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de Bortoli N, Visaggi P, Penagini R, Annibale B, Baiano Svizzero F, Barbara G, Bartolo O, Battaglia E, Di Sabatino A, De Angelis P, Docimo L, Frazzoni M, Furnari M, Iori A, Iovino P, Lenti MV, Marabotto E, Marasco G, Mauro A, Oliva S, Pellegatta G, Pesce M, Privitera AC, Puxeddu I, Racca F, Ribolsi M, Ridolo E, Russo S, Sarnelli G, Tolone S, Zentilin P, Zingone F, Barberio B, Ghisa M, Savarino EV. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis-Current Treatment and Monitoring. Dig Liver Dis 2024; 56:1173-1184. [PMID: 38521670 DOI: 10.1016/j.dld.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/11/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
The present document constitutes Part 2 of the EoETALY Consensus Statements guideline on the diagnosis and management of eosinophilic esophagitis (EoE) developed by experts in the field of EoE across Italy (i.e., EoETALY Consensus Group). Part 1 was published as a different document, and included three chapters discussing 1) definition, epidemiology, and pathogenesis; 2) clinical presentation and natural history and 3) diagnosis of EoE. The present work provides guidelines on the management of EoE in two final chapters: 4) treatment and 5) monitoring and follow-up, and also includes considerations on knowledge gaps and a proposed research agenda for the coming years. The guideline was developed through a Delphi process, with grading of the strength and quality of the evidence of the recommendations performed according to accepted GRADE criteria.This document has received the endorsement of three Italian national societies including the Italian Society of Gastroenterology (SIGE), the Italian Society of Neurogastroenterology and Motility (SINGEM), and the Italian Society of Allergology, Asthma, and Clinical Immunology (SIAAIC). The guidelines also involved the contribution of members of ESEO Italia, the Italian Association of Families Against EoE.
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Affiliation(s)
- Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, 00189, Rome, Italy
| | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | | | - Edda Battaglia
- Gastroenterology Unit ASLTO4, Chivasso - Ciriè - Ivrea, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, 27100, Pavia, Italy; First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, 27100, Pavia, Italy
| | - Paola De Angelis
- Digestive Endoscopy Unit - Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa,Genoa,Italy, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Iori
- Gastroenterology and Digestive Endoscopy Unit, 'Santa Chiara' Hospital, Trento, Italy
| | - Paola Iovino
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84084, Baronissi, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, 27100, Pavia, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa,Genoa,Italy, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Salvatore Oliva
- Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Italy
| | - Gaia Pellegatta
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy; Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Marcella Pesce
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | | | - Ilaria Puxeddu
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano - Milan, Italy
| | - Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Erminia Ridolo
- Allergy Unit, Department of Internal Medicine, University Hospital of Parma, Parma, Italy
| | - Salvatore Russo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliera Universitaria of Modena, Modena, Italy
| | - Giovanni Sarnelli
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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3
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Mechanisms and clinical management of eosinophilic oesophagitis: an overview. Nat Rev Gastroenterol Hepatol 2023; 20:101-119. [PMID: 36253463 DOI: 10.1038/s41575-022-00691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/03/2023]
Abstract
Since the first description of eosinophilic oesophagitis (EoE) less than three decades ago, we have observed a striking increase in the number of patients diagnosed with EoE and the understanding of its clinical and immunopathogenic background. Nonetheless, a plethora of open questions await elucidation. In this Review, we discuss the current state of knowledge regarding the underlying mechanisms, particularly environmental factors and their interaction with genetic susceptibility. Subsequently, we discuss how to translate these factors into the diagnostic and therapeutic management of this chronic, immune-mediated disorder. Finally, we dissect the still long list of unmet needs, such as reasons for and handling refractory EoE and atypical clinical presentations. These open questions can guide us through future research steps and potentially foster reconsideration of the diagnostic guidelines of EoE.
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4
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Kim SJ, Choi CW, Hwang CS. [Diagnosis and Treatment of Eosinophilic Esophagitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:99-108. [PMID: 35342167 DOI: 10.4166/kjg.2021.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/07/2021] [Accepted: 09/15/2021] [Indexed: 11/03/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. The diagnostic criteria for EoE have changed with our growing knowledge over the past two decades. Esophageal eosinophilia, which responds histologically to a proton pump inhibitor (PPI) is not a distinct disease but a subset of EoE. An endoscopic scoring system that relies on the assessment of exudates, rings, edema, furrows, and strictures is a useful tool for assessing endoscopic severity. PPIs are regarded as safe and effective first-line treatments for EoE. Oral topical corticosteroids or dietary therapy are also options for first-line treatment. Endoscopic dilation is effective for relieving the dysphagia symptoms of a patient with an esophageal stricture.
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Affiliation(s)
- Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheong Su Hwang
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Pathology, Pusan National University School of Medicine, Busan, Korea
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Marabotto E, Giannini EG, Zentilin P, Ziola S, Djahandideh Sheijani A, Savarino E, Savarino V. Pharmacotherapies in eosinophilic esophagitis: state of the art. Minerva Gastroenterol (Torino) 2022; 68:69-76. [PMID: 35302339 DOI: 10.23736/s2724-5985.21.02781-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Eosinophilic esophagitis is a chronic immune-mediated esophageal disease with a Th2 inflammatory response to inhalant and food allergens that cause an eosinophilic infiltration of esophageal mucosa. The diagnosis requires an upper endoscopy with esophageal bioptic samples, in particular the number of eosinophils must be >15 eos/high power field. The main symptoms of EoE in adults are dysphagia and food impaction, and its incidence is growing. Nowadays, the etiology of EoE is not well understood and no standard therapy is available. Therefore, the aim of this review was to analyze the major studies present in literature regarding the various therapeutic approaches to this disease.
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Affiliation(s)
- Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy -
| | - Edoardo G Giannini
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Sebastiano Ziola
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | | | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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6
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Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome. Dig Dis Sci 2020; 65:3434-3447. [PMID: 33052498 PMCID: PMC7669680 DOI: 10.1007/s10620-020-06642-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/09/2022]
Abstract
Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of esophageal dysfunction, including dysphagia. While EoE is still considered a rare disease, in practice it seems that more and more cases are diagnosed every week, research in the field is exploding, and the pipeline for treatments contains multiple agents, some of which are quite far along the development pathway. After only scattered cases and small series were published in the late 1970s and 1980, Stephen Attwood, Thomas Smyrk, Tom DeMeester, and James Jones, published in Digestive Diseases and Sciences in 1993 a seminal report that described a clinicopathologic syndrome of esophageal eosinophilia with dysphagia. This review details the origins of this paper and compares and contrast what was observed then and what is known now about multiple aspects of EoE, including the clinical presentation, diagnosis, epidemiology, natural history, and treatments and outcomes. Moreover, it will highlight how the paper presaged a number of controversies in the field that have yet to be resolved, as well as foreshadowed the collaborative, multidisciplinary approach that has led to rapid advances.
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7
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Chen JW. Management of Eosinophilic Esophagitis: Dietary and Nondietary Approaches. Nutr Clin Pract 2020; 35:835-847. [PMID: 32822071 DOI: 10.1002/ncp.10571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an allergen-driven chronic inflammatory condition, characterized by symptoms related to esophageal dysfunction and confirmed histologically by esophageal mucosal eosinophilia. Since its first description in the 1990s, the incidence and prevalence of EoE have been on the rise. It is known to affect all ages of various ethnic backgrounds and both sexes; however, it is most seen in White males. Children with EoE often present with abdominal pain, nausea, vomiting, and failure to thrive, whereas adults with EoE typically present with dysphagia and food impaction. Diagnosis of EoE requires histologic confirmation of elevated esophageal eosinophils in a symptomatic patient, and only after secondary causes have been excluded. Because EoE is a chronic and progressively fibrostenotic disease, treatment goals include resolution of symptoms, induction and maintenance of disease remission, and prevention and possibly reversal of fibrostenotic complications, while minimizing treatment-related adverse effects and improving quality of life. Treatment strategies include the "3 D's"-drugs, diet, and dilation. Standard drug therapies include proton-pump inhibitors and topical corticosteroids. Dietary therapies include elemental diet, allergy testing-directed elimination diet, and empiric elimination diets. Endoscopic esophageal dilation for EoE strictures can alleviate esophageal symptoms but has no effect on mucosal inflammation. Recent progress in EoE research has made possible evidence-based clinical guidelines. Ongoing pharmacologic trials show promise for novel biologic agents in the treatment of refractory EoE.
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Affiliation(s)
- Joan W Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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8
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Rossetti D, Isoldi S, Oliva S. Eosinophilic Esophagitis: Update on Diagnosis and Treatment in Pediatric Patients. Paediatr Drugs 2020; 22:343-356. [PMID: 32519266 DOI: 10.1007/s40272-020-00398-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disorder characterized by symptomatic esophageal dysfunction and an eosinophil-predominant inflammation of the esophagus. EoE arises from interaction between genetic and environmental factors. In pediatric patients, clinical manifestations vary depending on age, from a gastroesophageal reflux disease (GERD)-like condition to severe dysphagic symptoms. Upper endoscopy is considered the gold standard for diagnosis and monitoring of EoE; however, significant efforts are underway to identify noninvasive diagnostic tools and biomarkers to avoid repetitive invasive procedures. Therapeutic first-line options currently available for EoE are elimination diets, proton pump inhibitors (PPIs), and steroids. The aim of treatment is to improve clinical symptoms while obtaining mucosal healing and avoiding long-term complications. Dietary treatment options comprise different empiric diets or an exclusively amino acid formula. Despite the efficacy of diets, compliance is often challenging. PPIs and topical steroids represent the main pharmacological options for EoE, and both can induce and maintain remission. Topical steroids have been reported as more effective, but data on long-term safety remain insufficient for both these and PPIs. Endoscopic dilations are currently reserved for severe untreated fibrostenotic disease unresponsive to medical therapies. Several biologic agents are available but not yet approved for EoE.
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Affiliation(s)
- Danilo Rossetti
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy
| | - Sara Isoldi
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy.
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Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical review on the management of eosinophilic esophagitis: a report from the AGA institute and the joint task force on allergy-immunology practice parameters. Ann Allergy Asthma Immunol 2020; 124:424-440.e17. [PMID: 32336463 PMCID: PMC8171057 DOI: 10.1016/j.anai.2020.03.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
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Affiliation(s)
- Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona
| | - Rajiv N Sharaf
- Division of Gastroenterology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Division of Allergy Immunology Center for Immunity, Infection, and Inflammation, University of California, San Diego Rady Children's Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M Spergel
- Division of Allergy-Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland Veterans Affairs Medical Center and University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters. Gastroenterology 2020; 158:1789-1810.e15. [PMID: 32359563 PMCID: PMC9473155 DOI: 10.1053/j.gastro.2020.02.039] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
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Affiliation(s)
- Matthew A. Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo
Clinic, Scottsdale, Arizona
| | - Ravi N. Sharaf
- Division of Gastroenterology, Donald and Barbara
Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T. Furuta
- Digestive Health Institute, Children’s
Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of
Colorado School of Medicine, Aurora, Colorado
| | - Seema S. Aceves
- Division of Allergy Immunology Center for Immunity,
Infection, and Inflammation, University of California, San Diego Rady
Children’s Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children’s
Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M. Spergel
- Division of Allergy-Immunology, Children’s
Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania,
Philadelphia, Pennsylvania
| | - Yngve T. Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland
Veterans Affairs Medical Center and University Hospitals, Case Western Reserve
University School of Medicine, Cleveland, Ohio
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of
Gastroenterology and Hepatology, University of North Carolina School of Medicine,
Chapel Hill, North Carolina
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Kumar S, Choi S, Gupta SK. Eosinophilic Esophagitis-A Primer for Otolaryngologists. JAMA Otolaryngol Head Neck Surg 2020; 145:373-380. [PMID: 30789641 DOI: 10.1001/jamaoto.2018.4177] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Eosinophilic esophagitis (EoE) is a chronic, inflammatory condition of the esophagus. Prevalence of EoE is on the rise and, owing to its associated extragastrointestinal manifestations and comorbidities, otolaryngologists are increasingly encountering this condition in their practice. Observations Symptoms of EoE are vague and vary greatly based on patient's age. The gastrointestinal symptoms include dysphagia, food impaction, feeding difficulties, symptoms mimicking gastroesophageal reflux, abdominal pain, vomiting, and failure to thrive. Several otolaryngologic symptoms are associated with EoE including rhinosinusitis, chronic cough, recurrent croup, hoarseness, and other aerodigestive symptoms refractory to gastroesophageal reflux therapy. Eosinophilic esophagitis is also frequently associated with other atopic conditions, such as asthma, eczema, and food allergies. The diagnosis is made on endoscopy with biopsies that reveal eosinophil-predominant esophageal inflammation. There are 3 major treatment approaches to EoE, commonly referred to as the 3 Ds: diet, drugs, and dilation. Untreated inflammation of esophagus from EoE can result in irreversible structural damage to the esophagus, leading to fibrosis, strictures, and impaired esophageal function. Conclusions and Relevance Eosinophilic esophagitis is now a fairly prevalent condition with considerable morbidity. Otolaryngologists should be familiar with the various clinical presentations of this condition in different age groups. Early diagnosis and treatment of this condition is a key for avoiding or postponing its complications.
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Affiliation(s)
- Sanjay Kumar
- Pediatric Gastroenterologist, Ascension St John Providence Children's Hospital, Detroit, Michigan
| | - Sukgi Choi
- Department of Otolaryngology and Communication Enhancement, Harvard Medical School, Boston, Massachusetts
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine at Peoria, Peoria.,Children's Hospital of Illinois, Peoria, Illinois
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Mari A, Tsoukali E, Yaccob A. Eosinophilic Esophagitis in Adults: A Concise Overview of an Evolving Disease. Korean J Fam Med 2020; 41:75-83. [PMID: 32062959 PMCID: PMC7093678 DOI: 10.4082/kjfm.18.0162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease that encompasses esophageal symptoms along with eosinophilic infiltration of the esophageal epithelium. EoE is an evolving disease that has been a subject of interest to many researchers since the first studies recognized this condition as a new and distinct clinicopathological entity 25 years ago. Clinical presentation in adult patients may include dysphagia, food impaction, vomiting, and reflux symptoms. The diagnosis of EoE is based on the combination of clinical history suggestive of esophageal dysfunction, endoscopic features indicative of the disease, and histology revealing eosinophilic infiltration of the esophageal epithelium that persists after a trial of proton pump inhibitor therapy along with the exclusion of other disorders that may be associated with esophageal tissue eosinophilia. The interplay between EoE and gastroesophageal reflux disease (GERD) is complex, and differentiating these two conditions continues to be difficult and challenging in clinical practice. The mainstay treatment includes dietary modification, topical steroids, and/or endoscopic dilation. The primary care physician (PCP) plays an important role in improving patient care and quality of life by ensuring early referral and participating in management and follow-up. This article provides an overview of the current knowledge base regarding the disease including epidemiology, genetics, pathogenesis, common clinical presentations, the interplay between EoE and GERD, diagnostic approaches, and therapeutic options available to the PCP.
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Affiliation(s)
- Amir Mari
- Gastroenterology Institute, Nazareth EMMS Hospital, Nazareth, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | - Emmanouela Tsoukali
- Gastroenterology and Hepatology Department, Evangelismos General Hospital of Athens, Athens, Greece
| | - Afif Yaccob
- Gastroenterology and Liver Disease Department, Rambam Healthcare Campus, Haifa, Israel
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13
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Mast Cell Infiltration Is Associated With Persistent Symptoms and Endoscopic Abnormalities Despite Resolution of Eosinophilia in Pediatric Eosinophilic Esophagitis. Am J Gastroenterol 2020; 115:224-233. [PMID: 31913192 PMCID: PMC7491279 DOI: 10.14309/ajg.0000000000000474] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Mast cells (MCs) are increased in eosinophilic esophagitis (EoE). Endoscopic abnormalities, symptoms, and epithelial changes can persist after treatment despite a reduction of esophageal eosinophilia. It is unknown whether this could be due to persistent MC infiltration. We aimed to determine whether patients with histologically inactive (HI) EoE (defined as <15 eosinophils per high-powered field) with persistent symptoms, endoscopic, or epithelial abnormalities after treatment have increased MCs. METHODS Secondary analysis of prospective data from 93 children with EoE undergoing post-treatment endoscopy between 2011 and 2015. Thirty-five non-EoE controls were included. Immunohistochemistry for tryptase, an MC marker, was performed on mid and distal esophageal biopsies. Total and degranulated intraepithelial MCs per high-powered field (MC/hpf) were quantified. Symptoms and endoscopic findings were recorded at time of endoscopy. MC/hpf were compared between HI-EoE and control, and among HI-EoE based on endoscopic and histologic findings, and symptoms. Nine clinical remission (CR) patients were identified, with absence of endoscopic abnormalities and symptoms. RESULTS MC/hpf were increased in HI-EoE compared with control (17 ± 11 vs 8 ± 6, P < 0.0). Patients with persistent endoscopic abnormalities had increased total (20 ± 12 vs 13 ± 10, P = 0.001) and degranulated (8 ± 6 vs 5 ± 4, P = 0.002) MC/hpf, with no difference in eosinophils. MC/hpf predicted furrowing (odds ratio = 1.06, P = 0.01) and rings (odds ratio = 1.05, P = 0.03) after controlling for treatment type, proton-pump inhibitor, eosinophils, and duration of therapy. Patients with persistent basal zone hyperplasia and dilated intercellular spaces had increased MC/hpf. Eosinophils were weakly correlated with MC/hpf in the mid (r = 0.30, P < 0.001) and distal (r = 0.29, P < 0.001) esophagus. Clinical remission patients had lower MC/hpf compared with patients with persistent symptoms and/or endoscopic abnormalities. DISCUSSION MC density is increased in patients with endoscopic and epithelial abnormalities, as well as a few symptoms, despite resolution of esophageal eosinophilia after treatment. This association warrants further study to ascertain whether MCs play an eosinophil independent role in EoE.
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14
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Mari A, Abu Baker F, Mahamid M, Khoury T, Sbeit W, Pellicano R. Eosinophilic esophagitis: pitfalls and controversies in diagnosis and management. Minerva Med 2019; 111:9-17. [PMID: 31755670 DOI: 10.23736/s0026-4806.19.06322-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Formerly considered a rare disorder, eosinophilic esophagitis (EoE) has emerged as a leading cause of feeding problems in children and an increasingly recognized cause of dysphagia and food impaction in adults. Our understanding of EoE and its complex interplay with gastro-esophageal reflux disease (GERD) has evolved over the past decade and culminated in the introduction of proton pump inhibitor (PPI) responsive EoE as a distinct entity which has added to this complexity. It is now clear that this entity is on the same spectrum as the original EoE, and that PPIs should be considered as part of treatment protocol and should not be recommended as a diagnostic tool. As such, removing the PPI trial from the diagnostic algorithm has been encouraged recently. Recent guidelines and reviews thoroughly address various aspects in EoE pathogenesis and diagnostic workup as well as management endpoints, treatment options and novel therapies. However, despite the recent extensive study and the advances in our knowledge of this disease, unmet needs and pitfalls in diagnostic workup and management of these patients are still to be clarified and will be under focus in this review.
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Affiliation(s)
- Amir Mari
- Gastroenterology Unit, Nazareth Hospital EMMS, Faculty of Medicine, Bar Ilan University, Safed, Israel -
| | - Fadi Abu Baker
- Gastroenterology Unit, Hillel Yaffe MC, Technion, Haifa, Israel
| | - Mahmud Mahamid
- Gastroenterology Unit, Nazareth Hospital EMMS, Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Tawfik Khoury
- Gastroenterology Unit, Nazareth Hospital EMMS, Faculty of Medicine, Bar Ilan University, Safed, Israel.,Department of Gastroenterology, Galilee MC, Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Wisam Sbeit
- Department of Gastroenterology, Galilee MC, Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Rinaldo Pellicano
- Gastroenterology Unit, Molinette-San Giovanni Antica Sede Hospitals, Turin, Italy
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15
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Carr S, Chan ES, Watson W. Correction to: Eosinophilic esophagitis. Allergy Asthma Clin Immunol 2019; 15:22. [PMID: 31007687 PMCID: PMC6456987 DOI: 10.1186/s13223-019-0336-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an atopic condition of the esophagus that has become increasingly recognized over the last 15 years. Diagnosis of the disorder is dependent on the patient’s clinical manifestations, and must be confirmed by histologic findings on esophageal mucosal biopsies. Patients with EoE should be referred to an allergist for optimal management, which may include dietary modifications and pharmacologic agents such as proton pump inhibitors (PPI) and corticosteroids, and for the diagnosis and management of comorbid atopic conditions. Mechanical dilation of the esophagus may also be necessary. The epidemiology, pathophysiology, diagnosis, treatment, and prognosis of EoE are discussed in this review.
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Affiliation(s)
- Stuart Carr
- 1Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - Edmond S Chan
- 2Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC Canada.,3EoE Clinic, BC Children's Hospital, Vancouver, BC Canada
| | - Wade Watson
- 4Division of Allergy, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, NS Canada
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16
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Iuliano S, Minelli R, Vincenzi F, Gaiani F, Ruberto C, Leandro G, Bizzarri B, Nouvenne A, Di Mario F, De'Angelis GL. Eosinophilic esophagitis in pediatric age, state of the art and review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:20-26. [PMID: 30561413 PMCID: PMC6502212 DOI: 10.23750/abm.v89i8-s.7866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Indexed: 02/06/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated relapsing disease caused by eosinophilic infiltration of the esophageal mucosa which is normally lacking these cells. EoE belongs to the group of the so called Eosinophilic Gastrointestinal Disorders (EGIDs). From a rare and unusual disease, EoE has become an emerging entity and in recent years its incidence and prevalence have increased all over the world, also in children. The pathogenesis is very complex and still not completely clear. Esophageal disfunction symptoms (e.g. dysphagia and food impaction) represent the typical manifestation of EoE and this condition could be difficult to recognize, more in pediatric age than in adults. Moreover, symptoms can often overlap with those of gastro-esophageal reflux disease (GERD), leading to a delayed diagnosis. EoE is often related to atopy and an allergological evaluation is recommended. Untreated EoE could provoke complications such as strictures, esophageal rings, narrowing of the esophagus. Diagnosis is confirmed by the demonstration in biopsy specimens obtained through upper endoscopy of eosinophilic inflammation (>15 for high powered field) of the esophageal mucosa and other histological features. Other tests could be useful not specifically for the diagnosis, but for the characterization of the subtype of EoE. Since EoE incidence and knowledge about physiopathology and natural history have increased, the goal of the review is to provide some helpful tools for the correct management in pediatric age together with an overview about epidemiology, pathogenesis, clinical, diagnosis and treatment of the disease.
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Affiliation(s)
- Silvia Iuliano
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
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17
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Wong S, Ruszkiewicz A, Holloway RH, Nguyen NQ. Gastro-oesophageal reflux disease and eosinophilic oesophagitis: What is the relationship? World J Gastrointest Pathophysiol 2018; 9:63-72. [PMID: 30386667 PMCID: PMC6209579 DOI: 10.4291/wjgp.v9.i3.63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/17/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic oesophagitis (EoE) and gastro-oesophageal reflux disease (GORD) are the most common causes of chronic oesophagitis and dysphagia associated with oesophageal mucosal eosinophilia. Distinguishing between the two is imperative but challenging due to overlapping clinical and histological features. A diagnosis of EoE requires clinical, histological and endoscopic correlation whereas a diagnosis of GORD is mainly clinical without the need for other investigations. Both entities may exhibit oesophageal eosinophilia at a similar level making a histological distinction between them difficult. Although the term proton-pump inhibitor responsive oesophageal eosinophilia has recently been retracted from the guidelines, a relationship between EoE and GORD still exists. This relationship is complex as they may coexist, either interacting bidirectionally or are unrelated. This review aims to outline the differences and potential relationship between the two conditions, with specific focus on histology, immunology, pathogenesis and treatment.
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Affiliation(s)
- Stephanie Wong
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Andrew Ruszkiewicz
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Anatomical Pathology, SA Pathology, Adelaide SA 5000, Australia
| | - Richard H Holloway
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Nam Q Nguyen
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
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18
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Biedermann L, Straumann A. Medical and dietary treatments in eosinophilic esophagitis. Curr Opin Pharmacol 2018; 43:139-144. [PMID: 30336406 DOI: 10.1016/j.coph.2018.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/23/2018] [Accepted: 08/25/2018] [Indexed: 01/14/2023]
Abstract
Eosinophilic esophagitis (EoE) refers to a relatively new chronic inflammatory disease of the esophagus, which according to the current understanding underlies an immune-mediated pathogenesis driven by exposure to allergens. While several open questions remain regarding ethiopathogenesis as well as treatment options and their positioning, one thing has increasingly been recognized. The disease is on the rise and will increasingly be of importance in everyday's clinical practice, not only in expert physicians but also gastroenterologists with a broad clinical spectrum, allergologists and even general practitioners. The aim of this review is to provide a current overview on EoE treatment, including the rationale and endpoints of treatment in EoE, medical treatment options - providing the standard of current care, second-line options and outlook to emerging therapies - as well as dietary elimination approaches.
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Affiliation(s)
- Luc Biedermann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Switzerland.
| | - Alex Straumann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Switzerland
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19
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Abstract
Eosinophilic esophagitis (EoE) is an atopic condition of the esophagus that has become increasingly recognized over the last 15 years. Diagnosis of the disorder is dependent on the patient’s clinical manifestations, and must be confirmed by histologic findings on esophageal mucosal biopsies. Patients with EoE should be referred to an allergist for optimal management, which may include dietary modifications and pharmacologic agents such as corticosteroids, and for the diagnosis and management of comorbid atopic conditions. Mechanical dilation of the esophagus may also be necessary. The epidemiology, pathophysiology, diagnosis, treatment, and prognosis of EoE are discussed in this review.
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20
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Virkud YV, Wang J, Shreffler WG. Enhancing the Safety and Efficacy of Food Allergy Immunotherapy: a Review of Adjunctive Therapies. Clin Rev Allergy Immunol 2018; 55:172-189. [DOI: 10.1007/s12016-018-8694-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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21
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Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is rare but incidence and prevalence is increasing. EoE is characterized by eosinophilic inflammation of the esophagus causing gastrointestinal symptoms such as abdominal pain, vomiting, reflux, dysphagia, and food impactions. If untreated, remodeling and fibrosis of the esophagus can occur and stricture formation may result. Current treatment options are limited to food-restriction diets or medications including proton pump inhibitors (PPIs) or swallowed corticosteroids. Significant progress has been made in understanding the underlying mechanisms of EoE allowing for development of drugs that target specific points in EoE pathways. Investigation of these drugs is early with few controlled studies, but many show promise as future treatments. Areas covered: This review will provide an up to date discussion of current therapies and investigational drugs for EoE. Articles used in this review were retrieved from PubMed. Ongoing or completed clinical trials were obtained through clinicaltrials.gov and review of the PharmaProjects database. Expert Opinion: Multiple therapeutic targets have been identified and several have shown efficacy. Work is needed to define appropriate trial outcome measures. Collaboration between government agencies, patient advocacy groups, and investigator-led consortia is critical for completing new clinical trials which should pave the way for new therapies in clinical practice.
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Affiliation(s)
- Robert D Pesek
- a Department of Pediatrics and Division of Allergy and Immunology , University of Arkansas for Medical Sciences and Arkansas Children's Hospital , Little Rock , AR , United States
| | - Sandeep K Gupta
- b Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Illinois , University of Illinois College of Medicine , Peoria , IL , United States
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22
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Straumann A, Katzka DA. Diagnosis and Treatment of Eosinophilic Esophagitis. Gastroenterology 2018; 154:346-359. [PMID: 28756235 DOI: 10.1053/j.gastro.2017.05.066] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/16/2017] [Accepted: 05/19/2017] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is a new disease. It is caused by a T-helper type 2 cell response to food antigens in contact with the esophageal mucosa. Although no single feature defines EoE, a constellation of compatible demographic, clinical, endoscopic, and histologic findings establish the diagnosis. Children present with symptoms and endoscopic patterns characteristic of inflammation, whereas adolescents and adults have manifestations of fibrosis and gross esophageal strictures. Clinical and endoscopic scoring systems have helped to standardize diagnosis. There is controversy in EoE research over the optimal endpoint for treatment. Although the most common endpoint is a reduced number of eosinophils in biopsies, changes in symptoms and endoscopic features are becoming important targets of therapy. We should improve our understanding of EoE progression and the need for maintenance therapy, and continue development of diagnostic tools that avoid endoscopy and biopsy analyses to more easily monitor disease activity.
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Affiliation(s)
- Alex Straumann
- Swiss EoE Clinic, Praxis Römerhof, Olten, Switzerland; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David A Katzka
- Swiss EoE Clinic, Praxis Römerhof, Olten, Switzerland; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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23
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Schoepfer AM, Straumann A, Safroneeva E. Pharmacologic Treatment of Eosinophilic Esophagitis: An Update. Gastrointest Endosc Clin N Am 2018; 28:77-88. [PMID: 29129301 DOI: 10.1016/j.giec.2017.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Eosinophilic esophagitis (EoE) is defined as a chronic, immune-medicated or antigen-mediated, esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Food allergens are identified in most patients. Treatment strategies include elimination diets, drugs, and esophageal dilation. This article focuses on pharmacologic treatment. Currently, there is no pharmacologic treatment that has been approved by regulatory authorities. Established pharmacologic options to treat EoE include proton pump inhibitors and swallowed topical steroids. Several biologic therapies are currently under evaluation and some of them have shown promising results in improving biologic endpoints and patient-reported outcomes.
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Affiliation(s)
- Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV), Rue de Bugnon 44, 07/2409, Lausanne 1011, Switzerland.
| | - Alex Straumann
- Swiss EoE Clinic, Römerstrasse 7, 4600 Olten, Switzerland; Division of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
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24
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Management of eosinophilic esophagitis and celiac disease. Curr Opin Pharmacol 2017; 37:118-125. [DOI: 10.1016/j.coph.2017.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/13/2017] [Accepted: 10/16/2017] [Indexed: 12/23/2022]
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25
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Lipowska AM, Kavitt RT. Current Diagnostic and Treatment Strategies for Eosinophilic Esophagitis. Gastroenterol Hepatol (N Y) 2017; 13:527-535. [PMID: 29038643 PMCID: PMC5635428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder of the esophagus diagnosed by the presence of esophageal symptoms accompanied by an esophageal eosinophilic infiltrate. EoE has an increasing worldwide prevalence and can be a cause of dysphagia and food impactions. There is an important role for the use of proton pump inhibitors in the diagnostic pathway of EoE. Treatment paradigms for EoE aim to minimize esophageal inflammation and improve symptom control. Dietary therapy targets dietary allergens and encompasses the elemental diet, the allergy testing-directed elimination diet, and the empiric elimination diet. Pharmacologic options include topical corticosteroids as the standard first-line treatment. Multiple other pharmacologic interventions are currently under investigation and are not recommended in the most recent guidelines. Endoscopic dilation is usually reserved for patients who relapse on pharmacologic or dietary regimens or who have symptomatic stricturing disease. This article provides a comprehensive discussion of existing diagnostic and management strategies for EoE.
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Affiliation(s)
- Anna M Lipowska
- Dr Lipowska is a gastroenterology fellow and Dr Kavitt is an assistant professor of medicine and director of the Center for Esophageal Diseases in the Section of Gastroenterology, Hepatology, and Nutrition at The University of Chicago Medicine in Chicago, Illinois
| | - Robert T Kavitt
- Dr Lipowska is a gastroenterology fellow and Dr Kavitt is an assistant professor of medicine and director of the Center for Esophageal Diseases in the Section of Gastroenterology, Hepatology, and Nutrition at The University of Chicago Medicine in Chicago, Illinois
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26
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Abstract
The goal of this Review is to discuss the clinical approach to patients who do not respond to treatment for eosinophilic oesophagitis (EoE). Refractory EoE is challenging to manage as there are limited data to guide decision-making. In this Review, refractory EoE is defined as persistent eosinophilia in the setting of incomplete resolution of the primary presenting symptoms and incomplete resolution of endoscopic findings following a PPI trial, and after treatment with either topical steroids or dietary elimination. However, this definition is controversial. This Review will examine these controversies, explore how frequently non-response is observed, and highlight potential explanations and predictors of non-response. Non-response is common and affects a large proportion of patients with EoE. It is important to systematically assess multiple possible causes of non-response, as well as consider treatment complications and an incorrect diagnosis of EoE. If non-response is confirmed, second-line treatments are required. Although the overall response rate for second-line therapy is disappointing, with only half of patients eventually responding, there are several promising agents that are currently under investigation, and the future is bright for new treatment modalities for refractory EoE.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, CB# 7080, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, North Carolina 27599-7080, USA
- Center for Gastrointestinal Biology and Diseases, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, CB# 7080, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, North Carolina 27599-7080, USA
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27
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Hirano I, Spechler S, Furuta G, Dellon ES. White Paper AGA: Drug Development for Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2017; 15:1173-1183. [PMID: 28342955 PMCID: PMC5522639 DOI: 10.1016/j.cgh.2017.03.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/13/2017] [Accepted: 03/15/2017] [Indexed: 02/07/2023]
Abstract
Since first characterized in 2 small case series in the early 1990s, eosinophilic esophagitis (EoE) has emerged as a commonly identified cause of esophageal symptoms in children and adults.1,2 Although several highly effectively dietary, pharmacologic, and endoscopic therapies have been reported, none is currently approved by either the US Food and Drug Administration (FDA) or European regulatory authorities. Evolving diagnostic criteria have challenged drug development, in particular the recognition of complex interactions with the most prevalent esophageal disorder, gastroesophageal reflux disease (GERD). Heterogeneity in the clinical presentations of affected children and adults has created difficulties with uniform inclusion criteria and the development of disease-specific, patient-reported outcome (PRO) instruments. Furthermore, controversies regarding the appropriate therapeutic endpoints of EoE have impeded the design of clinical trials. Despite these obstacles, collaborative efforts by investigators, industry, the FDA, and patient advocacy groups have resulted in substantial progress in drug development in EoE over the past 2 decades.3 The purpose of this article is to summarize discussions on EoE based on the 2016 Drug Development Conference sponsored by the Center for Diagnostics and Therapeutics of the American Gastroenterological Association.
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Affiliation(s)
- Ikuo Hirano
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Stuart Spechler
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Glenn Furuta
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center at Dallas and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas
| | - Evan S Dellon
- Division of Gastroenterology, University of Colorado School of Medicine, Denver, Colorado
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28
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Cingi C, Gevaert P, Mösges R, Rondon C, Hox V, Rudenko M, Muluk NB, Scadding G, Manole F, Hupin C, Fokkens WJ, Akdis C, Bachert C, Demoly P, Mullol J, Muraro A, Papadopoulos N, Pawankar R, Rombaux P, Toskala E, Kalogjera L, Prokopakis E, Hellings PW, Bousquet J. Multi-morbidities of allergic rhinitis in adults: European Academy of Allergy and Clinical Immunology Task Force Report. Clin Transl Allergy 2017; 7:17. [PMID: 28572918 PMCID: PMC5452333 DOI: 10.1186/s13601-017-0153-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/12/2017] [Indexed: 12/14/2022] Open
Abstract
This report has been prepared by the European Academy of Allergy and Clinical Immunology Task Force on Allergic Rhinitis (AR) comorbidities. The aim of this multidisciplinary European consensus document is to highlight the role of multimorbidities in the definition, classification, mechanisms, recommendations for diagnosis and treatment of AR, and to define the needs in this neglected area by a literature review. AR is a systemic allergic disease and is generally associated with numerous multi-morbid disorders, including asthma, eczema, food allergies, eosinophilic oesophagitis (EoE), conjunctivitis, chronic middle ear effusions, rhinosinusitis, adenoid hypertrophy, olfaction disorders, obstructive sleep apnea, disordered sleep and consequent behavioural and educational effects. This report provides up-to-date usable information to: (1) improve the knowledge and skills of allergists, so as to ultimately improve the overall quality of patient care; (2) to increase interest in this area; and (3) to present a unique contribution to the field of upper inflammatory disease.
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Affiliation(s)
- C. Cingi
- Department of Otorhinolaryngology, Eskisehir Osmangazi University School of Medicine, Eskisehir, Turkey
| | - P. Gevaert
- Upper Airway Research Laboratory, Ghent University Hospital, Ghent, Belgium
| | - R. Mösges
- Institute of Medical Statistics, Informatics, and Epidemiology, Medical Faculty, University of Köln, Cologne, Germany
| | - C. Rondon
- Allergy Unit, IBIMA, Regional University Hospital of Malaga, UMA, Malaga, Spain
| | - V. Hox
- Clinical division of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Louvain, Belgium
| | - M. Rudenko
- London Allergy and Immunology Centre, London, UK
| | - N. B. Muluk
- ENT Department, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey
| | - G. Scadding
- Royal National Throat, Nose and Ear Hospital, London, UK
| | - F. Manole
- Faculty of Medicine, ENT Department, University of Oradea, Oradea, Romania
| | - C. Hupin
- Institut de Recherche Expérimentale et Clinique (IREC), Pole de Pneumologie, ORL & Dermatologie, Université catholique de Louvain, Louvain-la-Neuve, Belgium
| | - W. J. Fokkens
- Department of Otorhinolaryngology, Head and Neck Surgery, Academic Medical Centre (AMC), Amsterdam, The Netherlands
| | - C. Akdis
- Christine Kuhne-Center for Allergy Research and Education, Swiss Institute of Allergy and Asthma Research, University of Zurich, Davos, Switzerland
| | - C. Bachert
- Upper Airway Research Laboratory, Ghent University Hospital, Ghent, Belgium
| | - P. Demoly
- Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - J. Mullol
- Unitat de Rinologia i Clinica de l’Olfacte, Servei d’Otorinolaringologia, Hospital Clínic, Barcelona, Catalonia Spain
| | - A. Muraro
- The Referral Centre for Food Allergy Diagnosis and Treatment Veneto Region, Department of Mother and Child Health, University of Padua, Padua, Italy
| | - N. Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | | | - P. Rombaux
- Service d’ORL, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - E. Toskala
- Department of Otorhinolaryngology-Head and Neck Surgery, Temple University, Philadelphia, PA USA
| | - L. Kalogjera
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Sestre milosrdnice, Zagreb, Croatia
| | - E. Prokopakis
- Department of Otorhinolaryngology, University Hospital of Crete, Crete, Greece
| | - P. W. Hellings
- Clinical division of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Louvain, Belgium
| | - J. Bousquet
- Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
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Swift CJ, Ong J. Eosinophilic oesophagitis: an insidious but treatable cause of sore throat. Br J Gen Pract 2017; 67:91-92. [PMID: 28126881 PMCID: PMC5308115 DOI: 10.3399/bjgp17x689341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/19/2016] [Indexed: 10/31/2022] Open
Affiliation(s)
- Carla J Swift
- Department of Medicine, Lister Hospital, Stevenage, Hertfordshire, East of England Deanery
| | - John Ong
- Gastroenterology Department, Norfolk and Norwich University Hospital, Norwich, Norfolk, East of England Deanery
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Alexander JA, Ravi K, Enders FT, Geno DM, Kryzer LA, Mara KC, Smyrk TC, Katzka DA. Montelukast Does not Maintain Symptom Remission After Topical Steroid Therapy for Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2017; 15:214-221.e2. [PMID: 27650328 DOI: 10.1016/j.cgh.2016.09.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 08/16/2016] [Accepted: 09/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Montelukast, a cysteinyl leukotriene type-1 receptor blocker, has been shown in small retrospective studies to reduce symptoms in patients with eosinophilic esophagitis (EoE). We performed a randomized, placebo-controlled, double-blind trial to determine whether montelukast maintains symptomatic remission induced by topical steroid therapy in patients with EoE. METHODS We performed a prospective study of adult patients with EoE (solid-food dysphagia and a peak esophageal eosinophil count of >20 cells/high-powered field) enrolled at the Mayo Clinic in Rochester, Minnesota, from April 2008 through February 2015. All patients had been treated previously for at least 6 weeks with a topical steroid until their symptoms were in remission. Steroids were discontinued and patients then were assigned randomly to groups given montelukast (20 mg/day, n = 20) or placebo (n = 21) for 26 weeks (groups were matched for age, sex, history of allergic disease, reflux symptoms, and endoscopic findings of EoE). Study participants were assessed via a structured telephone interview at weeks 2, 4, 8, 12, 16, 20, and 24. Remission was defined as the absence of solid-food dysphagia. RESULTS Based on an intention-to-treat analysis, after 26 weeks, 40.0% of subjects in the montelukast group and 23.8% in the placebo group were in remission. The odds ratio for remission in the montelukast group was 0.48 (95% confidence interval, 0.10-2.16) (P = .33). No side effects were reported from either group. CONCLUSIONS In a randomized controlled trial of the ability of montelukast to maintain remission in patients in remission from EoE after steroid therapy, we found montelukast to be well tolerated; 40% of patients remained in remission, but this proportion did not differ significantly from that of the placebo group. ClinicalTrials.gov no: NCT00511316.
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Affiliation(s)
- Jeffrey A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota.
| | - Karthik Ravi
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Felicity T Enders
- Department of Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Debra M Geno
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Lori A Kryzer
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Kristin C Mara
- Department of Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Thomas C Smyrk
- Department of Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
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Ridolo E, Melli V, De' Angelis G, Martignago I. Eosinophilic disorders of the gastro-intestinal tract: an update. Clin Mol Allergy 2016; 14:17. [PMID: 27956893 PMCID: PMC5131414 DOI: 10.1186/s12948-016-0055-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/10/2016] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic diseases of the gastrointestinal tract, including eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE), are rare chronic pathologies of the digestive system, with an immuno-mediated pathogenesis. Recent data suggest that, together with the “classic” IgE-response to allergens, also a delayed hypersensitivity mechanism could be involved in the development of eosinophilic disorders. EoE and EGE were studied only in the latest decades and as a consequence accurate data are not yet available, concerning not only pathogenesis, but also epidemiology, treatment and outcomes. The diagnosis of EoE is centered on endoscopic findings but the certainty is obtained by histological examination from biopsy samples, that has a sensitivity of 100% when based on five samples. The currently available treatments include topical corticosteroids, specific diets and endoscopic treatment. Concerning EGE, three subtypes (mucosal, muscular, and serosal) were identified. The diagnosis is based, as for EoE, on endoscopic and histological assessment, and the treatment includes pharmacological and dietetic approaches. Further studies are warranted in order to better define the etiology and pathogenesis of eosinophilic diseases of the gastrointestinal tract, and thus to develop more appropriate and specific therapies.
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Affiliation(s)
- Erminia Ridolo
- Department of Clinical and Experimental Medicine, University of Parma, via Gramsci, 14, 43100 Parma, Italy
| | - Valerie Melli
- Department of Clinical and Experimental Medicine, University of Parma, via Gramsci, 14, 43100 Parma, Italy
| | - Gianluigi De' Angelis
- Department of Clinical and Experimental Medicine, University of Parma, via Gramsci, 14, 43100 Parma, Italy
| | - Irene Martignago
- Department of Clinical and Experimental Medicine, University of Parma, via Gramsci, 14, 43100 Parma, Italy
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32
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Zerbib F. [Eosinophilic esophagitis]. Presse Med 2016; 46:154-158. [PMID: 27745759 DOI: 10.1016/j.lpm.2016.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/05/2016] [Indexed: 11/15/2022] Open
Abstract
Eosinophilic esophagitis is a major cause of dysphagia and esophageal food impaction in young adults, although the diagnostic can be made in older patients. The diagnosis of eosinophilic esophagitis is suspected on endoscopic abnormalities of esophageal mucosa and confirmed by esophageal biopsy samples. Approximately 50% of patients with eosinophilic esophagitis do respond to proton pump inhibitors therapy. The first line therapy for eosinophilic esophagitis is proton pump inhibitor therapy. Ingested topical steroids represent a second-line therapy. The practical modalities of this treatment should be clearly explained to patients. A diet that eliminates most alimentary allergens provide a 75% clinical and histological remission rate. The progressive reintroduction protocol allows to identify the allergen(s) involved in the disease. Endoscopic dilatations should be proposed in patients with significant esophageal stricture.
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Affiliation(s)
- Frank Zerbib
- CHU de Bordeaux, hôpital du Haut-Lévêque, service d'hépato-gastroentérologie et oncologie digestive, avenue Magellan, 33600 Pessac, France.
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Hua S, Cook D, Walker MM, Talley NJ. Pharmacological treatment of eosinophilic gastrointestinal disorders. Expert Rev Clin Pharmacol 2016; 9:1195-209. [PMID: 27191032 DOI: 10.1080/17512433.2016.1190268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Eosinophilic gastrointestinal disorders (EGIDs) are increasingly prevalent chronic inflammatory diseases characterized by eosinophilic infiltration of the gastrointestinal (GI) tract, in the absence of other known causes of eosinophilia. AREAS COVERED Clinical management of EGIDs is challenging, as there are currently limited therapeutic options available. The most common EGID is eosinophilic esophagitis (EoE), and rarer forms are eosinophilic gastritis, eosinophilic gastroenteritis, and eosinophilic colitis. Clinical presentation depends on the affected GI site. Recently duodenal eosinophilia has been recognized to commonly be present in patients with functional dyspepsia. This review will provide an overview of the pathogenesis and therapeutic management of EGIDs, with particular focus on the pharmacological strategies for these conditions. Expert commentary: Despite the considerable progress made in understanding the pathogenesis of EGIDs, there is still an urgent need for the development of specific and effective therapeutic approaches. Therapeutic management protocols are required that are based on rigorous clinical investigation in large prospective controlled trials to better understand the risks, benefits and limitations of each therapy. More well-defined and consistent end-points are also required to assess treatment outcomes, as there has been variability between patient reported outcomes, clinical outcomes, and histological outcomes in the studies to date.
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Affiliation(s)
- Susan Hua
- a School of Biomedical Sciences and Pharmacy , University of Newcastle , Callaghan , NSW , Australia
- b Hunter Medical Research Institute , New Lambton Heights , NSW , Australia
| | - Dane Cook
- c John Hunter Hospital , New Lambton Heights , NSW , Australia
| | - Marjorie M Walker
- b Hunter Medical Research Institute , New Lambton Heights , NSW , Australia
- d School of Medicine & Public Health , University of Newcastle , Callaghan , NSW , Australia
| | - Nicholas J Talley
- b Hunter Medical Research Institute , New Lambton Heights , NSW , Australia
- d School of Medicine & Public Health , University of Newcastle , Callaghan , NSW , Australia
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Moawad FJ, Cheng E, Schoepfer A, Al-Haddad S, Bellizzi AM, Dawson H, El-Zimaity H, Guindi M, Penagini R, Safrooneva E, Chehade M. Eosinophilic esophagitis: current perspectives from diagnosis to management. Ann N Y Acad Sci 2016; 1380:204-217. [DOI: 10.1111/nyas.13164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/01/2016] [Accepted: 06/03/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Fouad J. Moawad
- Gastroenterology Service, Department of Medicine; Walter Reed National Military Medical Center; Bethesda Maryland
| | - Edaire Cheng
- Pediatric Gastroenterology, Hepatology & Nutrition Division; University of Texas Southwestern Medical Center; Dallas Texas
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology; Centre Hospitalier Universitaire; Vaudois/CHUV Lausanne Switzerland
| | - Sahar Al-Haddad
- Department of Laboratory Medicine; St. Michael's Hospital; Hamilton Ontario Canada
| | - Andrew M. Bellizzi
- Department of Pathology; University of Iowa Hospitals and Clinics, University of Iowa Carver College of Medicine; Iowa City Iowa
| | - Heather Dawson
- Institute of Pathology; University of Bern; Bern Switzerland
| | | | - Maha Guindi
- Department of Pathology and Laboratory Medicine; Cedars-Sinai Medical Center; Los Angeles California
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Pathophysiology and Transplantation; Università degli Studi; Milan Italy
| | - Ekaterina Safrooneva
- Institute of Social and Preventive Medicine; University of Bern; Bern Switzerland
| | - Mirna Chehade
- Department of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders; Icahn School of Medicine at Mount Sinai; New York New York
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Philpott HL, Nandurkar S, Thien F, Bloom S, Lin E, Goldberg R, Boyapati R, Finch A, Royce SG, Gibson PR. Seasonal recurrence of food bolus obstruction in eosinophilic esophagitis. Intern Med J 2016; 45:939-43. [PMID: 25871330 DOI: 10.1111/imj.12790] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 04/07/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a newly recognised condition that is apparently increasing in prevalence, and the aetiology is poorly understood. The role of aeroallergens in EoE is controversial, given the success of dietary therapy. Massive aeroallergen exposure leading to food bolus obstruction events (FBOE) has been described, and the diagnosis of EoE by esophageal biopsy noted to be more common in the pollen season according to previous case series. AIM To determine if a seasonal variation and a geographical variation occurred in EoE presenting as FBOE in adults, and to track the prevalence of FBOE and EoE over time. METHOD A retrospective case-control study analysis was performed from January 2002 to January 2012 to identify all FBOE in adults presenting to five tertiary hospitals in Melbourne, Australia. Endoscopy, histopathological reports, case notes and blood tests were examined, and postcodes recorded. Records of pollen counts were obtained. Cases were defined according to esophageal biopsy and grouped based on month of diagnosis. All other causes of FBOE served as controls. RESULTS One thousand, one hundred and thirty-two FBOE were identified. Biopsies were only performed in 278 of these cases, and 85 patients were found to have EoE after biopsy. Patients with EoE were younger (mean age 38 years, range 18-72) compared with those with alternative diagnosis (mean age 64.4 range 22-92), more likely to be male (M : F = 4:1 compared with 1.68:1 ) and had a higher eosinophil count in venous blood. Overall no seasonality was demonstrated in FBOE secondary to any diagnosis, although the six cases of recurrent FBOE secondary to EoE mainly occurred in the grass pollen season in subsequent years. FBOE cases were evenly distributed throughout metropolitan Melbourne irrespective of population density. EoE as a percentage of FBOE increased over time. CONCLUSION Seasonal aeroallergens may be important for a subgroup of patients with EoE presenting as recurrent FBOE. Esophageal biopsies are performed in a minority of patients, representing a significant departure from ideal management and contributing to recurrent unnecessary FBOE. EoE is an increasingly important cause of FBOE.
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Affiliation(s)
- H L Philpott
- Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia.,Department of Gastroenterology, St Vincents Hospital, Melbourne, Victoria, Australia
| | - S Nandurkar
- Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia
| | - F Thien
- Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia
| | - S Bloom
- Department of Gastroenterology, St Vincents Hospital, Melbourne, Victoria, Australia
| | - E Lin
- Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia
| | - R Goldberg
- Department of Gastroenterology, St Vincents Hospital, Melbourne, Victoria, Australia
| | - R Boyapati
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
| | - A Finch
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - S G Royce
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - P R Gibson
- Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Gastroenterology, The Alfred Hospital, Melbourne, Victoria, Australia
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36
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Mudde ACA, Lexmond WS, Blumberg RS, Nurko S, Fiebiger E. Eosinophilic esophagitis: published evidences for disease subtypes, indications for patient subpopulations, and how to translate patient observations to murine experimental models. World Allergy Organ J 2016; 9:23. [PMID: 27458501 PMCID: PMC4947322 DOI: 10.1186/s40413-016-0114-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/01/2016] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder of the esophagus and commonly classified as a Th2-type allergy. Major advances in our understanding of the EoE pathophysiology have recently been made, but clinicians struggle with highly unpredictable therapy responses indicative of phenotypic diversity within the patient population. Here, we summarize evidences for the existence of EoE subpopulations based on diverse inflammatory characteristics of the esophageal tissue in EoE. Additionally, clinical characteristics of EoE patients support the concept of disease subtypes. We conclude that clinical and experimental evidences indicate that EoE is an umbrella term for conditions that are unified by esophageal eosinophilia but that several disease subgroups with various inflammatory esophageal patterns and/or different clinical features exist. We further discuss strategies to study the pathophysiologic differences as observed in EoE patients in murine experimental EoE. Going forward, models of EoE that faithfully mimic EoE subentities as defined in humans will be essential because mechanistic studies on triggers which regulate the onset of diverse EoE subpopulations are not feasible in patients. Understanding how and why different EoE phenotypes develop will be a first and fundamental step to establish strategies that integrate individual variations of the EoE pathology into personalized therapy.
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Affiliation(s)
- Anne C A Mudde
- Department of Medicine, Harvard Medical School, and Division of Gastroenterology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Willem S Lexmond
- Department of Medicine, Harvard Medical School, and Division of Gastroenterology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Richard S Blumberg
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA USA
| | - Samuel Nurko
- Department of Medicine, Harvard Medical School, and Division of Gastroenterology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115 USA ; Center for Motility and Functional Gastrointestinal Disorders, Boston, MA USA ; Eosinophilic Gastrointestinal Disease Center, Boston Children's Hospital, Boston, MA USA
| | - Edda Fiebiger
- Department of Medicine, Harvard Medical School, and Division of Gastroenterology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
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Bancil AS, Hewett R, Hayat JO, Poullis A. Eosinophilic oesophagitis. Br J Hosp Med (Lond) 2016; 77:409-13. [PMID: 27388380 DOI: 10.12968/hmed.2016.77.7.409] [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 oesophagitis is a chronic immune-mediated inflammatory disorder of the oesophagus, characterized by symptoms of dysphagia or food bolus obstruction. Diagnosis is supported by typical histological findings. This article covers pertinent aspects of the disease, pathogenic explanations and treatment options.
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Affiliation(s)
- Aaron S Bancil
- Core Medical Trainee in the Department of Hepatology, King's College Hospital, London SE5 9RS
| | - Rhys Hewett
- Clinical Research Fellow in the Department of Gastroenterology, St George's Hospital, London
| | - Jamal O Hayat
- Consultant in the Department of Gastroenterology, St George's Hospital, London
| | - Andrew Poullis
- Consultant in the Department of Gastroenterology, St George's Hospital, London
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Schoepfer A, Safroneeva E, Straumann A. Eosinophilic Esophagitis: Impact of Latest Insights Into Pathophysiology on Therapeutic Strategies. Dig Dis 2016; 34:462-8. [PMID: 27333298 DOI: 10.1159/000445201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Eosinophilic esophagitis (EoE) has been defined as a 'chronic, immune/antigen-mediated, esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation'. A peak value of ≥15 eosinophils/high power field has been defined as histologic diagnostic cutoff. Other conditions associated with esophageal eosinophilia, such as gastro-esophageal reflux disease, PPI-responsive esophageal eosinophilia or Crohn's disease, need to be ruled out before EoE can be diagnosed. Males are affected more frequently than females and most of the patients have concomitant allergies. Currently, the EoE prevalence is about 1 of 2,000 inhabitants in Westernized countries. The first EoE patients were described only 2 decades ago. Despite this short period, considerable progress has been made regarding the understanding of the pathophysiology, natural history, assessment of disease activity and with respect to evaluating different therapeutic options. Untreated EoE can lead to esophageal remodeling with reduced compliance and stricture formation, which represents the main risk factor for food bolus impactions. The therapeutic options can be summarized with the 3 D's, which stand for drugs, diets and dilation. Of note, as of yet, there is no EoE-specific drug that has been approved by regulatory authorities. This is, among other reasons, related to the lack of validated outcome measurement instruments until recently. Swallowed topical steroids such as budesonide or fluticasone represent the standard of care for treating symptomatic pediatric and adult EoE patients with inflammatory activity. Several trials have already evaluated different biologic therapies, such as anti-interleukin-5 or anti-IgE. Further studies are on the way. As a non-pharmacologic alternative, different dietary regimens exist. Dilation can offer long-lasting symptomatic response in case of stricturing EoE but does not have any impact on the underlying inflammation. This review highlights the latest insights regarding pathophysiology and its impact regarding current and future therapeutic strategies.
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Affiliation(s)
- Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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39
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McEvoy T. Montelukast: Eosinophilic Esophagitis. Hosp Pharm 2016; 51:450-1. [DOI: 10.1310/hpj5106-450] [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
This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu .
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40
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Ahmed M. Eosinophilic esophagitis in adults: An update. World J Gastrointest Pharmacol Ther 2016; 7:207-213. [PMID: 27158535 PMCID: PMC4848242 DOI: 10.4292/wjgpt.v7.i2.207] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/10/2016] [Accepted: 03/16/2016] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic esophagitis is a worldwide chronic allergic disease of the esophagus. In the last decade, there is an epidemic of this entity in the western world. Mostly seen in children and young adults, patients present with dysphagia or food impaction in the emergency room. Characteristic endoscopic findings, esophageal eosinophilia and non-responsiveness to proton pump inhibitors help make the diagnosis. Avoidance of food allergens, administration of steroidal anti-inflammatory medications and dilation of the esophagus are the mainstays of treatment. Investigations are ongoing for mucosal healing and optimum maintenance treatment.
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Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by esophageal dysfunction and eosinophilic infiltrate (≥15/hpf) in the esophageal epithelium and the absence of other potential causes of eosinophilia. The prevalence is increasing and is the most common cause of solid food dysphagia in children and young adults. This article will review the diagnosis and management of EoE based on consensus conferences, systematic reviews, and meta-analysis and highlights seminal studies in our evolving treatment of this disease. However, all answers are not available and I will remark about the lessons learned in my clinical practice seeing EoE patients over the last 25 years. The complicated etiology of the complaint of dysphagia in EoE patients will be reviewed. The importance of utilizing endoscopy, biopsies, and barium esophagram to help define the 2 phenotypes (inflammatory, fibrostenosis) of EoE will be highlighted. The controversy about PPI-responsive esophageal eosinophilia will be discussed and contrasted with idiopathic EoE. Finally, the 3 treatment options for EoE (drugs, diet, dilation) will be reviewed in detail and a useful clinical management algorithm presented.
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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.
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43
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Current Approach to the Management of Eosinophilic Esophagitis in Adults. ACTA ACUST UNITED AC 2015; 13:441-51. [DOI: 10.1007/s11938-015-0069-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Straumann A. Medical therapy in eosinophilic oesophagitis. Best Pract Res Clin Gastroenterol 2015; 29:805-814. [PMID: 26552779 DOI: 10.1016/j.bpg.2015.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 06/09/2015] [Accepted: 06/18/2015] [Indexed: 01/31/2023]
Abstract
Eosinophilic oesophagitis (EoE) is a chronic-inflammatory disease of the oesophagus. If left untreated, eosinophilic inflammation induces fibrosis, angiogenesis and stricture formation, resulting finally in a so called remodelling with structural and functional damage of the organ. In addition, patients with untreated EoE are permanently at risk of experiencing food impactions. It is therefore widely accepted that active EoE should be treated. Any treatment applied in EoE should ideally achieve two therapeutic goals: first, resolution of symptoms, and, second, control of inflammation. Avoidance of food allergens by elimination diets as well as anti-inflammatory drugs have both the ability to achieve these goals. Among the pharmacological options, only corticosteroids have documented efficacy, whereas alternatives have shown rather disappointing results or are still under evaluation. Of note, swallowed topical corticosteroids are at least as efficient as systemically administered corticosteroids but have fewer side effects. As such topical corticosteroids are widely used as first-line drug in the treatment of EoE, even though this compound is currently not approved for this indication by regulatory authorities. Unfortunately, complete resolution of symptoms can be achieved with swallowed topical corticosteroids only in approximately 70% of patients despite appropriate dosing and despite correct administration of these compounds. Control of inflammation is even harder to achieve, as only in approximately 50% of patients tissue eosinophilia disappears completely under this anti-inflammatory medication. For this group of "difficult to treat" patients, therapeutic alternatives are urgently needed. Fortunately several anti-allergic drugs and several biologicals are currently under investigation.
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Affiliation(s)
- Alex Straumann
- Swiss EoE Clinic and EoE Research Network, Roemerstrasse 7, 4600 Olten, Switzerland.
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45
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Sodikoff J, Hirano I. Therapeutic strategies in eosinophilic esophagitis: Induction, maintenance and refractory disease. Best Pract Res Clin Gastroenterol 2015; 29:829-839. [PMID: 26552781 PMCID: PMC4946566 DOI: 10.1016/j.bpg.2015.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease that is increasingly recognized as one of the most common causes of dysphagia and foregut symptoms in adults and children. Topical corticosteroids, elimination diets, and esophageal dilations are effective options for both induction and maintenance therapy in EoE. Current pharmacologic options are being used off-label as no agent has yet been approved by regulatory authorities. Little is known about the natural history of EoE, however, raising controversy regarding the necessity of maintenance and therapy in asymptomatic or treatment-refractory patients. Furthermore, variability in treatment endpoints used in EoE clinical trials makes interpretation and comparability of EoE treatments challenging. Recent validation of a patient-related outcome (PRO) instruments, a histologic scoring tool, and an endoscopic grading system for EoE are significant advances toward establishing consistent treatment endpoints.
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Affiliation(s)
| | - Ikuo Hirano
- Corresponding author. Northwestern University, Feinberg School of Medicine, Department of Medicine, 676 St Clair St, Suite 1400, Chicago, IL 60611-2951, USA. Tel.: +1 312 695 5620. (I. Hirano)
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Kochar B, Dellon ES. Management of proton pump inhibitor responsive-esophageal eosinophilia and eosinophilic esophagitis: controversies in treatment approaches. Expert Rev Gastroenterol Hepatol 2015; 9:1359-69. [PMID: 26365201 PMCID: PMC4644096 DOI: 10.1586/17474124.2015.1088384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated clinicopathologic disease. The prevalence of EoE is approximately 1/2000 persons, EoE is now the most common cause of food impactions, with healthcare expenditures approaching US$ 1 billion annually. This article will discuss challenges related to proton pump inhibitor responsive esophageal eosinophilia, including distinguishing this condition from EoE and understanding the mechanisms behind the PPI response. For EoE, we will review multiple ongoing debates about treatment and monitoring strategies, including selecting treatment outcomes, optimizing medication formulations, approaching the steroid-refractory patient, conducting dietary elimination, prescribing long-term maintenance therapy and performing esophageal dilation.
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Affiliation(s)
- Bharati Kochar
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Abstract
OBJECTIVE We designed this systematic review and meta-analysis aiming to clarify the advantage of steroid therapy compared with non-steroid therapy for the treatment of eosinophilic esophagitis (EoE). METHODS PubMed, EMBASE, Medline, ISI Web of Science and the Cochrane Database of Systematic Reviews were searched to identify relevant randomized controlled trials (RCTs) comparing steroid and non-steroid therapy, and retrospective and prospective trials on steroid therapy for EoE. RevMan 5.2 was used for the analysis. Weighted mean difference and 95% confidence interval (CI) were estimated and pooled using meta-analysis methods. RESULTS Six RCTs including 193 participants fulfilled the inclusion criteria for meta-analysis, and another two RCTs, three prospective and five retrospective trials were included in systematic review. Meta-analysis showed that topical steroids significantly decreased the mean and peak esophageal eosinophils (EOS) count compared to non-steroid therapy (MDmean = -23.41, 95% CImean -42.08--4.73, P = 0.01 and MDpeak = -51.27, 95% CIpeak -78.62--23.92, P = 0.0002). There were 14 trials showing the efficacy of steroids on decreasing the EOS count, 10 showing the amelioration of symptoms, and five showing endoscopic improvement. Only mild adverse events were reported for topical steroids. CONCLUSIONS Steroids are effective on decreasing the EOS count in EoE patients. Its value in ameliorating symptoms and endoscopic changes remains undetermined due to the lack of comparable criteria.
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Affiliation(s)
- Nian Di Tan
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Ying Lian Xiao
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Min Hu Chen
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
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Lieberman JA. Pharmacotherapy for eosinophilic esophagitis. Ann Allergy Asthma Immunol 2015; 114:357-63. [PMID: 25952635 DOI: 10.1016/j.anai.2015.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/17/2015] [Accepted: 03/17/2015] [Indexed: 12/21/2022]
Affiliation(s)
- Jay Adam Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee.
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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.
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Straumann A, Safroneeva E. Pharmacologic Treatment of Eosinophilic Esophagitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2015. [DOI: 10.1007/s40521-015-0048-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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