are primarily composed of anti-depressants. Alternative medicine and psychological interventions may be provided alone or in combination with other therapeutic modalities.

The Mexican consensus on non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases.

AIM

To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients.

METHODS

Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system.

RESULTS AND CONCLUSIONS

The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

Factors predictive of gastroesophageal reflux disease and esophageal motility disorders in patients with non-cardiac chest pain

BACKGROUND

Patients with non-cardiac chest pain (NCCP) are referred for esophageal motility testing and pH monitoring since gastroesophageal reflux disease (GERD) and esophageal motility disorders are frequently encountered in these patients. Our aim was to determine the prevalence and distribution of these disorders and to identify predictors of abnormal esophageal function testing.

METHODS

We performed a retrospective study of NCCP patients who presented after a negative cardiac evaluation and underwent esophageal manometry, esophageal pH monitoring and upper endoscopy from January 2010 to January 2017.

KEY RESULTS

In a total of 177 patients, esophageal motility disorders were diagnosed in 31% and GERD in 35% of the patients. The most common diagnoses were ineffective esophageal motility (IEM) in 14.1%, jackhammer esophagus in 6.8%, diffuse esophageal spasm in 5.1% and achalasia in 2.3% patients. Older age [for every 5-year increment, odds ratio (OR) 1.2 (95% confidence intervals (CI) 1.00-1.3) p = .047] and dysphagia [OR 3.8 (95% CI, 1.9-7.5) p < .001] were predictors of esophageal motility disorders. Older age [for every 5-year increment, OR 1.2 (95% CI, 1.01-1.3) p = .032] was predictive of GERD. Abnormal esophageal testing was associated with male gender [OR 2.2 (95% CI, 1.04-4.6) p = .039], older age [for every 5-year increment, OR 1.2 (95% CI, 1.03-1.3) p = .016] and Caucasian race [OR 3.1 (95% CI, 1.1-8.7) p < .029].

CONCLUSIONS

Approximately two thirds of patients presenting with NCCP have GERD or esophageal motility disorders. Esophageal function testing in NCCP should be considered in older patients, men, Caucasians and those presenting with dysphagia.

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 Esophageal Hypersensitivity in Functional Heartburn

Functional heartburn (FH) is defined as a functional esophageal disorder characterized by symptoms of chronic heartburn with no apparent correlation to acid or nonacid reflux. In addition, its symptoms persist despite the lack of organic abnormalities or inflammation, esophageal motility disorders, or metabolic disorders. Although conditions presenting with esophageal symptoms without endoscopic abnormalities were previously categorized as nonerosive reflux disease, such conditions are now classified into 3 categories under Rome IV criteria: nonerosive reflux disease, reflux hypersensitivity, and FH. Although many aspects of FH remain unclear, its onset mechanism is considered to be strongly associated with peripheral or central sensitization, given the fact that its symptoms seem to be unrelated to gastroesophageal reflux. In addition, the cause of such hypersensitivity is an interesting topic in itself, and psychological factors, such as stress followed by increasing esophageal permeability are gaining attention as factors that can potentially influence this condition. There is a great unmet clinical need for therapeutic drugs that can be used to treat FH, and the development of novel drugs, diagnostic tests and biomarkers is eagerly awaited.

High-definition-iSCAN virtual chromoendoscopy has high sensitivity and specificity for the diagnosis of eosinophilic esophagitis

Background and study aims A major challenge in eosinophilic esophagitis (EoE) is disease recognition during endoscopy as there are no pathognomonic findings. We aimed to determine the utility of high-definition (HD) iSCAN virtual chromoendoscopy (VC) in diagnosis of EoE.

Patients and methods One hundred eighty-nine consecutive patients presenting with dysphagia or food bolus impaction were assessed using HD-iSCAN VC (Pentax, Japan) with biopsies from distal, mid, upper esophagus and from furrows where visible.

Results Of 189 patients, 45 (23.8 %, male = 29, median age 40y) had a histological diagnosis of EoE; 73.3 % of the patients were newly diagnosed. iSCAN endoscopic features of EoE were linear furrows (91 %), edema (77.8 %), rings or tracheal appearance (73.3 %), whitish exudates (26.6 %) and narrowing or stricture (5 %). One patient (2.2 %) had all 5 endoscopic features. Ten patients (22.2 %) had linear furrows, edema,rings or tracheal appearance and whitish exudates on iSCAN, with a positive predictive value (PPV) 100 % (95 % CI 69.1 %-100 %) and negative predictive value (NPV) 80.4 % (95 % CI 73.9 %-86 %). Thirteen patients (29 %) presented with linear furrows, edema and rings or tracheal appearance on iSCAN, with a PPV 100 % (95 % CI 75.3 %-100 %) and NPV 81.8 % (95 % CI 75.3 %-87.2 %). Six patients (13.3 %) had furrows and edema and 6 patients (13.3 %) had furrows and rings or tracheal appearance on iSCAN, with a PPV 100 % (95 % CI 54.1 %-100 %) and NPV 78.69 % (95 % CI 72 %-84.4 %), respectively. The sensitivity and specificity of HD-iSCAN endoscopy were 97.62 % (95 % CI 87.43 %-99.94 %) and 89.58 % (95 % CI 83.40 %-94.05 %). The accuracy of HD-iSCAN endoscopy was 92.47 % (95 % CI 87.67 %-95.56 %).

Conclusion HD-iSCAN endoscopy is sensitive and specific with good accuracy for EoE diagnosis. Linear furrows, edema and tracheal appearance were the most common findings and these 3 endoscopic features had a high predictive value for diagnosis of EoE.

Noncardiac chest pain: diagnosis and management

PURPOSE OF REVIEW

Noncardiac chest pain (NCCP) has been defined as recurrent chest pain that is indistinguishable from ischemic heart pain after excluding a cardiac cause. NCCP is a common and highly challenging clinical problem in Gastrointestinal practice that requires targeted diagnostic assessment to identify the underlying cause of the symptoms. Treatment is tailored according to the cause of NCCP: gastroesophageal reflux disease (GERD), esophageal dysmotility or functional chest pain. The purpose of this review is to discuss the current diagnosis and treatment of NCCP.

RECENT FINDINGS

Utilization of new diagnostic techniques such as pH-impedance and high-resolution esophageal manometry, and the introduction of a new definition for functional chest pain have helped to better diagnose the underlying mechanisms of NCCP. A better therapeutic approach toward GERD-related NCCP, the introduction of new interventions for symptoms due to esophageal spastic motor disorders and the expansion of the neuromodulator armamentarium for functional chest pain have changed the treatment landscape of NCCP.

SUMMARY

GERD is the most common esophageal cause of NCCP, followed by functional chest pain and esophageal dysmotility. The proton pump inhibitor test, upper endoscopy, wireless pH capsule and pH-impedance are used to identify GERD-induced NCCP. High-resolution esophageal manometry is the main tool to identify esophageal motor disorder in non-GERD-related NCCP. Negative diagnostic assessment suggests functional chest pain. Potent antireflux treatment is offered to patients with GERD-related NCCP; medical, endoscopic or surgical interventions are considered in esophageal dysmotility; and neuromodulators are prescribed for functional chest pain. Assessment and treatment of psychological comorbidity should be considered in all NCCP patients.

[Gastroenterological diseases as triggers of chest pain]

BACKGROUND

Non-cardiac chest pain is very common and gastroenterological diseases are one of the most important causes. The frequency distribution of the underlying causes depends on the sector of the healthcare system in which it is ascertained. In individual cases it must always be taken into consideration that detection of coronary heart disease, for example, does not exclude another origin of chest pain.

OBJECTIVE

This article provides a systematic review of gastroenterological diseases that can cause chest pain. Furthermore, a management algorithm was developed.

MATERIAL AND METHODS

This article is based on a selective search of the literature.

RESULTS AND DISCUSSION

The most frequent cause is gastroesophageal reflux disease, which is also known as reflux-chest pain syndrome. If there are no clinical alarm signals, treatment is carried out with a proton pump inhibitor either as a diagnostic test or as a probatory therapy. If this initial management does not lead to satisfactory symptom control, extended diagnostics are indicated. In individual cases this concerns the detection or exclusion of a reflux disease, of motility disorders and structural damage to the esophagus as well as diseases of the upper abdominal organs, which can evoke chest pain. After exclusion of these morphologically and/or functionally defined diseases, a so-called functional chest pain is present. The essential mechanisms are altered pain processing, esophageal hypersensitivity and mental comorbidities. The treatment of functional chest pain often proves to be difficult.

Advances in clinical management of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated clinicopathologic condition that has become an increasingly important cause of upper gastrointestinal morbidity in adults and children over the past 2 decades. It is diagnosed based on symptoms of esophageal dysfunction, the presence of at least 15 eosinophils/high-power field in esophageal biopsy specimens, and exclusion of competing causes of esophageal eosinophilia, including proton pump inhibitor-responsive esophageal eosinophilia. We review what we have recently learned about the clinical aspects of EoE, discussing the clinical, endoscopic, and histological features of EoE in adults and children. We explain the current diagnostic criteria and challenges to diagnosis, including the role of gastroesophageal reflux disease and proton pump inhibitor-responsive esophageal eosinophilia. It is also important to consider the epidemiology of EoE (with a current incidence of 1 new case per 10,000 per year and prevalence of 0.5 to 1 case per 1000 per year) and disease progression. We review the main treatment approaches and new treatment options; EoE can be treated with topical corticosteroids, such as fluticasone and budesonide, or dietary strategies, such as amino acid-based formulas, allergy test-directed elimination diets, and nondirected empiric elimination diets. Endoscopic dilation has also become an important tool for treatment of fibrostenotic complications of EoE. There are a number of unresolved issues in EoE, including phenotypes, optimal treatment end points, the role of maintenance therapy, and treatment of refractory EoE. The care of patients with EoE and the study of the disease span many disciplines; EoE is ideally managed by a multidisciplinary team of gastroenterologists, allergists, pathologists, and dieticians.

Evaluation of esophageal sensation

Dramatic progress has been made over the past decade in the sophistication and availability of equipment to test esophageal motility and sensation. High-resolution esophageal manometry and impedance have moved from the research clinic into clinical practice. Some of the testing is costly and time consuming, and requires extensive experience to perform the testing and properly interpret the results. These sensory studies are valuable in the interpretation of clinical problems, and provide important research information. Clinicians should evaluate the research studies to advance their understanding of the pathophysiology of the esophagus.

Epidemiology of eosinophilic esophagitis

In this article, the epidemiology of eosinophilic esophagitis (EoE) is reviewed. Demographic features and natural history are described, the prevalence and incidence of EoE are highlighted, and risk factors for EoE are discussed. EoE can occur at any age, there is a male predominance, it is more common in whites, and there is a strong association with atopic diseases. EoE is chronic, relapses are frequent, and persistent inflammation increases the risk of fibrostenotic complications. The prevalence is currently estimated at 0.5-1 in 1000, and EoE is now the most common cause of food impaction. The incidence of EoE is approximately 1/10,000 new cases per year, and the increase in incidence is outpacing increases in recognition and endoscopy volume, but the reasons for this evolving epidemiology are not yet fully delineated.

[What is the utility of proton pump inhibitor testing in non-cardiac chest pain?]

BACKGROUND AND AIMS

Noncardiac chest pain (NCCP) often represents a diagnostic and therapeutic challenge. Given that gastroesophageal reflux disease (GERD) is the most common cause of NCCP, initial treatment with proton-pump inhibitors (PPI) has been proposed for all patients (PPI testing), reserving esophageal function testing solely for non-responders. The aim of the present study was to provide evidence on the clinical utility of PPI testing with high-dose pantoprazole in patients with NCCP.

PATIENTS AND METHODS

We carried out a study of diagnostic performance with a cohort design in patients with NCCP, who had been assessed by the Cardiology Service. All patients underwent upper endoscopy, esophageal manometry, and 24h esophageal pH monitoring before PPI testing with pantoprazole 40 mg every 12h for 1 month. Before and after treatment, we assessed the severity (intensity and frequency) of chest pain, quality of life, and anxiety and depression by means of specific questionnaires. The diagnosis of GERD was based on a pathological finding of esophageal pH monitoring. A positive response to PPI testing was defined as an improvement in chest pain >50% compared with the baseline score after 1 month of PPI therapy.

RESULTS

We included 30 consecutive patients (17 men/13 women) with a mean age of 49 years. Of these 30 patients, 20 with NCCP had GERD (67%, 95%CI: 47%-83%). A positive response to PPI therapy was observed in 13 of the 30 (43%) patients with NCCP: 11 of the 20 (55%) patients in the GERD-positive group and 2 of the 10 (20%) in the GERD-negative group. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PPI testing was 55%, 80%, 85%, 47% and 63%, respectively. A significant reduction in chest pain after pantoprazole therapy (P=.003) and a slight non significant improvement in anxiety and depression was achieved in the GERD-positive group as compared to the GERD-negative group.

CONCLUSIONS

In NCCP, PPI testing with pantoprazole has a low sensitivity for the diagnosis of GERD, placing in doubt the strategy of reserving functional study to non-responders to antisecretory therapy. Esophageal function testing and accurate diagnosis would allow appropriate targeted therapy for all patients with NCCP.

Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis

BACKGROUND

Non-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation. The objective of the present work was to identify important diagnostic indicators and their accuracy for specific and non-specific conditions underlying NCCP.

METHODS

A systematic review and meta-analysis were performed. In May 2012, six databases were searched. Hand and bibliography searches were also conducted. Studies evaluating a diagnostic test against a reference test in patients with NCCP were included. Exclusion criteria were having <30 patients per group, and evaluating diagnostic tests for acute cardiovascular disease. Diagnostic accuracy is given in likelihood ratios (LR): very good (LR+ >10, LR- <0.1); good (LR + 5 to 10, LR- 0.1 to 0.2); fair (LR + 2 to 5, LR- 0.2 to 0.5); or poor (LR + 1 to 2, LR- 0.5 to 1). Joined meta-analysis of the diagnostic test sensitivity and specificity was performed by applying a hierarchical Bayesian model.

RESULTS

Out of 6,316 records, 260 were reviewed in full text, and 28 were included: 20 investigating gastroesophageal reflux disorders (GERD), 3 musculoskeletal chest pain, and 5 psychiatric conditions. Study quality was good in 15 studies and moderate in 13. GERD diagnosis was more likely with typical GERD symptoms (LR + 2.70 and 2.75, LR- 0.42 and 0.78) than atypical GERD symptoms (LR + 0.49, LR- 2.71). GERD was also more likely with a positive response to a proton pump inhibitor (PPI) test (LR + 5.48, 7.13, and 8.56; LR- 0.24, 0.25, and 0.28); the posterior mean sensitivity and specificity of six studies were 0.89 (95% credible interval, 0.28 to 1) and 0.88 (95% credible interval, 0.26 to 1), respectively. Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders. Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa.

CONCLUSIONS

In patients with NCCP, thorough clinical evaluation of the patient's history, symptoms, and clinical findings can indicate the most appropriate diagnostic tests. Treatment response to high-dose PPI treatment provides important information regarding GERD, and should be considered early. Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of noncardiac chest pain in women

Noncardiac chest pain (NCCP) is very prevalent in the community. Although mortality remains low, morbidity and the financial implications are high. Women, especially those of middle age, should be thoroughly investigated as per current guidelines for coronary artery disease before labeling their chest pain as NCCP. Gastroesophageal reflux disease is the most common cause of NCCP; however other esophageal pathology including esophageal hypersensitivity, neuromuscular disease and eosinophilic esophagitis may also cause NCCP. Proton pump inhibitors are commonly used initially to manage NCCP, although patients who do not respond to this therapy require further investigation and differing treatment regimes. This article will focus on current knowledge regarding GI tract-related NCCP management strategies.

Effect of synthetic cationic protein on mechanoexcitability of vagal afferent nerve subtypes in guinea pig esophagus

Eosinophilic esophagitis is characterized by increased infiltration and degranulation of eosinophils in the esophagus. Whether eosinophil-derived cationic proteins regulate esophageal sensory nerve function is still unknown. Using synthetic cationic protein to investigate such effect, we performed extracellular recordings from vagal nodose or jugular neurons in ex vivo esophageal-vagal preparations with intact nerve endings in the esophagus. Nerve excitabilities were determined by comparing action potentials evoked by esophageal distensions before and after perfusion of synthetic cationic protein poly-L-lysine (PLL) with or without pretreatment with poly-L-glutamic acid (PLGA), which neutralized cationic charges of PLL. Perfusion with PLL did not evoke action potentials in esophageal nodose C fibers but increased their responses to esophageal distension. This potentiation effect lasted for 30 min after washing out of PLL. Pretreatment with PLGA significantly inhibited PLL-induced mechanohyperexcitability of esophageal nodose C fibers. In esophageal nodose Aδ fibers, perfusion with PLL did not evoke action potentials. In contrast to nodose C fibers, both the spontaneous discharges and the responses to esophageal distension in nodose Aδ fibers were decreased by perfusion with PLL, which can be restored after washing out PLL for 30-60 min. Pretreatment with PLGA attenuated PLL-induced decrease in spontaneous discharge and mechanoexcitability of esophageal nodose Aδ fibers. In esophageal jugular C fibers, PLL neither evoked action potentials nor changed their responses to esophageal distension. Collectively, these data demonstrated that synthetic cationic protein did not evoke action potential discharges of esophageal vagal afferents but had distinctive sensitization effects on their responses to esophageal distension.