1
|
Collins MH, Arva NC, Bernieh A, Lopez-Nunez O, Pletneva M, Yang GY. Histopathology of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:205-221. [PMID: 38575219 DOI: 10.1016/j.iac.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Microscopic examination of esophageal biopsies is essential to diagnose eosinophilic esophagitis (EoE). Eosinophil inflammation is the basis for the diagnosis, but additional abnormalities may contribute to persistent symptoms and epithelial barrier dysfunction. Both peak eosinophil count and assessments of additional features should be included in pre-therapy and post-therapy pathology reports. Pathologic abnormalities identified in esophageal biopsies of EoE are reversible in contrast to esophageal strictures.
Collapse
Affiliation(s)
- Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Pathology ML1035, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Nicoleta C Arva
- Department of Pathology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Anas Bernieh
- Pathology ML1035, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave.nue Cincinnati, OH 45229, USA
| | - Oscar Lopez-Nunez
- Pathology ML1035, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave.nue Cincinnati, OH 45229, USA
| | - Maria Pletneva
- Department of Pathology, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132, USA
| | - Guang-Yu Yang
- Department of Pathology, Ward Building Ward 4-115, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL. 60611, USA
| |
Collapse
|
2
|
Biedermann L, Straumann A. Clinical Evaluation of the Adult with Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:185-196. [PMID: 38575217 DOI: 10.1016/j.iac.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Adult patients with eosinophilic esophagitis (EoE) typically present with a history of dysphagia for solids, sometimes with additional reflux-like pain and a history of prior food impactions. In contrast to these alarming symptoms, the general appearance and physical examination of adult patients with EoE is in line with apparently healthy individuals. Therefore, the diagnosis is based on a history of solid-food dysphagia and eosinophilic tissue infiltration. Importantly, the increasing prevalence of EoE variants, that is, typical EoE symptoms in the absence of a relevant eosinophilia, and several studies with eosinophil-targeting drugs, call the pathogenic role of eosinophils into question.
Collapse
Affiliation(s)
- Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrassse 100, CH-8091 Zurich, Switzerland.
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrassse 100, CH-8091 Zurich, Switzerland
| |
Collapse
|
3
|
Simadibrata DM, Lesmana E, Fass R. Role of endoscopy in gastroesophageal reflux disease. Clin Endosc 2023; 56:681-692. [PMID: 37822063 PMCID: PMC10665616 DOI: 10.5946/ce.2023.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 10/13/2023] Open
Abstract
In general, gastroesophageal reflux disease (GERD) is diagnosed clinically based on typical symptoms and/or response to proton pump inhibitor treatment. Upper gastrointestinal endoscopy is reserved for patients presenting with alarm symptoms, such as dysphagia, odynophagia, significant weight loss, gastrointestinal bleeding, or anorexia; those who meet the criteria for Barrett's esophagus screening; those who report a lack or partial response to proton pump inhibitor treatment; and those with prior endoscopic or surgical anti-reflux interventions. Newer endoscopic techniques are primarily used to increase diagnostic yield and provide an alternative to medical or surgical treatment for GERD. The available endoscopic modalities for the diagnosis of GERD include conventional endoscopy with white-light imaging, high-resolution and high-magnification endoscopy, chromoendoscopy, image-enhanced endoscopy (narrow-band imaging, I- SCAN, flexible spectral imaging color enhancement, blue laser imaging, and linked color imaging), and confocal laser endomicroscopy. Endoscopic techniques for treating GERD include esophageal radiofrequency energy delivery/Stretta procedure, transoral incisionless fundoplication, and endoscopic full-thickness plication. Other novel techniques include anti-reflux mucosectomy, peroral endoscopic cardiac constriction, endoscopic submucosal dissection, and endoscopic band ligation. Currently, many of the new endoscopic techniques are not widely available, and their use is limited to centers of excellence.
Collapse
Affiliation(s)
- Daniel Martin Simadibrata
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elvira Lesmana
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
4
|
Ptaschinski C, Zhu D, Fonseca W, Lukacs NW. Stem cell factor inhibition reduces Th2 inflammation and cellular infiltration in a mouse model of eosinophilic esophagitis. Mucosal Immunol 2023; 16:727-739. [PMID: 37557983 PMCID: PMC10680063 DOI: 10.1016/j.mucimm.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Abstract
Eosinophilic esophagitis (EoE) is a T helper (Th)2-mediated inflammatory disorder characterized endoscopically by eosinophilic infiltration leading to fibrosis of the esophagus. Stem cell factor (SCF), a multifunctional cytokine, is upregulated in several allergic diseases, including in patients with EoE. Mast cells and eosinophils express c-kit, the cell surface receptor for SCF, and have been found to play an important role in EoE. Therefore, we investigated whether blocking SCF represents a potential therapeutic approach for EoE. Esophageal inflammation was induced in mice using peanut allergen. In mice with experimental EoE, we found that SCF was upregulated in the esophageal tissue. In EoE mice injected with a polyclonal antibody specific for SCF, we observed a decrease in both mast cells and eosinophils by histological and flow cytometric analysis. Furthermore, Th2 cytokines in the esophagus were decreased in anti-SCF treated mice, as were levels of Th2 cytokines from lung-draining and esophageal lymph nodes. Serum levels of peanut-specific immunoglobulin E were reduced following treatment with anti-SCF. In Kitlf/f-Col1-Cre-ERT mice, which have SCF deleted primarily in myofibroblasts that develop in EoE, we observed similar results as the anti-SCF treated animals for inflammatory cell accumulation, cytokines, and histopathology. These results indicate that therapeutic treatments targeting SCF can reduce allergic inflammation in EoE.
Collapse
Affiliation(s)
- Catherine Ptaschinski
- Department of Pathology, University of Michigan, Ann Arbor, USA; Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, USA.
| | - Diana Zhu
- Department of Pathology, University of Michigan, Ann Arbor, USA
| | - Wendy Fonseca
- Department of Pathology, University of Michigan, Ann Arbor, USA
| | - Nicholas W Lukacs
- Department of Pathology, University of Michigan, Ann Arbor, USA; Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, USA
| |
Collapse
|
5
|
Franciosi JP, Gordon M, Sinopoulou V, Dellon ES, Gupta SK, Reed CC, Gutiérrez-Junquera C, Venkatesh RD, Erwin EA, Egiz A, Elleithy A, Mougey EB. Medical treatment of eosinophilic esophagitis. Cochrane Database Syst Rev 2023; 7:CD004065. [PMID: 37470293 PMCID: PMC10358040 DOI: 10.1002/14651858.cd004065.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic antigen-mediated eosinophilic inflammatory disease isolated to the esophagus. As a clinicopathologic disorder, a diagnosis of EoE requires a constellation of clinical symptoms of esophageal dysfunction and histologic findings (at least 15 eosinophils/high-powered microscope field (eos/hpf)). Current guidelines no longer require the failure of response to proton pump inhibitor medications to establish a diagnosis of EoE, but continue to suggest the exclusion of other etiologies of esophageal eosinophilia. The treatment goals for EoE are improvement in clinical symptoms, resolution of esophageal eosinophilia and other histologic abnormalities, endoscopic improvement, improved quality of life, improved esophageal function, minimized adverse effects of treatment, and prevention of disease progression and subsequent complications. Currently, there is no cure for EoE, making long-term treatment necessary. Standard treatment modalities include dietary modifications, esophageal dilation, and pharmacologic therapy. Effective pharmacologic therapies include corticosteroids, rapidly emerging biological therapies, and proton pump inhibitor medications. OBJECTIVES To evaluate the efficacy and safety of medical interventions for people with eosinophilic esophagitis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and WHO ICTRP to 3 March 2023. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing any medical intervention or food elimination diet for the treatment of eosinophilic esophagitis, either alone or in combination, to any other intervention (including placebo). DATA COLLECTION AND ANALYSIS Pairs of review authors independently selected studies and conducted data extraction and risk of bias assessment. We expressed outcomes as a risk ratio (RR) and as the mean or standardized mean difference (MD/SMD) with 95% confidence interval (CI). We assessed the certainty of the evidence using GRADE. Our primary outcomes were: clinical, histological, and endoscopic improvement, and withdrawals due to adverse events. Secondary outcomes were: serious and total adverse events, and quality of life. MAIN RESULTS We included 41 RCTs with 3253 participants. Eleven studies included pediatric patients while the rest recruited both children and adults. Four studies were in patients with inactive disease while the rest were in patients with active disease. We identified 19 intervention comparisons. In this abstract we present the results of the primary outcomes for the two main comparisons: corticosteroids versus placebo and biologics versus placebo, based on the prespecified outcomes defined of the primary studies. Fourteen studies compared corticosteroids to placebo for induction of remission and the risk of bias for these studies was mostly low. Corticosteroids may lead to slightly better clinical improvement (20% higher), measured dichotomously (risk ratio (RR) 1.74, 95% CI 1.08 to 2.80; 6 studies, 583 participants; number needed to treat for an additional beneficial outcome (NNTB) = 4; low certainty), and may lead to slightly better clinical improvement, measured continuously (standard mean difference (SMD) 0.51, 95% CI 0.17 to 0.85; 5 studies, 475 participants; low certainty). Corticosteroids lead to a large histological improvement (63% higher), measured dichotomously (RR 11.94, 95% CI 6.56 to 21.75; 12 studies, 978 participants; NNTB = 3; high certainty), and may lead to histological improvement, measured continuously (SMD 1.42, 95% CI 1.02 to 1.82; 5 studies, 449 participants; low certainty). Corticosteroids may lead to little to no endoscopic improvement, measured dichotomously (RR 2.60, 95% CI 0.82 to 8.19; 5 studies, 596 participants; low certainty), and may lead to endoscopic improvement, measured continuously (SMD 1.33, 95% CI 0.59 to 2.08; 5 studies, 596 participants; low certainty). Corticosteroids may lead to slightly fewer withdrawals due to adverse events (RR 0.64, 95% CI 0.43 to 0.96; 14 studies, 1032 participants; low certainty). Nine studies compared biologics to placebo for induction of remission. Biologics may result in little to no difference in clinical improvement, measured dichotomously (RR 1.14, 95% CI 0.85 to 1.52; 5 studies, 410 participants; low certainty), and may result in better clinical improvement, measured continuously (SMD 0.50, 95% CI 0.22 to 0.78; 7 studies, 387 participants; moderate certainty). Biologics result in better histological improvement (55% higher), measured dichotomously (RR 6.73, 95% CI 2.58 to 17.52; 8 studies, 925 participants; NNTB = 2; moderate certainty). We could not draw conclusions for this outcome when measured continuously (SMD 1.01, 95% CI 0.36 to 1.66; 6 studies, 370 participants; very low certainty). Biologics may result in little to no difference in endoscopic improvement, measured dichotomously (effect not estimable, low certainty). We cannot draw conclusions for this outcome when measured continuously (SMD 2.79, 95% CI 0.36 to 5.22; 1 study, 11 participants; very low certainty). There may be no difference in withdrawals due to adverse events (RR 1.55, 95% CI 0.88 to 2.74; 8 studies, 792 participants; low certainty). AUTHORS' CONCLUSIONS Corticosteroids (as compared to placebo) may lead to clinical symptom improvement when reported both as dichotomous and continuous outcomes, from the primary study definitions. Corticosteroids lead to a large increase in histological improvement (dichotomous outcome) and may increase histological improvement (continuous outcome) when compared to placebo. Corticosteroids may or may not increase endoscopic improvement (depending on whether the outcome is measured dichotomously or continuously). Withdrawals due to adverse events (dichotomous outcome) may occur less frequently when corticosteroids are compared to placebo. Biologics (as compared to placebo) may not lead to clinical symptom improvement when reported as a dichotomous outcome and may lead to an increase in clinical symptom improvement (as a continuous outcome), from the primary study definitions. Biologics lead to a large increase in histological improvement when reported as a dichotomous outcome, but this is uncertain when reported as a continuous outcome, as compared to placebo. Biologics may not increase endoscopic improvement (dichotomous outcome), but this is uncertain when measured as a continuous outcome. Withdrawals due to adverse events as a dichotomous outcome may occur as frequently when biologics are compared to placebo.
Collapse
Affiliation(s)
- James P Franciosi
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours Children's Hospital, Orlando, FL, USA
- College of Medicine, University of Central Florida, Orlando, USA
| | - Morris Gordon
- School of Medicine, University of Central Lancashire, Preston, UK
| | | | - Evan S Dellon
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine at Peoria and Children's Hospital of Illinois, Peoria, IN, USA
| | - Craig C Reed
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology, University Hospital Puerta de Hierro Majadahonda. Autonomous University of Madrid, Madrid, Spain
| | - Rajitha D Venkatesh
- Pediatrics, Gastroenterology & Hepatology & Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Elizabeth A Erwin
- Pediatric Allergy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Abdullah Egiz
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Assem Elleithy
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Edward B Mougey
- Clinical Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, USA
| |
Collapse
|
6
|
Keles MN, Ertoy Karagol HI, Serel Arslan S, Egritas Gurkan O, Sari S, Elbasan B, Dalgic B, Bakirtas A. Oropharyngeal Dysphagia in Children with Eosinophilic Esophagitis. Dysphagia 2023; 38:474-482. [PMID: 35781555 DOI: 10.1007/s00455-022-10489-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 06/20/2022] [Indexed: 01/27/2023]
Abstract
Dysphagia is the most troublesome symptom of eosinophilic esophagitis (EoE). This study aimed to investigate oropharyngeal dysphagia in children with EoE and possible related factors. Children with a definite diagnosis of EoE were included in the study. Medical and feeding histories were recorded. A disease control level was determined for each child. An oral structure examination, the Turkish version of the Mastication and Observation Evaluation (T-MOE), the Pediatric version of the Eating Assessment Tool-10 (PEDI-EAT-10) and the 3-oz water swallow test were applied in screening for oropharyngeal dysphagia. Fifty-two children participated in the study. Oropharyngeal dysphagia took the form of abnormal swallowing (PEDI-EAT-10 score ≥ 4) and increased aspiration risk (PEDI- EAT-10 score ≥ 13) in 51.9% and 25.0% of the children, respectively. Seven children failed the 3-oz water swallow test. Abnormal swallowing and aspiration risk were significantly higher in children with prolonged mealtimes, impaired chewing function, and uncontrolled disease (p < 0.05). Chewing function was the most important risk factor for abnormal swallowing and increased aspiration (R2 = 0.36, R2 = 0.52, p < 0.001, respectively). Oropharyngeal dysphagia is common in children with EoE and associated with increased aspiration risk in a subpopulation. Uncontrolled disease, prolonged mealtimes, and impaired chewing function may provide clues for oropharyngeal dysphagia in EoE.
Collapse
Affiliation(s)
- Muserrefe Nur Keles
- Department of Physiotherapy and Rehabilitation, Gazi University Faculty of Health Sciences, Cankaya, 06490, Ankara, Turkey.
| | | | - Selen Serel Arslan
- Faculty of Physiotherapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Odul Egritas Gurkan
- Department of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Sinan Sari
- Department of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Bulent Elbasan
- Department of Physiotherapy and Rehabilitation, Gazi University Faculty of Health Sciences, Cankaya, 06490, Ankara, Turkey
| | - Buket Dalgic
- Department of Pediatric Gastroenterology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Arzu Bakirtas
- Department of Pediatric Allergy, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | |
Collapse
|
7
|
Jiang ZY, Gatcliffe C, Mai T, Huang Z. Aerodigestive Approach to Pediatric Chronic Cough. Otolaryngol Clin North Am 2022; 55:1233-1242. [DOI: 10.1016/j.otc.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
8
|
Yalon M, Tahboub Amawi AD, Kelm ZS, Wells ML, Teo LLS, Heiken JP, Sheedy SP, Torbenson MS, Fidler JL, Venkatesh SK. Eosinophilic Disorders of the Gastrointestinal Tract and Associated Abdominal Viscera: Imaging Findings and Diagnosis. Radiographics 2022; 42:1081-1102. [PMID: 35749291 DOI: 10.1148/rg.220004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Eosinophilic gastrointestinal disorders (EGIDs) are inflammatory conditions of the gastrointestinal tract that are characterized by tissue eosinophilia and end-organ dysfunction or damage. Primary EGIDs are associated with atopy and other allergic conditions, whereas secondary EGIDs are associated with underlying systemic diseases or hypereosinophilic syndrome. Within the spectrum of EGIDs, eosinophilic esophagitis is the most prevalent. Eosinophilic gastroenteritis and eosinophilic colitis are relatively uncommon. Eosinophilic infiltration of the liver, biliary tree, and/or pancreas also can occur and mimic other inflammatory and malignant conditions. Although endoscopic evaluation is the method of choice for eosinophilic esophagitis, radiologic evaluation of the esophagus plays an important role in the assessment of disease severity. CT and MR enterography are the modalities of choice for demonstrating specific forms of eosinophilic gastroenteritis. CT and MRI are important in the detection of abdominal visceral involvement in EGIDs. Diagnosis is often challenging and relies on symptoms, imaging findings, histologic confirmation of tissue eosinophilia, and correlation with peripheral eosinophilia. Imaging is crucial for identifying characteristic organ-specific findings, although imaging findings are not specific. When promptly treated, EGIDs usually have a benign clinical course. However, a delayed diagnosis and associated surgical interventions have been associated with morbidity. Therefore, a radiologist's knowledge of the imaging findings of EGIDs in the appropriate clinical settings may aid in early diagnosis and thereby improve patient care. An overview of the clinical features and imaging findings of EGIDs and the eosinophilic disorders of associated abdominal viscera is provided. Online supplemental material is available for this article. ©RSNA, 2022.
Collapse
Affiliation(s)
- Mariana Yalon
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| | - Ali D Tahboub Amawi
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| | - Zachary S Kelm
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| | - Michael L Wells
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| | - Lynette L S Teo
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| | - Jay P Heiken
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| | - Shannon P Sheedy
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| | - Michael S Torbenson
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| | - Jeff L Fidler
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| | - Sudhakar K Venkatesh
- From the Department of Radiology (M.Y., A.D.T.A., Z.S.K., M.L.W., J.P.H., S.P.S., J.L.F., S.K.V.) and Department of Laboratory Medicine and Pathology (M.S.T.), Mayo Clinic, 200 2nd St SW, Rochester, MN 55905; and Department of Diagnostic Imaging, National University Health System, Singapore (L.L.S.T.)
| |
Collapse
|
9
|
Garcia E, Ladak Z, Landry T, Wollin M, Persad ARL, Sergi CM, Huynh HQ, Persad R, Persad S. Epithelial-mesenchymal transition, regulated by β-catenin and Twist, leads to esophageal wall remodeling in pediatric eosinophilic esophagitis. PLoS One 2022; 17:e0264622. [PMID: 35239721 PMCID: PMC8893662 DOI: 10.1371/journal.pone.0264622] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 02/14/2022] [Indexed: 01/07/2023] Open
Abstract
Eosinophilic Esophagitis (EoE) is an antigen-triggered inflammatory condition of the esophageal lining characterized by eosinophilic infiltration. EoE is associated with significant remodeling, and although this remodeling is reversed by current treatment regimens, symptoms of EoE and associated remodeling reappear upon cessation of therapies. We hypothesized that structural remodeling of cell-cell adhesion is a key factor in the pathogenesis of EoE and that epithelial to mesenchymal transition (EMT) was a viable molecular process to lead to this remodeling. Endoscopically obtained biopsy samples from 18 EoE and 18 control pediatric patients were evaluated by transmission electron microscopy to measure intercellular spaces (IS) between cells. Biopsy samples from all groups were analyzed for cellular levels of cell-cell adhesion proteins: E-cadherin, zonula occludens associated protein-1 (ZO-1), and N-cadherin. We also analyzed for cellular levels and localization two of transcription factors, Twist1 and β-catenin, that are associated with promoting EMT. The IS was significantly increased in the EoE group compared to the control. We observed a significant decrease in E-cadherin and ZO-1 levels and a concomitant increase in N-cadherin levels in EoE samples compared to control. Further, while there was no significant change in cellular levels of β-catenin, we observed an altered localization of the protein from the cell membrane in control tissue to a nuclear/perinuclear localization in EoE. We observed higher levels of the transcription factor Twist1 in the EoE group compared to normal which was localized mainly at the nucleus. Our results suggest that the integrity of normally sealed esophageal epithelia is compromised in the EoE patients compared to control subjects, and this is due to alterations in the expression of cell adhesion molecules at the esophageal epithelium. Our data also suggest that EMT, potentially regulated by transcription factors β-catenin and Twist1, may be responsible for the molecular alteration which leads to the remodeling of esophageal epithelia in EoE.
Collapse
Affiliation(s)
- Elizabeth Garcia
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Zeenat Ladak
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Takaaki Landry
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Wollin
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Amit R. L. Persad
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Consolato M. Sergi
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Hien Q. Huynh
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Sujata Persad
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
| |
Collapse
|
10
|
Barni S, Arasi S, Mastrorilli C, Pecoraro L, Giovannini M, Mori F, Liotti L, Saretta F, Castagnoli R, Caminiti L, Cianferoni A, Novembre E. Pediatric eosinophilic esophagitis: a review for the clinician. Ital J Pediatr 2021; 47:230. [PMID: 34809686 PMCID: PMC8609874 DOI: 10.1186/s13052-021-01178-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 10/27/2021] [Indexed: 12/16/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic clinical-pathologic disease characterized by eosinophilic infiltration of the esophageal epithelium with esophageal dysfunction symptoms.EoE can occur at any age and has different clinical manifestations depending on the age onset.To date, esophago-gastroduodenal endoscopy (EGD) with biopsy is the gold-standard for EoE diagnosis.According to the recent consensus guidelines, proton pump inhibitors, corticosteroids and elimination diets could be a first-line therapy option. The aim of the treatment is clinical and histological remission for preventing long-lasting untreatable fibrosis.A multidisciplinary approach (allergist, gastroenterology, dietitian, and pathologist) is recommended for managing patients affected by EoE, given the complexity of its treatment.This review will provide a practical guide to assist pediatricians treating children with EoE.Moreover, it highlights the unmet needs in diagnosis and treatment that require urgent attention from the scientific community in the aim of improving the management of patients with EoE.
Collapse
Affiliation(s)
- Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Stefania Arasi
- Predictive and Preventive Medicine Research Unit, Multifactorial and Systemic Diseases Research Area, Pediatric Allergy Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Carla Mastrorilli
- Pediatric Unit and Emergency, University Hospital Consortium Corporation Polyclinic of Bari, Pediatric Hospital Giovanni XXIII, Bari, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Luca Pecoraro
- Department of Medicine, University of Verona, Policlinico GB Rossi, Verona, Italy
- Pediatric Unit, ASST Mantua, Mantua, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Lucia Liotti
- Pediatric Unit, Senigallia Hospital, Senigallia, Italy
| | - Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Riccardo Castagnoli
- Department of Pediatrics, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Development Age “Gaetano Barresi”, Allergy Unit, Department of Pediatrics, AOU Policlinico Gaetano Martino, Messina, Italy
| | - Antonella Cianferoni
- Pediatrics Department, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Allergy and Immunology Division, The Children’s Hospital of Philadelphia, Philadelphia, USA
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| |
Collapse
|
11
|
Fass R, Boeckxstaens GE, El-Serag H, Rosen R, Sifrim D, Vaezi MF. Gastro-oesophageal reflux disease. Nat Rev Dis Primers 2021; 7:55. [PMID: 34326345 DOI: 10.1038/s41572-021-00287-w] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 02/07/2023]
Abstract
Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.
Collapse
Affiliation(s)
- Ronnie Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical System, Case Western Reserve University, Cleveland, OH, USA.
| | - Guy E Boeckxstaens
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Royal London Hospital, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
12
|
Burris AD, Burris J, Järvinen KM. Cow's Milk Protein Allergy in Term and Preterm Infants: Clinical Manifestations, Immunologic Pathophysiology, and Management Strategies. Neoreviews 2020; 21:e795-e808. [PMID: 33262206 DOI: 10.1542/neo.21-12-e795] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cow's milk allergy is a common food allergy among infants. Symptoms of cow's milk allergy are wide-ranging and depend on the mechanism involved. There are immunoglobulin E (IgE)-mediated, non-IgE-mediated, and mixed mechanisms of food allergy. Symptoms of IgE-mediated cow's milk allergy may be mild or may progress to anaphylaxis, which can be life-threatening. Non-IgE-mediated allergy includes food protein-induced allergic proctocolitis (FPIAP), food protein-induced enterocolitis syndrome, food protein-induced enteropathy, and Heiner syndrome (pulmonary hemosiderosis). These diagnoses comprise about half of all cow's milk allergies. The most common manifestation of cow's milk allergy in infants is FPIAP. FPIAP is commonly seen in healthy, full-term infants who present with rectal bleeding and are otherwise well-appearing. This can occur in both formula-fed and exclusively breastfed infants. Food proteins secreted in maternal breast milk can contribute to the development of these symptoms. Maternal cow's milk elimination diet is often successful in helping resolve symptoms. A period of reintroduction of cow's milk resulting in re-emergence of symptoms in stable asymptomatic infants is an excellent diagnostic tool to confirm a cow's milk allergy. Preterm infants are susceptible to food allergy, as demonstrated from several case reports of necrotizing enterocolitis-like illnesses that responded clinically to cow's milk elimination. Further study is needed about food allergy in the preterm infant population.
Collapse
Affiliation(s)
- Amy D Burris
- Division of Allergy and Immunology and Center for Food Allergy, and
| | - Jonathan Burris
- Division of Neonatology, Department of Pediatrics, University of Rochester School of Medicine and Dentistry and Golisano Children's Hospital, Rochester, NY
| | - Kirsi M Järvinen
- Division of Allergy and Immunology and Center for Food Allergy, and
| |
Collapse
|
13
|
Pediatric Eosinophilic Esophagitis: Results of the European Retrospective Pediatric Eosinophilic Esophagitis Registry (RetroPEER). J Pediatr Gastroenterol Nutr 2019; 68:552-558. [PMID: 30540712 DOI: 10.1097/mpg.0000000000002215] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Recommendations for diagnosing and treating eosinophilic esophagitis (EoE) are evolving; however, information on real world clinical practice is lacking. To assess the practices of pediatric gastroenterologists diagnosing and treating EoE and to identify the triggering allergens in European children. METHODS Retrospective anonymized data were collected from 26 European pediatric gastroenterology centers in 13 countries. Inclusion criteria were: Patients diagnosis with EoE, completed investigations prescribed by the treating physician, and were on stable medical or dietary interventions. RESULTS In total, 410 patients diagnosed between December 1999 and June 2016 were analyzed, 76.3% boys. The time from symptoms to diagnosis was 12 ± 33.5 months and age at diagnosis was 8.9 ± 4.75 years. The most frequent indications for endoscopy were: dysphagia (38%), gastroesophageal reflux (31.2%), bolus impaction (24.4%), and failure to thrive (10.5%). Approximately 70.3% had failed proton pump inhibitor treatment. The foods found to be causative of EoE by elimination and rechallenge were milk (42%), egg (21.5%), wheat/gluten (10.9%), and peanut (9.9%). Elimination diets were used exclusively in 154 of 410 (37.5%), topical steroids without elimination diets in 52 of 410 (12.6%), both diet and steroids in 183 of 410 (44.6%), systemic steroids in 22 of 410 (5.3%), and esophageal dilation in 7 of 410 (1.7%). Patient refusal, shortage of endoscopy time, and reluctance to perform multiple endoscopies per patient were noted as factors justifying deviation from guidelines. CONCLUSIONS In this "real world" pediatric European cohort, milk and egg were the most common allergens triggering EoE. Although high-dose proton pump inhibitor trials have increased, attempted PPI treatment is not universal.
Collapse
|
14
|
Cianferoni A, Shuker M, Brown-Whitehorn T, Hunter H, Venter C, Spergel JM. Food avoidance strategies in eosinophilic oesophagitis. Clin Exp Allergy 2019; 49:269-284. [DOI: 10.1111/cea.13360] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Antonella Cianferoni
- Division of Allergy and Immunology; The Children’s Hospital of Phialdelphia; Phialdelphia Pennsylvania
- Department of Pediatrics; Perelman School of Medicine; University of Pennsylvania
| | - Michelle Shuker
- Division of Allergy and Immunology; The Children’s Hospital of Phialdelphia; Phialdelphia Pennsylvania
| | - Terri Brown-Whitehorn
- Division of Allergy and Immunology; The Children’s Hospital of Phialdelphia; Phialdelphia Pennsylvania
- Department of Pediatrics; Perelman School of Medicine; University of Pennsylvania
| | - Hannah Hunter
- Allergy; Guy's and Saint Thomas’ NHS Foundation Trust; London UK
| | - Carina Venter
- Allergy and Immunology; Children's Hospital Colorado; Aurora Colorado
| | - Jonathan M. Spergel
- Division of Allergy and Immunology; The Children’s Hospital of Phialdelphia; Phialdelphia Pennsylvania
- Department of Pediatrics; Perelman School of Medicine; University of Pennsylvania
| |
Collapse
|
15
|
Rubinstein E, Rosen RL. Respiratory symptoms associated with eosinophilic esophagitis. Pediatr Pulmonol 2018; 53:1587-1591. [PMID: 30238702 DOI: 10.1002/ppul.24168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/04/2018] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is an atopic condition diagnosed based on eosinophilic infiltration in the esophagus and symptoms of esophageal dysfunction. Typical clinical manifestations of EoE include feeding refusal, vomiting, and dysphagia however recent reports highlight an associations with extraesophageal symptoms. By definition the inflammatory response in EoE is restricted to the esophagus. However, accounts of symptoms such as chronic refractory cough, recurrent croup, hoarseness as well as subglottic stenosis, and an increase in otolaryngologic surgeries in patients with EoE raise the possibility of extraesophageal manifestations of the disease. These symptoms have been reported at times in the absence of typical gastrointestinal symptoms. While the condition is usually managed by gastroenterologist and/or allergist, the presence of extraesophageal symptoms and comorbid conditions may result in patients presenting initially to providers in other subspecialties such as pulmonology and otorhinolaryngology. The use of proton pump inhibitors and corticosteroids are part of the management of EoE. Awareness of the possibility of EoE before the empiric use of these therapies is important as there use can make identifying and diagnosing patients with EoE correctly challenging. We review the medical literature regarding extraesophageal manifestations of EoE and highlight the importance of awareness for subspecialist outside of gastroenterology and allergy for the condition.
Collapse
Affiliation(s)
- Eitan Rubinstein
- Aerodigestive Center, Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel L Rosen
- Aerodigestive Center, Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
16
|
Abstract
Although eosinophilic esophagitis (EoE) has been described in the literature for a substantial period, its recognition as a disease entity on the global stage is still relatively new. It has become a major diagnosis of consideration by medical providers when both adult and pediatric patients present with dysphagia, food impaction, and gastroesophageal reflux-like symptoms. In addition to the clinical work of specialists such as allergy-immunologists and gastroenterologists, the evolution of research organizations and advocacy groups focused on EoE have greatly assisted in bringing attention to, and raising awareness about, this disease. As a result of their efforts, diagnosis and treatment guidelines have been developed, and medical providers now have a specific ICD code for EoE. This represents a new model for the interaction of patients and medical provider, where patients not only advocate for their disorder, but also drive physician education and a patient-centered research agenda and its funding. It should be noted, though, that these organizations and advocacy groups are mainly located in North America and Europe, and as a result, EoE has largely been associated with the Caucasian demographic. However, it has been described in Asia, the Middle East, Latin America, and Africa. Physicians from these areas have increased awareness and understanding in the medical and research communities in their countries through case reports and the establishment and analysis of potential patient cohorts. At this time, the prevalence of EoE in these regions is comparably lower, but this may be due to less recognition and understanding of EoE, as well as medical efforts being directed towards more ubiquitous disease processes, such as infectious diseases. With the support and ongoing work of researchers, patients, and their family members, understanding and recognition of EoE as a clinically significant disease entity will continue to grow.
Collapse
|
17
|
Adamiak T, Plati KF. Pediatric Esophageal Disorders: Diagnosis and Treatment of Reflux and Eosinophilic Esophagitis. Pediatr Rev 2018; 39:392-402. [PMID: 30068740 DOI: 10.1542/pir.2017-0266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Gastroesophageal reflux (GER) occurs frequently in infants, generally at its worst at 4 months of age, with approximately two-thirds of infants spitting up daily. GER typically improves after 7 months of age, with only ∼5% of infants continuing to have reflux at 1 year of age. The diagnosis can often be made based on clinical symptoms. Upper GI (UGI) study has low sensitivity and specificity and should not be ordered as a diagnostic test for reflux. UGI study is best for evaluating other anatomic causes of vomiting. GER becomes problematic gastroesophageal reflux disease (GERD) when complications are present, including feeding difficulties and poor weight gain. Conservative treatment and thickened formula can be helpful for treating GERD. Proton pump inhibitors (PPIs) are frequently prescribed for treating reflux. However, studies do not show a definite benefit in infants, and there are potential side effects. Older children with GERD may present with regurgitation, heartburn, chest discomfort, dysphagia, abdominal pain, vomiting, poor appetite, or poor weight gain. Upper endoscopy is considered for children with concerning symptoms, persistent symptoms despite treatment, and relapse of symptoms after treatment. Other esophageal disorders can have a similar clinical presentation as GERD, notably eosinophilic esophagitis (EoE). EoE is a chronic immune-mediated disorder of the esophagus, which may present as dysphagia, food impaction, heartburn, vomiting, abdominal pain, feeding difficulties, or failure to thrive. Diagnosis is made histologically by the presence of esophageal eosinophilia on endoscopic biopsies in the correct clinical setting.
Collapse
Affiliation(s)
- Tonya Adamiak
- Department of Pediatrics, Sanford Children's Hospital, Sioux Falls, SD
| | | |
Collapse
|
18
|
Abstract
OBJECTIVE Pediatric colonic eosinophilia represents a confounding finding with a wide differential. It is often difficult to determine which children may progress to inflammatory bowel disease (IBD), which have an eosinophilic colitis (EC), and which may have no underlying pathology. There is little guidance for the practitioner on the approach to these patients. To define the clinical presentations of colonic eosinophilia and identify factors which may aid in diagnosis we reviewed patients with colonic eosinophilia and the clinicopathologic factors associated with their diagnoses. METHODS An 8-year retrospective chart review of children whose histopathology identified colonic eosinophilia (N = 72) compared to controls with normal biopsies (N = 35). RESULTS Patients with colonic eosinophilia had increased eosinophils/high-power field compared to controls (P < 0.001) and had 3 clinical phenotypes. Thirty-six percent had an inflammatory phenotype with elevated erythrocyte sedimentation rate (P < .0001), chronic inflammation on colonic biopsies (P < 0.001), and were diagnosed as having IBD. Thirty-seven percent were diagnosed as having EC, associated with male sex (P < 0.005) and peripheral eosinophilia (P = 0.041). Twenty-one percent had no significant colonic pathology. Forty-three percent of patients had >1 colonoscopy and 68% of these had change from initial diagnoses. CONCLUSIONS There are 3 main phenotypes of children with colonic eosinophilia. Signs of chronic systemic inflammation raise suspicion for IBD. Peripheral eosinophilia and male sex are associated with EC. A significant percent of children with colonic eosinophilia do not have colonic disease. Eosinophils/high-power field is not reliable to differentiate etiologies. Repeat colonoscopies may be required to reach final diagnoses.
Collapse
|
19
|
Schuyler AJ, Wilson JM, Tripathi A, Commins SP, Ogbogu PU, Kruzsewski PG, Barnes BH, McGowan EC, Workman LJ, Lidholm J, Rifas-Shiman SL, Oken E, Gold DR, Platts-Mills TAE, Erwin EA. Specific IgG 4 antibodies to cow's milk proteins in pediatric patients with eosinophilic esophagitis. J Allergy Clin Immunol 2018; 142:139-148.e12. [PMID: 29678750 DOI: 10.1016/j.jaci.2018.02.049] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 02/13/2018] [Accepted: 02/20/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Allergen-specific IgG4 (sIgG4) antibodies are often associated with tolerance, but sIgG4 antibodies to causally relevant foods have been reported recently in adults with eosinophilic esophagitis (EoE). Prevalence and levels of food sIgG4 are not well established in the general pediatric population. OBJECTIVE We sought to investigate serum food sIgG4 with component diagnostics in children with EoE and children from an unselected birth cohort and to explore the effects of sex, age, and milk consumption on sIgG4 levels. METHODS Sera from 71 pediatric patients with EoE and 210 early adolescent children from an unselected birth cohort (Project Viva) were assayed for sIgG4 and specific IgE (sIgE) to major cow's milk (CM) proteins (α-lactalbumin, β-lactoglobulin, and caseins) and to wheat, soy, egg, and peanut proteins. RESULTS In the EoE cohort high-titer sIgG4 (≥10 μg/mL) to CM proteins was more common than in control sera and achieved odds ratios for EoE ranging from 5.5 to 8.4. sIgE levels to CM proteins were mostly 4 IU/mL or less in patients with EoE, such that sIgG4/sIgE ratios were often 10,000 or greater. When adjusted for age and milk consumption, high-titer sIgG4 to CM proteins was strongly associated with EoE, with an odds ratio of greater than 20 to all 3 CM proteins in boys. CONCLUSIONS sIgG4 to CM proteins are common and high titer in children with EoE. Although it is not clear that this response is pathogenic, sIgG4 levels imply that these antibodies are an important feature of the local immune response that gives rise to EoE.
Collapse
Affiliation(s)
- Alexander J Schuyler
- Division of Allergy & Clinical Immunology, University of Virginia, Charlottesville, Va
| | - Jeffrey M Wilson
- Division of Allergy & Clinical Immunology, University of Virginia, Charlottesville, Va
| | - Anubha Tripathi
- Division of Allergy & Clinical Immunology, University of Virginia, Charlottesville, Va
| | - Scott P Commins
- Division of Rheumatology, Allergy & Immunology, University of North Carolina, Chapel Hill, NC
| | - Princess U Ogbogu
- Allergy and Immunology, Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Patrice G Kruzsewski
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Emory University, Atlanta, Ga
| | - Barrett H Barnes
- Division of Pediatric Gastroenterology, University of Virginia, Charlottesville, Va
| | - Emily C McGowan
- Division of Allergy & Clinical Immunology, University of Virginia, Charlottesville, Va
| | - Lisa J Workman
- Division of Allergy & Clinical Immunology, University of Virginia, Charlottesville, Va
| | | | - Sheryl L Rifas-Shiman
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Emily Oken
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Diane R Gold
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Mass
| | | | - Elizabeth A Erwin
- Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, Ohio.
| |
Collapse
|
20
|
Shaheen NJ, Mukkada V, Eichinger CS, Schofield H, Todorova L, Falk GW. Natural history of eosinophilic esophagitis: a systematic review of epidemiology and disease course. Dis Esophagus 2018; 31:4958126. [PMID: 29617744 PMCID: PMC6102800 DOI: 10.1093/dote/doy015] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/03/2018] [Indexed: 12/14/2022]
Abstract
Eosinophilic esophagitis is a chronic immune-mediated esophageal disorder. For its timely diagnosis, clinicians must recognize common symptoms, and understand differences in symptoms across patient groups. The aim of this study is to systematically review the epidemiology and natural history of eosinophilic esophagitis. The MEDLINE, Embase, and Cochrane databases were searched from 1974 to February 2017 for studies describing the epidemiology and natural history of eosinophilic esophagitis. Congress abstracts from 2014 to 2016 were also searched. Search results were screened against predetermined inclusion/exclusion criteria by two independent reviewers, and data extraction was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 1376 articles identified, 47 met the inclusion criteria: 20 on epidemiology and 27 on natural history. Incidence and prevalence of eosinophilic esophagitis varied widely across North America and Europe, and increased over time. Incidence increased 131-fold in the Netherlands (1996-2010), 20-fold in Denmark (1997-2006), and 5.1-fold in Calgary, Canada (2004-2008). The most commonly reported symptoms were emesis and abdominal pain in children, and dysphagia and food impaction in adults. Age at diagnosis was 5.9-12.0 years in children, and approximately 30 years in adults. Time between symptom onset and diagnosis was 1.2-3.5 years in children and 3.0-8.0 years in adults. Diagnostic delay was associated with an increased risk of endoscopic features of fibrostenosis. Symptoms of eosinophilic esophagitis differed significantly by age and race. In conclusion, there is an increasing incidence and prevalence of eosinophilic esophagitis. The considerable delay between symptom onset and diagnosis suggests that clinicians do not readily recognize the disease, which may have important clinical ramifications.
Collapse
Affiliation(s)
- N J Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina,Address correspondence to: Nicholas J. Shaheen, MD, MPH, Division of Gastroenterology & Hepatology, University of North Carolina School of Medicine, CB#7080, 130 Mason Farm Road, Suite 4150, Chapel Hill, NC 27599-7080, USA.
| | - V Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | | | - G W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
21
|
May M, Abrams JA. Emerging Insights into the Esophageal Microbiome. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2018; 16:72-85. [PMID: 29350339 PMCID: PMC5843540 DOI: 10.1007/s11938-018-0171-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Analysis of the esophageal microbiome remains a relatively new field of research, and most studies to date have focused on characterizing the esophageal microbiome in states of health and disease. Microbiome alterations have been implicated in the pathogenesis of inflammatory and neoplastic conditions in the colon and elsewhere in the gastrointestinal tract. The epidemiology of various esophageal conditions including Barrett's esophagus (BE), esophageal adenocarcinoma (EAC), esophageal squamous cell carcinoma (ESCC), and eosinophilic esophagitis (EoE) point to the microbiome as a potential co-factor in disease pathogenesis, and the possibility exists that these microbiome alterations could contribute directly to the inflammatory environments necessary for the carcinogenesis or atopy involved in these conditions. RECENT FINDINGS The native esophageal microbiome is similar in composition to the oral microbiome, with a high relative abundance of the phylum Firmicutes and the genus Streptococcus. Limited studies to date suggest that there are certain microbiome alterations associated with esophageal diseases. Additionally, it may be possible to indirectly assess the esophageal microbiome via non-endoscopic means. This raises the possibility that non-invasive microbiome analysis could be used for disease screening and monitoring. Further understanding of the role of the esophageal microbiome in disease pathogenesis, as well as methods for microbiome alteration, may help elucidate future targets for disease modifying therapies, or minimally invasive screening tools in patients at high risk for development of various esophageal conditions.
Collapse
Affiliation(s)
- Michael May
- Department of Medicine, Columbia University College of Physicians & Surgeons, 630 W 168th Street, P&S 3-401, New York, NY, 10032, USA
| | - Julian A Abrams
- Department of Medicine, Columbia University College of Physicians & Surgeons, 630 W 168th Street, P&S 3-401, New York, NY, 10032, USA.
| |
Collapse
|
22
|
He YT, Christos PJ, Reisacher WR. Airborne and food sensitization patterns in children and adults with eosinophilic esophagitis. Int Forum Allergy Rhinol 2018; 8:571-576. [DOI: 10.1002/alr.22095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/20/2017] [Accepted: 01/10/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Yu Ting He
- Weill Cornell Medical College; New York NY
| | - Paul J. Christos
- Department of Healthcare Policy & Research; Weill Cornell Medical College; New York NY
| | - William R. Reisacher
- Department of Otolaryngology-Head and Neck Surgery; Weill Cornell Medical College; New York NY
| |
Collapse
|
23
|
A Statistically Significant Association Between Esophageal Granular Cell Tumors and Eosinophilic Esophagitis: A 16-year Analysis at Two Large Hospitals of 167,434 EGDs. Dig Dis Sci 2017; 62:3517-3524. [PMID: 29064014 DOI: 10.1007/s10620-017-4802-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/10/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Esophageal granular cell tumor (eGCT) is a rare, usually benign, neoplasm of neuroectodermic origin. Eosinophilic esophagitis (EoE) is a relatively uncommon, immune-mediated, chronic disease. Both diseases commonly present with dysphagia. One case has been reported of simultaneous occurrence of both diseases. AIMS To determine the association between diseases. METHODS The present study was an IRB-approved, retrospective review of esophagogastroduodenoscopies (EGDs) with esophageal biopsies from two large hospitals, 1999-2014. RESULTS Among 29,235 EGDs with esophageal biopsies for 16 years (167,434 total EGDs), 16 patients had pathologically diagnosed eGCT, and 1225 patients had pathologically diagnosed EoE. Five (31%) of 16 patients with eGCT had concomitant EoE (p = 0.001, OR 10.43, 95% ORCI 3.16-32.44, Fisher's exact test). Patients with simultaneous eGCT and EoE were young (mean age = 33.6 ± 12.9 years). Three were female. Dysphagia was presenting symptom in 4 (80%) of patients. Three had asthma. All five patients had > 20 eosinophils/hpf in esophageal biopsy specimens. Three patients had endoscopic esophageal abnormalities suggesting EoE. Four patients were treated with a PPI (before and after diagnosis of EoE), and 2 patients underwent six-food-elimination diet with partial symptomatic improvement. The eGCTs averaged 13.4 ± 4.2 mm in maximal diameter and were located in upper-2, middle-2, and lower esophagus-2 (1 patient had 2 eGCTs). eGCTs were endoscopically resected-3 patients, and monitored-2 patients. Surveillance endoscopies revealed no recurrence or growth of eGCTs after resection (mean follow-up = 4.6 years). CONCLUSIONS This novel report of 5 patients with simultaneous EoE and eGCT adds to one, previously published case and suggests these two diseases are associated, and have a common pathophysiologic link, despite apparently different pathogenesis. Large, prospective, endoscopic and pathologic studies are warranted to further investigate this association.
Collapse
|
24
|
Wilson JM, McGowan EC. Diagnosis and Management of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2017; 38:125-139. [PMID: 29132668 DOI: 10.1016/j.iac.2017.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Unlike traditional food allergies, immunoglobulin E (IgE) is not a key mediator of eosinophilic esophagitis (EoE). Nonetheless, foods antigens are important triggers of EoE, and allergists play an important role in management of this chronic disease. This review addresses insights into the diagnosis and management as it relates to our evolving understanding about the pathogenesis of EoE.
Collapse
Affiliation(s)
- Jeffrey M Wilson
- Division of Allergy and Immunology, Department of Medicine, University of Virginia, PO Box 801355, Charlottesville, VA 22908, USA
| | - Emily C McGowan
- Division of Allergy and Immunology, Department of Medicine, University of Virginia, PO Box 801355, Charlottesville, VA 22908, USA; Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, 501 Hopkins Bayview Circle, Baltimore, MD 21224, USA.
| |
Collapse
|
25
|
Erwin EA, Rhoda DA, Redmond M, Ly JB, Russo JM, Hill ID, Platts-Mills TA. Using Serum IgE Antibodies to Predict Esophageal Eosinophilia in Children. J Pediatr Gastroenterol Nutr 2017; 65:520-525. [PMID: 28981449 PMCID: PMC5665571 DOI: 10.1097/mpg.0000000000001553] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Symptoms of eosinophilic esophagitis are variable and can be nonspecific. Food-specific serum immunoglobulin E (IgE) antibodies are frequently found in patients with eosinophilic esophagitis and are obtained using a widely available blood test. Our objective was to evaluate the ability of food-specific IgE antibodies to predict the presence of esophageal eosinophilia. METHODS We reviewed 144 medical records for pediatric patients having esophageal biopsy and serum analysis for IgE antibodies to food (exploratory group). We performed logistic regression using sex and number of positive food-specific IgE tests to develop a model that predicts ≥15 eosinophils/high-power field (hpf) in the esophagus. We tested the model using 142 additional patients (validation group). RESULTS The probability of having ≥15 eosinophils/hpf in the esophagus was higher in boys and increased with the number of positive food-specific IgE tests from 12% (95% confidence interval 4.8-26) in girls with 0 foods positive to 86% (95% confidence interval 71-94) for boys with 4 or 5 foods positive. The statistical model using sex and number of positive IgE tests to predict patients having ≥15 eosinophils/hpf showed acceptable discriminative ability (area under the receiver operating characteristic curve 0.80). The performance metrics for the model to predict ≥15 eosinophils/hpf in the validation group were similar (area under the receiver operating characteristic curve 0.75). CONCLUSIONS Requiring only a blood test and a simple algorithm, analysis for IgE antibodies to food may expedite an esophagogastroduodenoscopy and decrease delays in the diagnosis and treatment of patients with nonspecific gastrointestinal symptoms who have increased eosinophils in the esophagus.
Collapse
Affiliation(s)
- Elizabeth A. Erwin
- Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, OH
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Margaret Redmond
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jean B. Ly
- Division of Allergy and Immunology, All Children's Hospital, Sarasota, FL
| | - John M. Russo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Ivor D. Hill
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | | |
Collapse
|
26
|
The Association Between Celiac Disease and Eosinophilic Esophagitis: Mayo Experience and Meta-analysis of the Literature. J Pediatr Gastroenterol Nutr 2017; 65:58-63. [PMID: 28045773 DOI: 10.1097/mpg.0000000000001499] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The association between celiac disease (CD) and eosinophilic esophagitis (EoE) has been the focus of multiple studies with variable results. Both diseases are immune mediated, and dietary triggers play a role in their pathogenesis. OBJECTIVES The aim of the study was to analyze the risk of EoE in children with CD, assess the magnitude of association between CD and EoE in children, and report the characteristics and outcomes of children with both conditions. METHODS We conducted a retrospective study of the Mayo Clinic Electronic medical records between January 1, 1998 and December 31, 2015. Systematic review and meta-analysis of multiple databases was conducted to include studies reporting on the same association. Random-effects model was used to report pooled odds ratio (OR) and 95% confidence interval (CI). RESULTS In this cohort study, of 10,201 children who underwent at least 1 endoscopy, 595 had EoE, and 546 had CD. The risk of having EoE was not increased in children with CD compared to those without CD (OR, 0.29; 95% CI, 0.154-0.545). Nine of 10 children improved with gluten-free diet, topical glucocorticosteroid, and/or elimination diet. One child lost to follow-up.Meta-analysis of 5 studies showed similar results (OR, 0.525; 95% CI, 0.364-0.797). A total of 45 cases in the literature had both CD and EoE (mean age, 10 years; 64% boys; majority presenting with abdominal pain, vomiting, and diarrhea). CONCLUSIONS Based on our cohort and the observational data, the diagnosis of CD in children is not associated with increased risk of EoE.
Collapse
|
27
|
Abstract
Eosinophilic esophagitis (EoE) is an atopic disease that is characterized by an isolated infiltration of eosinophils into the epithelium of the esophagus and is triggered by specific allergens. Patients should undergo an upper endoscopy with biopsy after 6 to 8 weeks of treatment with a proton pump inhibitor in order to make the diagnosis of EoE. Eosinophilic gastroenteritis is a pathologic eosinophilic infiltration of any portion of the gastrointestinal tract, and eosinophilic proctocolitis is an eosinophilic infiltration in the colon alone.
Collapse
Affiliation(s)
- Lisa M Fahey
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7NW, Philadelphia, PA 19104, USA; Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 7NW, Philadelphia, PA 19104, USA; Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| |
Collapse
|
28
|
Warsi Q, Kirby C, Beg M. Pediatric Tourette Syndrome: A Tic Disorder with a Tricky Presentation. Case Rep Gastroenterol 2017; 11:89-94. [PMID: 28611559 PMCID: PMC5465645 DOI: 10.1159/000456609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/16/2017] [Indexed: 01/07/2023] Open
Abstract
Dysphagia is a condition in which disruption of the swallowing process interferes with a patient's ability to eat. This may result in coughing or choking while swallowing, food sticking in the throat, or globus sensation. Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease with a varied clinical spectrum of symptoms including dysphagia. Tourette syndrome (TS) is an inherited neurological disorder that manifests itself as a series of motor and vocal tics and may include oropharyngeal dysphagia. Dysphagia as a result of TS generally affects female, elderly patients and is not reported in children. While the pathophysiology is relatively unknown, experts believe TS is closely linked to damage or abnormalities in the basal ganglia of the brain. We present this interesting pediatric case of dysphagia due to EoE, which had been previously thought to be related to the patient's TS.
Collapse
Affiliation(s)
- Qurratul Warsi
- aUniversity of California San Francisco, San Francisco, California, USA
| | - Caroline Kirby
- bSUNY Upstate Medical University, Syracuse, New York, USA
| | - Mirza Beg
- bSUNY Upstate Medical University, Syracuse, New York, USA
| |
Collapse
|
29
|
Abstract
Eosinophilic esophagitis (EoE) is an emerging chronic atopic clinical-pathologic disease with an estimated prevalence of 1/1000 similar to the one of Crohn's diseases. Usually, EoE is firstly suspected due to symptoms that are caused by esophageal dysfunction and/or fibrosis. EoE diagnosis is confirmed if the esophageal biopsy shows at least 15 eosinophils per high power field (eos/hpf) as a peak value in one or more of at least four specimens obtained randomly from the esophagus. Most of the patients affected by EoE have other atopic diseases such as allergic rhinitis, asthma, IgE-mediated food allergies, and/or atopic dermatitis. The local inflammation is a T helper type 2 (Th2) flogosis, which most likely is driven by a mixed IgE and non-IgE-mediated reaction to food and/or environmental allergens. Recently published genetic studies showed also that EoE is associated with single nucleotide polymorphism (SNP) on genes which are important in atopic inflammation such as thymic stromal lymphopoietin (TSLP) located close to the Th2 cytokine cluster (IL-4, IL-5, IL-13) on chromosome 5q22. When the EoE diagnosis is made, it is imperative to control the local eosinophilic inflammation not only to give symptomatic relief to the patient but also to prevent complications such as esophageal stricture and food impaction. EoE is treated like many other atopic diseases with a combination of topical steroids and/or food antigen avoidance.
Collapse
Affiliation(s)
- Antonella Cianferoni
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Jonathan Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
30
|
Venkateshaiah SU, Manohar M, Verma AK, Blecker U, Mishra A. Possible Noninvasive Biomarker of Eosinophilic Esophagitis: Clinical and Experimental Evidence. Case Rep Gastroenterol 2016; 10:685-692. [PMID: 27920662 PMCID: PMC5126594 DOI: 10.1159/000452654] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/17/2016] [Indexed: 12/30/2022] Open
Abstract
Eosinophilic esophagitis (EoE) diagnosis and follow-up response to therapy is based on repeated endoscopies and histological examination for eosinophils/HPF. The procedure is invasive and risky in particular for the pediatric population. Presently, there is no highly sensitive and specific noninvasive blood test available to monitor the disease pathogenesis. Reports indicate the expression of PDL1 (CD274) on the eosinophils in allergic patients. Herein, we report that CD274-expressing and -nonexpressing eosinophils were detected in both examined pediatric and adult EoE patients. We show that CD274 expression on blood eosinophils and blood mRNA expression levels increase in the blood of EoE patients and decrease following treatment. These observations are consistent with the esophageal eosinophilia of before and after treatment in both examined patients. These two clinical and experimental analysis reports provide the possibility that the CD274 mRNA and CD274-expressing esinophil levels may be novel possible noninvasive biomarkers for EoE.
Collapse
Affiliation(s)
| | - Murli Manohar
- Department of Medicine, Tulane Eosinophilic Disorders Center (TEDC), Section of Pulmonary Diseases, New Orleans, LA, USA
| | - Alok K Verma
- Department of Medicine, Tulane Eosinophilic Disorders Center (TEDC), Section of Pulmonary Diseases, New Orleans, LA, USA
| | - Uwe Blecker
- Section of Pediatric Gastroentrology, Tulane University, School of Medicine, New Orleans, LA, USA
| | - Anil Mishra
- Department of Medicine, Tulane Eosinophilic Disorders Center (TEDC), Section of Pulmonary Diseases, New Orleans, LA, USA
| |
Collapse
|
31
|
Dauer EH, Ponikau JU, Smyrk TC, Murray JA, Thompson DM. Airway Manifestations of Pediatric Eosinophilic Esophagitis: A Clinical and Histopathologic Report of an Emerging Association. Ann Otol Rhinol Laryngol 2016; 115:507-17. [PMID: 16900805 DOI: 10.1177/000348940611500705] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Pediatric eosinophilic esophagitis (EE) typically presents with dysphagia, vomiting, dyspepsia, or food impaction. The purpose of this study was to highlight the emerging association of pediatric EE and airway disease. An additional goal of this study was to describe the unique histopathologic findings found in EE and specifically explore the potential role of the cytotoxic protein called eosinophil major basic protein (MBP) in the pathophysiology of the disease. Methods: A retrospective review of 3 children with EE and airway symptoms included symptom presentation, aerodigestive tract endoscopic findings, ambulatory 24-hour dual pH-metry, allergy tests, treatment modalities, and treatment response. Esophageal tissue obtained from biopsies of each patient was evaluated by hematoxylin and eosin to determine the number of eosinophils per high-power field, by immunofluorescent anti-MBP staining to determine the presence of MBP, and by standard light and transmission electron microscopy to evaluate eosinophil migration patterns. Results: All patients had airway inflammation that included nonspecific laryngeal edema and grade I or II subglottic stenosis. Allergy testing was positive in the 2 patients who were tested. All patients had symptoms refractory to standard reflux therapy. Ambulatory pH-metry findings were normal in 2 patients and abnormal in 1 patient despite maximum treatment. Two patients had visual abnormalities seen during esophageal examination. The number of eosinophils ranged from 20 to 45 per high-power field. Intracellular and extracellular MBP deposition was found in all esophageal biopsy specimens. All patients were treated with swallowed fluticasone, and 2 had symptom relapses that required repeat treatment. Conclusions: The spectrum of pediatric EE can include upper airway disease. Intracellular and extracellular MBP deposition is present in EE, which potentially releases cytotoxic mediators that explain the esophageal and airway clinical symptoms seen in those with the disease. Eosinophilic esophagitis should be considered in patients with a history of atopic diseases and unexplained upper airway findings refractory to reflux treatment. Treatment with swallowed fluticasone is successful; however, relapses are common and require repeat treatment and close follow-up.
Collapse
Affiliation(s)
- Eileen H Dauer
- Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Eugenio Litta Children's Hospital Rochester, Minnesota, USA
| | | | | | | | | |
Collapse
|
32
|
Dauer EH, Freese DK, El-Youssef M, Thompson DM. Clinical Characteristics of Eosinophilic Esophagitis in Children. Ann Otol Rhinol Laryngol 2016; 114:827-33. [PMID: 16358601 DOI: 10.1177/000348940511401103] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: The role of eosinophilic esophagitis (EE) in aerodigestive tract disorders in children is underestimated and overlooked, primarily because of a lack of understanding of this disorder by otolaryngologists. We sought to better characterize the clinical presentation of EE in order to increase awareness among otolaryngologists. Methods: We retrospectively reviewed 71 children with biopsy-proven EE to determine the most common symptoms and laboratory findings that should increase the clinical suspicion of EE. Results: Dysphagia, food impaction, and emesis were the most common symptoms in children with EE. Asthma was the most common airway diagnosis. Rhinosinusitis was the most common otolaryngological diagnosis. Food allergy was present in 60% of the children tested. Eighty-three percent of the children with elevated immunoglobulin E levels had thick linear streaking or patchy white exudate of the esophagus seen on esophagoscopy. Other major medical comorbidities existed in more than half of the children with EE, of which psychiatric disorders and other disorders of the aerodigestive tract were the most common. Conclusions: Eosinophilic esophagitis may contribute to treatment failure in patients with common and complicated aerodigestive tract disorders. To encourage clinicians to avoid overlooking the diagnosis, we present an evaluative algorithm to increase the suspicion of this entity.
Collapse
Affiliation(s)
- Eileen H Dauer
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | | | | |
Collapse
|
33
|
Hill DA, Spergel JM. The Immunologic Mechanisms of Eosinophilic Esophagitis. Curr Allergy Asthma Rep 2016; 16:9. [PMID: 26758862 DOI: 10.1007/s11882-015-0592-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease that is triggered by food and/or environmental allergens and is characterized by a clinical and pathologic phenotype of progressive esophageal dysfunction due to tissue inflammation and fibrosis. EoE is suspected in patients with painful swallowing, among other symptoms, and is diagnosed by the presence of 15 or more eosinophils per high-power field in one or more of at least four esophageal biopsy specimens. The prevalence of EoE is increasing and has now reached rates similar to those of other chronic gastrointestinal disorders such as Crohn's disease. In recent years, our understanding of the immunologic mechanisms underlying this condition has grown considerably. Thanks to new genetic, molecular, cellular, animal, and translational studies, we can now postulate a detailed pathway by which exposure to allergens results in a complex and coordinated type 2 inflammatory cascade that, if not intervened upon, can result in pain on swallowing, esophageal strictures, and food impaction. Here, we review the most recent research in this field to synthesize and summarize our current understanding of this complex and important disease.
Collapse
Affiliation(s)
- David A Hill
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Allergy and Immunology, The Children's Hospital of Philadelphia, 3550 Market St., Philadelphia, PA, 19104, USA
| | - Jonathan M Spergel
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Division of Allergy and Immunology, The Children's Hospital of Philadelphia, 3550 Market St., Philadelphia, PA, 19104, USA.
| |
Collapse
|
34
|
Ishihara S, Kinoshita Y, Schoepfer A. Eosinophilic Esophagitis, Eosinophilic Gastroenteritis, and Eosinophilic Colitis: Common Mechanisms and Differences between East and West. Inflamm Intest Dis 2016; 1:63-69. [PMID: 29922659 DOI: 10.1159/000445131] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 03/02/2016] [Indexed: 12/20/2022] Open
Abstract
Background Eosinophilic esophagitis (EoE), eosinophilic gastroenteritis (EGE), and eosinophilic colitis (EoC) have been diagnosed with an increasing frequency over the last decades. All these diseases share pathogenic similarities with respect to triggering by food antigens in the majority of patients once secondary causes of tissue eosinophilia have been excluded. While diagnostic criteria for EoE have been published, the exact criteria for EGE and EoC still need to be defined. This review highlights similarities and differences between affected patients when comparing the Western with the Eastern world. Summary The incidence and prevalence of EoE are on the rise in countries from the Western and Eastern world. Very limited epidemiologic data exist regarding EGE and EoC. Characteristics of patients with eosinophilic gastrointestinal disorders regarding gender distribution, age at diagnosis, and associated comorbidities are similar when comparing Eastern with Western countries. Similar modalities are applied to diagnose EoE, EGE, and EoC when comparing Eastern with Western countries. Additionally, comparable therapeutic measures are applied to treat eosinophilic gastrointestinal diseases in Eastern and Western countries. While EoE treatment recommendations are based on increasingly solid evidence, recommendations for the treatment of EGE and EoC are based on low evidence. Key Messages Eosinophilic gastrointestinal diseases are diagnosed and treated using similar approaches in Eastern and Western countries. Further efforts should be undertaken to help clarify the underlying pathogenic mechanisms and to establish evidence-based diagnostic and therapeutic protocols.
Collapse
Affiliation(s)
- Shunji Ishihara
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo, Japan
| | - Yoshikazu Kinoshita
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo, Japan
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois/CHUV, Lausanne, Switzerland
| |
Collapse
|
35
|
Tan LNM, Srivastava S, Teh M, Quak SH, Aw MM. Eosinophilic oesophagitis in children: an uncommon occurrence in a predominantly Chinese population in Singapore. Singapore Med J 2016; 58:218-222. [PMID: 26976221 DOI: 10.11622/smedj.2016060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION We aimed to determine the prevalence and clinical manifestations of eosinophilic oesophagitis (EoE) in children who presented to a tertiary care hospital in Singapore. METHODS We conducted a retrospective review of all oesophageal biopsies taken during oesophagogastroduodenoscopy (OGD) from March 2010 to December 2011. The patients' demographics and clinical characteristics were collected. Biopsies were reviewed by a single pathologist who was blinded to the original reports, using the current consensus criteria for the histological diagnosis of EoE. RESULTS Of the 88 children who had biopsies during OGD, 4 (4.5%) children (three boys, one girl; three Chinese, one Caucasian) were diagnosed with EoE. Their median age was 9.5 (range 4.0-12.0) years. The main clinical presentations were abdominal pain (in the three older children) and vomiting (in the youngest child). Three children had a history of atopy. Three children were diagnosed with EoE in the original histology reports, while one was diagnosed after the second review following histology demonstrating > 15 eosinophil granulocytes per high power field and microabscess formation. Endoscopy findings revealed oesophagitis in two children, one of whom was already on acid suppression therapy. Although three children were started on acid suppression therapy, they continued to be symptomatic. One child was also treated with swallowed fluticasone and two with food allergen avoidance, resulting in symptom improvement. CONCLUSION Although EoE is uncommon in Singapore, greater awareness is needed among family physicians and general paediatricians. Paediatric gastroenterologists should alert pathologists when sending biopsy specimens that are suspicious for EoE.
Collapse
Affiliation(s)
- Li Nien Michelle Tan
- Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore
| | - Supriya Srivastava
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Ming Teh
- Department of Pathology, National University Health System, Singapore
| | - Seng Hock Quak
- Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Marion M Aw
- Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| |
Collapse
|
36
|
Yawn RJ, Fazili M, Provo-Bell G, Wootten CT. The utility of bronchoalveolar lavage findings in the diagnosis of eosinophilic esophagitis in children. Int J Pediatr Otorhinolaryngol 2015; 79:1834-7. [PMID: 26362482 DOI: 10.1016/j.ijporl.2015.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 08/08/2015] [Accepted: 08/10/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Bronchoalveolar lavage (BAL)-nucleated cell counts and the lipid-laden alveolar macrophage index (LLMI) have been investigated in predicting chronic aspiration as well as reflux esophagitis with variable results. To date, BAL neutrophil percentages and the LLMI have not been described in patients with eosinophilic esophagitis (EoE). OBJECTIVES To evaluate BAL neutrophil percentages and LLMI levels in patients with EoE and compare these levels in patients with aerodigestive concerns without biopsy-proven EoE. METHODS Retrospective review of patients referred to an aerodigestive evaluation team for overlapping aerodigestive complaints (dysphagia, stridor, subglottic stenosis, feeding intolerance, and chronic aspiration). Patients underwent microlaryngoscopy, esophagogastroduodenoscopy with biopsy, and bronchoscopy and BAL were indicated by symptoms. BAL neutrophil percentages, LLMI levels, esophageal biopsy results, and esophageal dual-probe pH/impedance were recorded and compared. RESULTS Fifty-one patients were included in the study that underwent comprehensive workup for aerodigestive complaints. Patients were subdivided into two groups: (1) negative esophageal biopsy (for EoE) and (2) positive esophageal biopsy. There were no significant differences between the groups in percentage neutrophils (p=0.55, unpaired t-test) or LLMI levels (p=0.14, unpaired t-test). DISCUSSION BAL neutrophil percentages and the LLMI are unreliable in identifying patients with silent aspiration and gastroesophageal reflux. To date, there is no report of the utility of BAL neutrophil percentages and the LLMI in diagnosing patients with EoE. Our series indicates no correlation in neutrophil percentages or LLMI in patients with EoE versus patients without EoE that are referred to tertiary centers with aerodigestive concerns. CONCLUSION BAL neutrophil percentages and LLMI levels are not a reliable predictor of eosinophilic esophagitis in children with complex aerodigestive concerns. Esophageal biopsy remains the gold standard for diagnosis of EoE and the challenge remains to find other markers that raise suspicion for EoE for the non-gastroenterologist or that stage the extent of disease beyond the esophagus.
Collapse
Affiliation(s)
- Robert J Yawn
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, TN 37232 USA
| | - Mohammad Fazili
- Division of Pediatric Allergy, Immunology and Pulmonary Medicine, Vanderbilt Children's Hospital, Nashville, TN 37232 USA
| | - Gwen Provo-Bell
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, TN 37232 USA
| | - Christopher T Wootten
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, TN 37232 USA.
| |
Collapse
|
37
|
Eosinophilic oesophagitis: a systematic review for otolaryngologists. The Journal of Laryngology & Otology 2015; 129:1156-66. [PMID: 26467493 DOI: 10.1017/s0022215115002777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis is a chronic, immune/antigen-mediated oesophageal disease, only recently, but increasingly, recognised in the world literature. It is diagnosed and managed primarily by medical gastroenterologists and allergy specialists, and is a distinct disease entity, affecting both children and adults. Few studies have been published in otolaryngology journals, although otolaryngologists will encounter patients with undiagnosed eosinophilic oesophagitis. Patients may present with dysphagia, bolus obstruction or with other ENT disorders, such as atopic rhinitis, reflecting the underlying systemic allergic disorder. OBJECTIVE This paper systematically reviews the evidence base published on the epidemiology, clinical presentation, diagnosis, treatment and prognosis of eosinophilic oesophagitis, particularly as it relates to otolaryngology practice.
Collapse
|
38
|
Abstract
Esophageal and aspirated foreign bodies have important clinical significance, and both should be considered carefully when the history or physical examination findings raise sufficient suspicion. The published evidence regarding the diagnosis and management of foreign body ingestion or aspiration is weighted disproportionately with observational studies, case controls, expert opinion, and systematic reviews. Most of the publications would receive a categorization of C (observational studies including case-control and cohort design) and D (expert opinion, case reports, and clinical reasoning). One of the few prospective studies examining the diagnostic evaluation of foreign body aspiration in children could be considered level B evidence (randomized clinical trials, systematic reviews, or diagnostic studies with minor limitations). This study found that the medical history is the most important predictive part of the evaluation. There is evidence for considering bronchoscopy if there is significant history suggestive of foreign body aspiration, even in the setting of normal physical examination findings. (28). Most ingested foreign bodies spontaneously pass without incident. However, special attention should be paid to objects in the esophagus as well as to batteries and magnets. Based on a systematic review of the literature (level B evidence) and the potential for rapid and life-threatening damage, batteries in the esophagus should be removed immediately. (10) Other objects, such as coins, may be observed for passage in an asymptomatic patient. In addition, given the high risk of significant complications, ingestion of high-powered magnets should be quickly and carefully evaluated. Although single magnets are likely to pass without complication, multiple magnets or magnets ingested with other metal objects can cause significant damage and should be removed if there is any concern for mural entrapment, bowel perforation, or failure to progress. (10)(16)(17)(18)(19). Lastly, another systematic review of the literature (level B evidence) about the aspiration of food objects in children suggests that this is a significant public health concern with potentially devastating consequences. Despite clear legislation and regulation by the Consumer Product Safety Commission regarding toys, there is no similar regulation of high-risk foods. The data suggest that there is opportunity for improvement in legislation about the production and packaging of high-risk items as well as in the education of caregivers. (22)
Collapse
Affiliation(s)
- S Sarah Green
- Pediatrics, Oregon Health & Science University, Portland, OR
| |
Collapse
|
39
|
Martin LJ, Franciosi JP, Collins MH, Abonia JP, Lee JJ, Hommel KA, Varni JW, Grotjan JT, Eby M, He H, Marsolo K, Putnam PE, Garza JM, Kaul A, Wen T, Rothenberg ME. Pediatric Eosinophilic Esophagitis Symptom Scores (PEESS v2.0) identify histologic and molecular correlates of the key clinical features of disease. J Allergy Clin Immunol 2015; 135:1519-28.e8. [PMID: 26051952 DOI: 10.1016/j.jaci.2015.03.004] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 02/18/2015] [Accepted: 03/05/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Pediatric Eosinophilic Esophagitis Symptom Score (PEESS v2.0) measures patient-relevant outcomes. However, whether patient-identified domains (dysphagia, gastroesophageal reflux disease [GERD], nausea/vomiting, and pain) align with clinical symptomology and histopathologic and molecular features of eosinophilic esophagitis (EoE) is unclear. OBJECTIVE The purpose of this study was to determine whether clinical features of EoE, measured through PEESS v2.0, associate with histopathologic and molecular features of EoE. This represents a novel approach for analysis of allergic diseases, given the availability of allergic tissue biopsy specimens. METHODS We systematically recruited treated and untreated pediatric patients with EoE (aged 2-18 years) and examined parent proxy-reported symptoms using the PEESS v2.0. Clinical symptomology was collected by questionnaire. Esophageal biopsy samples were quantified for levels of eosinophils, eosinophil peroxidase (EPX) immunohistochemical staining, and mast cells. Molecular features were assessed by using the EoE Diagnostic Panel (94 EoE-related gene transcripts). Associations between domain scores and clinical symptoms and biological features were analyzed with Wilcoxon rank sum and Spearman correlation. RESULTS The PEESS v2.0 domains correlated to specific parent-reported symptoms: dysphagia (P = .0012), GERD (P = .0001), and nausea/vomiting (P < .0001). Pain correlated with multiple symptoms (P < .0005). Dysphagia correlated most strongly with overall histopathology, particularly in the proximal esophagus (P ≤ .0049). Markers of esophageal activity (EPX) were significantly associated with dysphagia (strongest r = 0.37, P = .02). Eosinophil levels were more associated with pain (r = 0.27, P = .06) than dysphagia (r = 0.24, P = .13). The dysphagia domain correlated most with esophageal gene transcript levels, predominantly with mast cell-specific genes. CONCLUSION We have (1) established a validated, parent proxy-reported measure for pediatric EoE, the PEESS v2.0; (2) verified that the parent proxy effectively captures symptoms; (3) determined that the dysphagia domain most closely aligns with symptoms and tissue-based molecular biomarkers; (4) established that symptoms correlate with EPX staining; and (5) observed association between mast cells and dysphagia.
Collapse
Affiliation(s)
- Lisa J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - James P Franciosi
- Division of Gastroenterology, Department of Pediatrics, Nemours Children's Health System, Orlando, Fla
| | - Margaret H Collins
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio; Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - J Pablo Abonia
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James J Lee
- Department of Biochemistry and Molecular Biology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Kevin A Hommel
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio; Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James W Varni
- Department of Pediatrics, College of Medicine, Department of Landscape Architecture and Urban Planning, College of Architecture, Texas A&M University, College Station, Tex
| | - J Tommie Grotjan
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael Eby
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hua He
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Keith Marsolo
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Philip E Putnam
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio; Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jose M Garza
- Children's Center for Digestive Health Care, Atlanta, Ga
| | - Ajay Kaul
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio; Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ting Wen
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marc E Rothenberg
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| |
Collapse
|
40
|
Proton pump inhibitor-responsive oesophageal eosinophilia and eosinophilic oesophagitis: more similarities than differences. Curr Opin Gastroenterol 2015; 31:309-15. [PMID: 26039722 PMCID: PMC4586084 DOI: 10.1097/mog.0000000000000185] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The purpose of this study is to discuss the clinical, endoscopic and histologic features, pathogenesis and disease mechanisms of proton pump inhibitor (PPI)-responsive oesophageal eosinophilia (PPI-REE), and to highlight similarities and differences with eosinophilic oesophagitis (EoE). RECENT FINDINGS PPI-REE is a condition in which patients have clinical and histologic findings similar to EoE, but achieve complete remission with PPI treatment. More than one-third of patients who have oesophageal symptoms associated with oesophageal eosinophilia respond to PPI treatment. Emerging data elucidating the pathogenesis of PPI-REE have shown that Th2-related inflammatory factors such as interleukin (IL)-13, IL-5, eotaxin-3 and major basic protein (MBP) are elevated in PPI-REE, similar to EoE. PPI-REE also shares a genetic expression signature with EoE that reverses with PPI treatment. Mechanisms proposed to explain the PPI response include an acid-independent, anti-inflammatory action of PPIs and PPI-induced restoration of oesophageal barrier function. SUMMARY Multiple features of PPI-REE overlap extensively with EoE. This raises the question of whether PPI-REE is merely a subtype of EoE rather than an independent condition. This similarity may have future implications for algorithms informing evaluation and treatment of oesophageal eosinophilia.
Collapse
|
41
|
Erwin EA, Tripathi A, Ogbogu PU, Commins SP, Slack MA, Cho CB, Hamilton RG, Workman LJ, Platts-Mills TAE. IgE Antibody Detection and Component Analysis in Patients with Eosinophilic Esophagitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:896-904.e3. [PMID: 26099818 DOI: 10.1016/j.jaip.2015.05.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 04/07/2015] [Accepted: 05/05/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although IgE antibodies to cow's milk and wheat are common in patients with eosinophilic esophagitis (EoE), titers are low and responses to diet are not dependent on having IgE antibodies. OBJECTIVE To better define specific IgE antibody responses to foods, focusing on those foods that appear to play a role in EoE. METHODS Adult (n = 46) and pediatric (n = 51) patients with EoE were recruited for skin prick testing and serum measurement (whole and diluted) of IgE antibodies specific for aeroallergens, food extracts, and component allergens by ImmunoCAP. Immuno Solid-phase Allergen Chip analysis was also used to measure the specificity of IgE antibodies to 112 allergen molecules. RESULTS In adults and children, there was a higher prevalence of sensitization to food extracts by ImmunoCAP than by skin prick testing. Using Immuno Solid-phase Allergen Chip to assess the specificity of IgE antibodies to 112 allergen molecules, we found that results for food allergens were mostly negative. In contrast, ImmunoCAP assays for specific milk allergens gave positive IgE antibody results in 31 of 34 sera. The correlations between specific IgE antibody to Bos d 4 or Bos d 5 and milk extract were strong (R = 0.89 and 0.76, respectively; P < .001). The evidence that IgE antibodies to foods were directed at minor components of the extracts was further supported by measurements on diluted sera. CONCLUSIONS The IgE responses in cow's milk-sensitized patients with EoE are frequently to whey proteins Bos d 4 and Bos d 5, minor components of the extract. These IgE assays may be able to identify the proteins that are relevant to EoE even though IgE is not the primary mechanism.
Collapse
Affiliation(s)
- Elizabeth A Erwin
- Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, Columbus, Ohio.
| | - Anubha Tripathi
- Division of Allergy and Immunology, University of Virginia, Charlottesville, Va
| | - Princess U Ogbogu
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Scott P Commins
- Division of Allergy and Immunology, University of Virginia, Charlottesville, Va
| | - Maria A Slack
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Christine B Cho
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Robert G Hamilton
- Dermatology, Allergy and Clinical Immunology Laboratory, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Lisa J Workman
- Division of Allergy and Immunology, University of Virginia, Charlottesville, Va
| | | |
Collapse
|
42
|
Abstract
Eosinophil-associated disorders can affect practically all tissues and organs in the body, either individually or in combination. This article provides an overview of end-organ manifestations of eosinophilia and discusses selected organ systems, including the upper and lower respiratory, cardiovascular, gastrointestinal, nervous, dermatologic, and renal systems. Mechanisms by which eosinophilia leads to end-organ damage are also considered.
Collapse
Affiliation(s)
- Praveen Akuthota
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA; Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - Peter F Weller
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA; Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| |
Collapse
|
43
|
|
44
|
Sawas T, Dhalla S, Sayyar M, Pasricha PJ, Hernaez R. Systematic review with meta-analysis: pharmacological interventions for eosinophilic oesophagitis. Aliment Pharmacol Ther 2015; 41:797-806. [PMID: 25728929 DOI: 10.1111/apt.13147] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 01/06/2015] [Accepted: 02/11/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is a growing cause of dysphagia. Current therapies include dietary manipulation, steroids and biological drugs. AIM To perform a systematic review and summarise the effect of different medical interventions on EoE. METHODS Two reviewers searched Pubmed and Embase for studies on treatment for EoE. We included randomised controlled trials (RCT) limited to pharmacological interventions. Two reviewers selected studies. Meta-analysis was done using random effects model to estimate odds ratio (OR). Heterogeneity was determined by Cochran's Q statistic and I(2) . RESULTS Seventeen references met our inclusion criteria. Eleven RCTs involving 455 participants were included in the meta-analysis. 325 participants were evaluated for symptomatic improvement and 330 were evaluated for histological remission. Symptomatic improvement with topical steroids (7 studies, 250 participants) compared to the control group (placebo or PPI) was noted (OR: 3.03, 95% confidence interval, CI: 1.57-5.87). Histological remission was also noted in nine studies involving 330 participants (OR: 13.66, 95% CI: 2.65-70.34) comparing topical steroids to a control (placebo or PPI). There was no difference between anti-IL-5 drugs and placebo in terms of symptomatic improvement (OR: 0.69, 95% CI: 0.34-1.42). CONCLUSIONS Topical steroids induce significant symptomatic and histological remission, and should be considered as a first line treatment. Anti-IL-5 therapy has a minor effect on eosinophilic oesophagitis. Future research in eosinophilic oesophagitis should standardise methodology according to published guidelines to improve quality and allow direct comparison between therapies.
Collapse
Affiliation(s)
- T Sawas
- Department of Gastroenterology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | | | | |
Collapse
|
45
|
Yawn RJ, Acra S, Goudy SL, Flores R, Wootten CT. Eosinophilic Laryngitis in Children with Aerodigestive Dysfunction. Otolaryngol Head Neck Surg 2015; 153:124-9. [DOI: 10.1177/0194599815577568] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 02/24/2015] [Indexed: 01/06/2023]
Abstract
Objective To describe the presence of laryngeal eosinophils and associated symptomatology in patients with aerodigestive dysfunction. Study Design Case series with chart review. Setting Single tertiary pediatric referral center. Subjects Eighty-one consecutive pediatric patients referred to a multidisciplinary aerodigestive clinic with upper airway concerns. Methods Microlaryngoscopy and posterior arytenoid biopsy, flexible bronchoscopy, esophagogastroduodenoscopy and esophageal biopsy, and impedance probe testing were performed as indicated by clinical symptoms. Positive versus negative posterior arytenoid biopsy for eosinophils and the presence or absence of concomitant histopathological laryngitis and/or esophagitis were measured. Results Nine of 81 (11%) patients had positive laryngeal biopsy for eosinophils (range, 1-29 eosinophils/high-powered field [HPF]). Three of these 9 patients also had concurrent biopsy-proven eosinophilic esophagitis, while 8 of 81 total patients had biopsy-proven eosinophilic esophagitis. The frequency of biopsy-proven eosinophilic esophagitis was higher in patients with posterior arytenoid eosinophils versus patients without laryngeal eosinophils (33% versus 6.9%, P = .0408). Conclusions Eosinophilic inflammation in the larynx has not been described in children with complex aerodigestive complaints. Posterior arytenoid eosinophils may serve as a marker of chronic laryngeal inflammation in children with aerodigestive dysfunction, although their exact role in this inflammation remains unclear. In our population, >15 eosinophils/HPF within posterior arytenoid biopsies was associated with concomitant eosinophilic esophagitis.
Collapse
Affiliation(s)
- Robert J. Yawn
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Sari Acra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt Children’s Hospital, Nashville, Tennessee, USA
| | - Steven L. Goudy
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Raina Flores
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, Tennessee, USA
| | - Christopher T. Wootten
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
| |
Collapse
|
46
|
Han SG, Chen Y, Qian ZH, Yang L, Yu RS, Zhu XL, Li QH, Chen Q. Eosinophilic gastroenteritis associated with eosinophilic cystitis: Computed tomography and magnetic resonance imaging findings. World J Gastroenterol 2015; 21:3139-3145. [PMID: 25780317 PMCID: PMC4356939 DOI: 10.3748/wjg.v21.i10.3139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 11/07/2014] [Accepted: 12/22/2014] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic gastroenteritis (EG) is a rare, distinct clinical entity, and EG associated with eosinophilic cystitis (EC) is extremely rare and has not been well documented. Here, we report two cases of EG and coexistent EC along with findings from computed tomography (CT) and magnetic resonance imaging (MRI). An 18-year-old male with a history of hematuria, urgency and occasional urodynia for two weeks and a 34-year-old male with a history of abdominal distention for one week were admitted to our hospital. Abdominal contrast-enhanced CT in both patients revealed wall thickening in different parts of the gastrointestinal tract with inhomogeneous reinforcement, coexistent with local or diffuse bladder wall thickening with progressive enhancement, and also showed that the bladder mucosal lining was nondestructive. Pelvic MRI showed that the local or diffuse thickened bladder wall was iso-intense on T1-weighted images, hypo-intense on T2-weighted images, and slightly restricted on diffusion weighted imaging (DWI) in one case. After therapy, the thickened wall of the gastrointestinal tract and urinary bladder had improved markedly in the two cases. To the best of our knowledge, this is the first report on the radiological imaging of EG and coexistent EC by both CT and MRI and the first with DWI findings.
Collapse
|
47
|
Leung AJT, Persad S, Slae M, Abdelradi A, Kluthe C, Shirton L, Danchuk R, Persad R, Meddings J, Huynh HQ. Intestinal and gastric permeability in children with eosinophilic esophagitis and reflux esophagitis. J Pediatr Gastroenterol Nutr 2015; 60:236-9. [PMID: 25304889 DOI: 10.1097/mpg.0000000000000590] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Eosinophilic esophagitis (EoE) is an allergic and immune-mediated entity that leads to a characteristic inflammation of esophageal mucosa. Patients complain of dysphagia and reflux-like symptoms. As many as 80% of patients with EoE may also have a history of atopy, and patients with asthma and eczema have previously been shown to have increased intestinal permeability. This study was designed to assess small intestinal and gastric permeability in patients with EoE and to see whether it differed from healthy individuals and patients with reflux esophagitis (RE). METHODS Gastric and small intestinal permeability was measured using sugar probe tests containing lactulose, mannitol, and sucrose. Lactulose-to-mannitol (L/M) ratios in the patient's urine were a measure for intestinal permeability, and total sucrose was a measure for gastric permeability. RESULTS We analyzed samples from 23 patients with EoE, 20 RE, 14 normal upper endoscopy with gastrointestinal symptoms, and 26 healthy controls. All of the 4 groups had L/M ratios less than the upper limit of normal (<0.025). There was no statistically significant difference in gastric permeability between the 4 groups (L/M P = 0.26, sucrose P = 0.46). CONCLUSIONS Our data suggest that an alteration in gastric and intestinal permeability does not play a role in EoE or RE pathogenesis.
Collapse
Affiliation(s)
- Aldrich J T Leung
- *Division of Pediatric GI Nutrition, University of Alberta †Women and Children's Health Research Institute ‡Department of Pediatrics, University of Alberta, Edmonton §Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Cianferoni A, Spergel JM. Immunotherapeutic approaches for the treatment of eosinophilic esophagitis. Immunotherapy 2015; 6:321-31. [PMID: 24762076 DOI: 10.2217/imt.14.3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a clinical pathologic disease characterized by symptoms of esophageal dysfunction and eosinophilia of the esophagus. When the diagnosis is confirmed, it is important to treat the eosinophilic inflammation not only to control the presenting symptoms, but also to prevent acute and chronic complications. The pathogenesis of EoE is most likely a mixed IgE and non-IgE food-mediated reaction, where Th2 cytokines drive esophageal eosinophilia as in other atopic diseases. Hence, it is not surprising that therapy is based on inflammation control, with steroids (oral or topical) and/or food antigen avoidance. However, these treatment options are not specific, reduce the quality of life of patients and have significant side effects, therefore, there is an ongoing effort to design more specific immunotherapies. In this review, we review standard and immunotherapeutic options for EoE treatment, such as anti-IL-5, anti-TNFα, anti-IgE, anti-CRTH, oral allergy desensitization and environmental immunotherapy.
Collapse
Affiliation(s)
- Antonella Cianferoni
- Divisions of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, ARC 1216H, 3615 Civic Center Blvd, Philadelphia, PA 19104, USA
| | | |
Collapse
|
49
|
Doerfler B, Bryce P, Hirano I, Gonsalves N. Practical approach to implementing dietary therapy in adults with eosinophilic esophagitis: the Chicago experience. Dis Esophagus 2015; 28:42-58. [PMID: 24602224 DOI: 10.1111/dote.12175] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated esophageal disease characterized by esophageal dysfunction and esophageal mucosal eosinophilia. Diet therapy is effective in the treatment of EoE in both children and adults. The role of food allergens is well established in the pathogenesis and treatment of eosinophilic esophagitis. Empiric elimination with a six-food elimination diet (avoiding milk, wheat, egg, soy, peanuts/tree nuts, and fish/shellfish) demonstrates remission in over 70% of adults with this disease. Dietary therapy in adult EoE is becoming more accepted by both patients and clinicians. Dietary therapy can be effectively implemented in clinical practice with appropriate dietary education, patient resources, and close communication with physician and clinical staff. The ability to identify specific food triggers to help tailor dietary therapy for long-term management allows for a return to consumption of most table foods. Furthermore, the diet approach avoids the need for chronic topical corticosteroid use and possible long-term side effects of these medications. The decision to proceed with dietary therapy should be decided by patient preference and available resources. A collaborative and multidisciplinary approach including gastroenterologists, allergists, nurses, and dietitians is essential in the success of this approach.
Collapse
Affiliation(s)
- B Doerfler
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | | |
Collapse
|
50
|
Kelly EA, Linn D, Keppel KL, Noel RJ, Chun RH. Otolaryngologic surgeries are frequent in children with eosinophilic esophagitis. Ann Otol Rhinol Laryngol 2014; 124:355-60. [PMID: 25385840 DOI: 10.1177/0003489414558108] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim was to study the prevalence of otolaryngologic surgeries in pediatric patients with eosinophilic esophagitis (EoE). METHODS Retrospective cohort study at a tertiary care center. The type of otolaryngologic surgeries performed in patients with diagnosis of EoE was recorded during a 5-year period. RESULTS Seventy-five percent of patients were male, with average age of EoE diagnosis at 7.5 years with an 83% incidence of atopy. Cohort analysis revealed that 33% (119/362) had a total of 275 otolaryngologic surgeries. Surgeries performed on 119 patients are as follows: 20% bilateral myringotomy with tubes, 14% tonsillectomy, 18.5% adenoidectomy, 1.4% sinus irrigation, 3.3% bronchoscopy, and 1.4% laryngotracheoplasty (LTP); 63% of patients underwent multiple procedures. Thirty percent of patients undergoing bilateral myringotomy with tube placement (BMT) needed additional tubes. Four of 5 LTP patients had successful operations. Twelve percent of patients had EoE diagnosis prior to an otolaryngologic surgery. CONCLUSION Thirty-three percent of children with EoE required otolaryngologic surgical intervention and nearly one-third who underwent BMT required additional ear tubes. A large fraction of children with EoE will undergo an otolaryngologic surgery, only a minority with a preoperative EoE diagnosis. Until the nature of this relationship is clarified, the high coincidence with otolaryngologic surgeries dictates that otolaryngologists should be familiar with diagnosis of EoE in patients.
Collapse
Affiliation(s)
- Elizabeth A Kelly
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David Linn
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kristina L Keppel
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Richard J Noel
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Robert H Chun
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|