Idiopathic eosinophilic esophagitis in adults: the ringed esophagus

Oesophageal fluoroscopy in adults-when and why?

Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.

Pathophysiology and Clinical Impact of Esophageal Remodeling and Fibrosis in Eosinophilic Esophagitis

Most of the major clinical signs and consequences of eosinophilic esophagitis seem to be related to tissue remodeling. Important data on remodeling activity in patients with eosinophilic esophagitis are provided by a range of current and new biologic markers and diagnostics. To completely clarify the possible advantages and restrictions of therapeutic approaches, clinical studies should take into consideration the existence and reversibility of esophageal remodeling. The degree of mucosal or submucosal disease activity may not be reflected by epithelial eosinophilic inflammation, which is used to define one criterion of disease activity".

Vasoactive Intestinal Peptide Receptor, CRTH2, Antagonist Treatment Improves Eosinophil and Mast Cell-Mediated Esophageal Remodeling and Motility Dysfunction in Eosinophilic Esophagitis

BACKGROUND AND AIMS

Ultrasonography has shown that eosinophils accumulate in each segment of the esophageal mucosa in human EoE, ultimately promoting esophageal motility dysfunction; however, no mechanistic evidence explains how or why this accumulation occurs.

METHODS

Quantitative PCR, ELISA, flow cytometry, immunostaining, and immunofluorescence analyses were performed using antibodies specific to the related antigens and receptors.

RESULTS

In deep esophageal biopsies of EoE patients, eosinophils and mast cells accumulate adjacent to nerve cell-derived VIP in each esophageal segment. qRT-PCR analysis revealed five- to sixfold increases in expression levels of VIP, CRTH2, and VAPC2 receptors and proteins in human blood- and tissue-accumulated eosinophils and mast cells. We also observed a significant correlation between mRNA CRTH2 levels and eosinophil- and nerve cell-derived VIPs in human EoE (p < 0.05). We provide evidence that eosinophil and mast cell deficiency following CRTH2 antagonist treatment improves motility dysfunction in a chronic DOX-inducible CC10-IL-13 murine model of experimental EoE.

CONCLUSIONS

CRTH2 antagonist treatment is a novel therapeutic strategy for inflammatory cell-induced esophageal motility dysfunction in IL-13-induced chronic experimental EoE.

Allergen-induced NLRP3/caspase1/IL-18 signaling initiate eosinophilic esophagitis and respective inhibitors protect disease pathogenesis

The current report describes a stepwise mechanistic pathway of NLRP3/caspase1/IL-18-regulated immune responses operational in eosinophilic esophagitis (EoE). We show that esophageal epithelial cells and macrophage-derived NLRP3 regulated IL-18 initiate the disease and induced IL-5 facilitates eosinophil growth and survival. We also found that A. fumigatus-exposed IL-18-/- mice or IL-18-neutralized mice are protected from EoE induction. Most importantly, we present that intravascular rIL-18 delivery to ΔdblGATA mice and CD2-IL-5 mice show the development of EoE characteristics feature like degranulated and intraepithelial eosinophils, basal cell hyperplasia, remodeling and fibrosis. Similarly, we show an induced NLRP3-caspase1-regulated IL-18 pathway is also operational in human EoE. Lastly, we present the evidence that inhibitors of NLRP3 and caspase-1 (MCC950, BHB, and VX-765) protect A. fumigatus- and corn-extract-induced EoE pathogenesis. In conclusion, the current study provides a new understanding by implicating NLRP3/caspase1-regulated IL-18 pathway in EoE pathogenesis. The study has the clinical significance and novel therapeutic strategy, which depletes only IL-18-responsive pathogenic eosinophils, not naïve IL-5-generated eosinophils critical for maintaining innate immunity.

"Imaging Findings of Eosinophilic Gastrointestinal Diseases in Adults"

Eosinophilic gastrointestinal (GI) disorders are a group of conditions marked by pathologic eosinophilic infiltration of one or multiple locations in the GI tract. Conditions include eosinophilic esophagitis, eosinophilic gastritis, eosinophilic enteritis, and eosinophilic colitis. The site and depth of eosinophilic infiltration of the GI tract usually determines clinical presentation. These conditions should be considered in the differential diagnosis for several GI symptoms, such as food impaction or dysphagia. Histopathology is the gold standard for diagnosis of eosinophilic disorders. Nevertheless, findings from endoscopy, barium studies, computed tomography or magnetic resonance imaging, can aid in the diagnosis, by allowing for earlier diagnosis as well as proper management. Eosinophilic gastrointestinal disorders are typically managed with corticosteroids or dietary elimination. A high index of suspicion is required for diagnosis as it can often be challenging.

Endoscopic Diagnosis of Eosinophilic Esophagitis: Basics and Recent Advances

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease, characterized by esophageal dysfunction and intense eosinophil infiltration localized in the esophagus. In recent decades, EoE has become a growing concern as a major cause of dysphagia and food impaction in adolescents and adults. EoE is a clinicopathological disease for which the histological demonstration of esophageal eosinophilia is essential for diagnosis. Therefore, the recognition of the characteristic endoscopic features with subsequent biopsy are critical for early definitive diagnosis and treatment, in order to prevent complications. Accumulating reports have revealed that EoE has several non-specific characteristic endoscopic findings, such as rings, furrows, white exudates, stricture/narrowing, edema, and crepe-paper esophagus. These findings were recently unified under the EoE endoscopic reference score (EREFS), which has been widely used as an objective, standard measurement for endoscopic EoE assessment. However, the diagnostic consistency of those findings among endoscopists is still inadequate, leading to underdiagnosis or misdiagnosis. Some endoscopic findings suggestive of EoE, such as multiple polypoid lesions, caterpillar sign, ankylosaurus back sign, and tug sign/pull sign, will aid the diagnosis. In addition, image-enhanced endoscopy represented by narrow band imaging, endocytoscopy, and artificial intelligence are expected to render endoscopic diagnosis more efficient and less invasive. This review focuses on suggestions for endoscopic assessment and biopsy, including recent advances in optical technology which may improve the diagnosis of EoE.

Eosinophilic Disorders of the Gastrointestinal Tract and Associated Abdominal Viscera: Imaging Findings and Diagnosis

Eosinophilic gastrointestinal disorders (EGIDs) are inflammatory conditions of the gastrointestinal tract that are characterized by tissue eosinophilia and end-organ dysfunction or damage. Primary EGIDs are associated with atopy and other allergic conditions, whereas secondary EGIDs are associated with underlying systemic diseases or hypereosinophilic syndrome. Within the spectrum of EGIDs, eosinophilic esophagitis is the most prevalent. Eosinophilic gastroenteritis and eosinophilic colitis are relatively uncommon. Eosinophilic infiltration of the liver, biliary tree, and/or pancreas also can occur and mimic other inflammatory and malignant conditions. Although endoscopic evaluation is the method of choice for eosinophilic esophagitis, radiologic evaluation of the esophagus plays an important role in the assessment of disease severity. CT and MR enterography are the modalities of choice for demonstrating specific forms of eosinophilic gastroenteritis. CT and MRI are important in the detection of abdominal visceral involvement in EGIDs. Diagnosis is often challenging and relies on symptoms, imaging findings, histologic confirmation of tissue eosinophilia, and correlation with peripheral eosinophilia. Imaging is crucial for identifying characteristic organ-specific findings, although imaging findings are not specific. When promptly treated, EGIDs usually have a benign clinical course. However, a delayed diagnosis and associated surgical interventions have been associated with morbidity. Therefore, a radiologist's knowledge of the imaging findings of EGIDs in the appropriate clinical settings may aid in early diagnosis and thereby improve patient care. An overview of the clinical features and imaging findings of EGIDs and the eosinophilic disorders of associated abdominal viscera is provided. Online supplemental material is available for this article. ^©RSNA, 2022.

Eosinophilic Esophagitis

Eosinophilic esophagitis is a recently defined condition that has dramatically increased in prevalence in the last several decades. It may occur at any age, but the clinical presentation in young children is often more vague than the classic solid food dysphagia and food impacting that are the major presenting symptoms of eosinophilic esophagitis in adults and adolescents. Successful therapies exist, including medications and dietary modifications, but disease typically recurs when the intervention is discontinued.

Eosinophilic esophagitis: imaging features with endoscopic and pathologic correlation

OBJECTIVE

We aim to review the imaging features of eosinophilic esophagitis on fluoroscopy and present how they can correlate with endoscopic and pathologic findings.

RESULTS

Eosinophilic esophagitis is a chronic immune-mediated disease that results in esophageal dysfunction. Upper esophagogastroduodenoscopy is high yield and required for biopsies to demonstrate the hallmark histologic findings of eosinophil-predominant inflammation. While esophagogastroduodenoscopy is currently mandatory for diagnosis, imaging findings can provide valuable information regarding the structural and functional properties of the esophagus. In addition, fluoroscopic studies may be very helpful in the setting of subtle findings and to evaluate fibrotic remodeling changes.

CONCLUSION

Radiologic examinations are a valuable tool in the assessment of eosinophilic esophagitis and can highlight changes of fibrostenotic disease, as overall narrowing can be more conspicuous fluoroscopically than endoscopically. As the disease increases in prevalence, it is critical that physicians recognize this condition and facilitate diagnosis and treatment.

Clinical relevance of esophageal subepithelial activity in eosinophilic esophagitis

Esophageal subepithelial activity (ESEA) is an important determinant of disease severity and complications in eosinophilic esophagitis (EoE). Inflammation and fibrosis of the lamina propria and muscularis propria result in esophageal dysfunction and stricture formation that are clinically manifest by symptoms of dysphagia and food impaction as well as the need for esophageal dilation. Esophageal biopsies that are limited to the evaluation of the esophageal epithelium are an inadequate means to assess overall, clinical disease severity in EoE. Instruments for the assessment of subepithelial activity in EoE are both limited and/or underutilized and thus represent an important unmet clinical need. Studies using endoscopic features, endoscopic ultrasonography, and barium esophagography have demonstrated improvement in ESEA parameters with topical steroid therapy. Impedance planimetry is being evaluated as an objective and quantifiable measure of esophageal distensibility that is a consequence of ESEA. In conjunction with symptom and histologic assessment, evaluation of ESEA provides a more complete evaluation of disease activity in EoE that will enhance clinical care as well as provide insights into the strengths and limitations of therapeutic interventions.

Eosinophilic Esophagitis

Eosinophilic esophagitis is a recently defined condition that has dramatically increased in prevalence in the last several decades. It may occur at any age, but the clinical presentation in young children is often more vague than the classic solid food dysphagia and food impacting that are the major presenting symptoms of eosinophilic esophagitis in adults and adolescents. Successful therapies exist, including medications and dietary modifications, but disease typically recurs when the intervention is discontinued.

Eosinophilic gastroenteritis: diagnosis and clinical perspectives

Eosinophilic gastroenteritis (EGE) is a digestive disorder in children and adults that is characterized by eosinophilic infiltration in the stomach and intestine. The underlying molecular mechanisms predisposing to this disease are unknown, but it seems that hypersensitivity response plays a major role in its pathogenesis, as many patients have a history of seasonal allergies, food sensitivities, asthma, and eczema. Symptoms and clinical presentations vary, depending on the site and layer of the gastrointestinal wall infiltrated by eosinophils. Laboratory results, radiological findings, and endoscopy can provide important diagnostic evidence for EGE; however, the cornerstone of the diagnosis remains the histological examination of gastric and duodenal specimens for evidence of eosinophilic infiltration (>20 eosinophils per high-power field), and finally clinicians make the diagnosis in correlation with and by exclusion of other disorders associated with eosinophilic infiltration. Although spontaneous remission is reported in around 30%–40% of EGE cases, most patients require ongoing treatment. The management options for this disorder include both dietary and pharmacological approaches, with corticosteroids being the mainstay of therapy and highly effective. The subsequent course is quite variable. Some patients have no recurrences, while a few experience recurrent symptoms during or immediately after corticosteroid interruption. An alternative therapeutic armamentarium includes mast-cell stabilizers, leukotriene antagonists, antihistamines, immunomodulators, and biological agents. In this review, we provide a summary of the different diagnostic tools utilized in practice, as well as the different therapeutic approaches available for EGE management.

Elevated Tryptase in EoE Is an Independent Phenomenon Associated with Extra-Esophageal Symptoms

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic disease characterized histologically by > 15 eosinophils per high-power field (eos/hpf). Esophageal mucosal mast cells have been implicated in EoE pathogenesis. The association of atopy with EoE has been established but has not been correlated with levels of serum tryptase. The lack of concurrent atopy in some patients suggests the possibility that atopy may either be the related subtype of EoE or may be a sign of comorbidities. No study has looked at whether patients present with different phenotypes/comorbid disease when they have evidence of elevated serum tryptase. We hypothesized that these patients differ with respect to presentation and comorbidities with more refractory GI disease.

AIMS

To examine whether elevations of serum tryptase associate with different, more severe clinical presentations in EoE patients which may be explained via mast cell activation.

MATERIALS AND METHODS

Retrospective chart review identified 72 patients with EoE with results for serum tryptase between 2015 and 2016. Patients were classified as Tryptase^HI (tryptase > 10.9 µg/l) and Tryptase^LO (< 10.9 µg/l). Clinical characteristics and treatment response were compared using univariate analysis and multivariate regression between the groups.

RESULTS

Out of 72 patients, 12 were tested as Tryptase^HI (16.7%, 95% CI 8.1-25.3%). Tryptase^HI was associated frequently with asthma (P = 0.0003), urticaria (P = 0.002), arthralgia (P = 0.005), sinusitis (P = 0.03), nausea/vomiting (P = 0.046), and eosinophilic gastrointestinal disease (P = 0.001). Asthma and arthralgia were found to be significantly associated with Tryptase^HI (P = 0.0013, P = 0.0098, respectively). Mucosal eosinophil counts and tryptase levels were not correlated (R² 0.095, P = 0.77). Tryptase did not resolve with resolution of esophageal eosinophilia.

CONCLUSIONS

We found that EoE patients with elevated tryptase levels more commonly presented with asthma, urticaria, arthralgia, nausea/vomiting, sinusitis, and more distal eosinophilia. This indicates that atopy in EoE patients warrants further exploration. The lack of correlation between histologic remission and reduction of serum tryptase levels post-treatment suggests that mast cell activation may be an independent, yet associated disease. More study into this unique association is warranted.

Diffuse Esophageal Narrowing in Eosinophilic Esophagitis: A Barium Contrast Study

Background

Patients with eosinophilic esophagitis (EoE) present with mechanical type dysphagia. Barium esophagrams occasionally demonstrate focal strictures or multiple concentric rings. Diffuse narrowing has also been reported but may be difficult to recognize because of lack of normative data.

Aim

The aim of this study is to assess esophageal diameters at multiple sites in healthy controls in comparison with EoE patients.

Methods

A standardized barium swallow was performed in 22 healthy male volunteers without esophageal symptoms and compared with 10 untreated EoE patients. A radiopaque ruler attached at the subject’s back was used to measure maximal esophageal diameter at three esophageal sites by a blinded observer. Peak intraepithelial eosinophil counts and Mayo Dysphagia Questionnaire scores were correlated to esophageal diameters in EoE patients.

Results

Two of 10 EoE patients had areas of focal narrowing on barium Xray. Esophageal diameters were significantly less at all three esophageal sites in EoE patients compared with controls. Using a total esophageal diameter score (i.e., sum of the three diameters) to establish the 95th percentile for minimal diameter in controls, four of 10 EoE patients fell below the normal range. There was no significant correlation between esophageal diameters, peak eosinophil counts and any of the Mayo Dysphagia Questionnaire severity scores.

Conclusion

Patients with EoE have a diffusely narrow esophagus in comparison to healthy controls, and this abnormality may not be appreciated without using appropriate normative data.

Eosinophilic Esophagitis Is an Underlying Cause for Gastrointestinal Concerns in Children

Eosinophilic esophagitis (EoE) is a chronic immune antigen-mediated disorder characterized by symptoms of esophageal dysfunction in combination with dense esophageal eosinophilia. The clinical presentation of EoE can vary depending on children's age and their ability to report symptoms, therefore a high index of suspicion for EoE is required because children and teenagers may develop coping strategies around eating. The development of symptoms measurement tools in EoE assists in not only assessing symptoms, but also coping strategies children may have developed. While the diagnosis of EoE requires endoscopic evaluation with histologic assessment of esophageal mucosal biopsy samples, several emerging methods to assess and survey the esophageal mucosa have been developed. Advances in the field to better understand the natural history, clinical and molecular features of phenotypes in EoE will be important in considering novel therapeutic options and assessing outcomes.

Eosinophilic Enteritis: A Delayed Diagnosis

Eosinophilic gastrointestinal disorders are a rare and complex group of disorders that are characterized by eosinophilic infiltration of the gastrointestinal tract. Patients often present with a wide range of signs and symptoms as any length or layer of the GI tract can be involved such as mucosal, muscular, or serosal. As a part of the workup, patients frequently undergo computed tomography scans and multiple endoscopies before the diagnosis is finally made as was true in our case of a 59-year-old male patient presenting with 2 months of nausea, abdominal pain, and weight loss. He underwent esophagogastroduodenoscopies, colonoscopies, video capsule study, and balloon enteroscopy before the diagnosis was confirmed histologically. Endoscopic and radiographic findings can be variable and are usually unpredictable. The diagnosis is confirmed on histopathological examination of biopsies that must show >15-50 eosinophils/high-power field based on the location in the GI tract. In our patient, erythema, scalloping, whitish exudate, and patches of villous blunting were noted in the duodenum to proximal ileum endoscopically with >50 eosinophils/high-power field confirming the diagnosis of eosinophilic enteritis. This class of diseases is often found in patients with a history of allergic disorders suggestive of hypersensitivity in the etiology of the disease although our patient had no such known history. Elimination diets and steroids are the mainstay of therapy and often lead to complete resolution of symptoms as well as endoscopic and radiographic findings in up to 90% of patients as was seen in our patient, although some patients have a chronic remitting course.

Diseases of the esophagus: a pattern approach

The esophagus may be involved by a variety of morphologic abnormalities, including nodules and plaques, ulceration, distal esophageal strictures and rings, upper or midesophageal strictures, and diffuse narrowing (also known as a small-caliber esophagus). The use of a pattern approach for evaluating esophageal disease on barium studies facilitates diagnosis of a host of pathologic conditions associated with these morphologic abnormalities. This article therefore presents an approach for diagnosing esophageal disease on barium studies that emphasizes the radiographic and clinical features used to differentiate the underlying causes of disease and the diagnostic pitfalls associated with performing and interpreting these studies.

Imaging of the oesophagus: beyond cancer

Abstract

Non-malignant oesophageal diseases are critical to recognize, but can be easily overlooked or misdiagnosed radiologically. In this paper, we cover the salient clinical features and imaging findings of non-malignant pathology of the oesophagus. We organize the many non-malignant diseases of the oesophagus into two major categories: luminal disorders and wall disorders. Luminal disorders include dilatation/narrowing (e.g. achalasia, scleroderma, and stricture) and foreign body impaction. Wall disorders include wall thickening (e.g. oesophagitis, benign neoplasms, oesophageal varices, and intramural hematoma), wall thinning/outpouching (e.g. epiphrenic diverticulum, Zenker diverticulum, and Killian-Jamieson diverticulum), wall rupture (e.g. iatrogenic perforation, Boerhaave Syndrome, and Mallory-Weiss Syndrome), and fistula formation (e.g. pericardioesophageal fistula, tracheoesophageal fistula, and aortoesophageal fistula). It is the role of the radiologist to recognize the classic imaging patterns of these non-malignant oesophageal diseases to facilitate the delivery of appropriate and prompt medical treatment.

Teaching Points

• Nonmalignant oesophageal disease can be categorised by the imaging appearance of wall and lumen.

• Scleroderma and achalasia both cause lumen dilatation via different pathophysiologic pathways.

• Oesophageal wall thickening can be inflammatory, neoplastic, traumatic, or vascular in aetiology.

Cardiopulmonary and Gastrointestinal Manifestations of Eosinophil- associated Diseases and Idiopathic Hypereosinophilic Syndromes: Multimodality Imaging Approach

Eosinophil-associated diseases (EADs) are a diverse group of disorders characterized by an increase in circulating or tissue eosinophils. Cardiopulmonary and gastrointestinal system involvement can be due to primary EAD with no known cause or can be secondary to known systemic disease. The cardiopulmonary spectrum of EADs comprises simple pulmonary eosinophilia, acute eosinophilic pneumonia, chronic eosinophilic pneumonia, Churg-Strauss syndrome, allergic bronchopulmonary aspergillosis, bronchocentric granulomatosis, parasitic infections, and idiopathic hypereosinophilic syndrome. Eosinophilic gastrointestinal disorders include eosinophilic esophagitis, eosinophilic gastroenteritis, and eosinophilic colitis. Diagnosis is often challenging and requires a combination of clinical and imaging features along with laboratory findings. The absolute eosinophil count in peripheral blood and the percentage of eosinophils in bronchoalveolar lavage fluid are crucial in evaluation of various eosinophilic lung diseases. Although chest radiography is the initial imaging modality used in suspected cases of pulmonary EAD, multidetector computed tomography may demonstrate more characteristic pulmonary patterns, nodules, and subtle parenchymal abnormalities. Barium esophagography is used to assess mucosal abnormalities and the length and diameter of esophageal strictures. Magnetic resonance imaging is superior in providing valuable information in select patients, especially in evaluation of cardiac and gastrointestinal system involvement. Many patients require a multimodality imaging approach to enable diagnosis, guide treatment, and assess treatment response. Knowledge of the clinical features and imaging findings of the spectrum of EADs involving the lungs, heart, and gastrointestinal tract permits optimal patient care.

History and Evolution of the Barium Swallow for Evaluation of the Pharynx and Esophagus

This article reviews the history of the barium swallow from its early role in radiology to its current status as an important diagnostic test in modern radiology practice. Though a variety of diagnostic procedures can be performed to evaluate patients with dysphagia or other pharyngeal or esophageal symptoms, the barium study has evolved into a readily available, non-invasive, and cost-effective technique that can facilitate the selection of additional diagnostic tests and guide decisions about medical, endoscopic, or surgical management. This article focuses on the evolution of fluoroscopic equipment, radiography, and contrast media for evaluating the pharynx and esophagus, the importance of understanding pharyngoesophageal relationships, and major advances that have occurred in the radiologic diagnosis of select esophageal diseases, including gastroesophageal reflux disease, infectious esophagitis, eosinophilic esophagitis, esophageal carcinoma, and esophageal motility disorders.

How does esophagus look on barium esophagram in pediatric eosinophilic esophagitis?

Purpose

The clinical, endoscopic, and histologic findings of eosinophilic esophagitis (EoE) are well characterized; however, there have been very limited data regarding the radiologic findings of pediatric EoE. We report on the radiologic findings of pediatric EoE observed on barium esophagram and correlate them with the endoscopic findings.

Methods and materials

We identified children diagnosed with EoE in our center from 2004 to 2015. Two pediatric radiologists met after their independent evaluations of each fluoroscopic study to reach a consensus on each case. Clinical and endoscopic data were collected by retrospective chart review.

Results

Twenty-six pediatric EoE cases (age range 2–13 years; median 7.5 years) had barium esophagram done as part of the diagnostic approach for dysphagia. Thirteen children had abnormal radiologic findings of esophagus (50%): rings formation (n = 4), diffuse irregularity of mucosa (n = 8), fixed stricture formation (n = 3), and narrow-caliber esophagus (n = 10). Barium esophagram failed to show one of 10 cases of narrow-caliber esophagus and 10 of 14 cases of rings formation visualized endoscopically. The mean duration of symptoms prior to diagnosis of EoE was longer (3.7 vs. 1.7 year; p value 0.019), and the presentation with intermittent food impaction was commoner in the group with abnormal barium esophagram as compared to the group with normal barium esophagram (69% vs. 8%; p value 0.04).

Conclusion

Barium swallow study is frequently normal in pediatric EoE. With the exception of narrow-caliber esophagus, our data show poor correlation between radiologic and endoscopic findings.

Contribution of Esophagram to the Evaluation of Complicated Pediatric Eosinophilic Esophagitis

OBJECTIVES

In contrast to peptic strictures, clinically significant strictures in patients with eosinophilic esophagitis (EoE) may be subtle and go unrecognized at the time of endoscopy. We aimed to identify how often stricture was identified by endoscopy as compared with contrast esophagram.

METHODS

We retrospectively reviewed esophagram and endoscopy examinations of all of the patients with EoE with esophageal stricture seen at a tertiary care pediatric hospital over a 6-year period who had both procedures completed within a 3-month time frame. Medical charts were reviewed for clinicopathologic information including age, duration of symptoms, histology, and treatment.

RESULTS

Twenty-two children with EoE-associated stricture completed both esophagram and endoscopic assessments. Esophageal strictures were identified by esophagram, and not endoscopy, in 55% of these children. Patients with stricture identified at esophagram alone had a shorter duration of symptoms (2.1 years duration vs 5.4 years duration, P = 0.03) than the group identified by endoscopy. Preoperative radiographic identification of a stricture was associated with dilation more often being performed.

CONCLUSIONS

Esophagram is a valuable test to assess esophageal anatomy in children with complicated EoE. Esophagram may be able to detect subtle fibrostenosis earlier in the natural history of the disease than endoscopy.

Clinical implications and pathogenesis of esophageal remodeling in eosinophilic esophagitis

In eosinophilic esophagitis (EoE), remodeling changes are manifest histologically in the epithelium and subepithelium where lamina propria fibrosis, expansion of the muscularis propria, and increased vascularity occur. The clinical symptoms and complications of EoE are largely consequences of esophageal remodeling. Available therapies have demonstrated variable ability to reverse existing remodeling changes of the esophagus. Systemic therapies have the potential of addressing subepithelial remodeling. Esophageal dilation remains a useful, adjunctive therapeutic maneuver in symptomatic adults with esophageal stricture. As novel treatments emerge, it is essential that therapeutic end points account for the fundamental contributions of esophageal remodeling to overall disease activity.

Barium esophagram: does it have a role in gastroesophageal reflux disease?

The barium esophagram is an integral part of the assessment and management of patients with gastroesophageal reflux disease (GERD) before, and especially after, antireflux procedures. While many of the findings on the examination can be identified with endosocopy, a gastric emptying study and an esophageal motility examination, the barium esophagram is better at demonstrating the anatomic findings after anti-reflux surgery, especially in symptomatic patients. These complementary examinations, when taken as a whole, fully evaluate a patient with suspected GERD as well as symptomatic patients after antireflux procedures.

Management guidelines of eosinophilic esophagitis in childhood

OBJECTIVES

Eosinophilic esophagitis (EoE) represents a chronic, immune/antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. With few exceptions, 15 eosinophils per high-power field (peak value) in ≥1 biopsy specimens are considered a minimum threshold for a diagnosis of EoE. The disease is restricted to the esophagus, and other causes of esophageal eosinophilia should be excluded, specifically proton pump inhibitor-responsive esophageal eosinophilia. This position paper aims at providing practical guidelines for the management of children and adolescents with EoE.

METHODS

Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of an evidence base, recommendations reflect the expert opinion of the authors. Final consensus was obtained during 3 face-to-face meetings of the Gastroenterology Committee and 1 teleconference.

RESULTS

The cornerstone of treatment is an elimination diet (targeted or empiric elimination diet, amino acid-based formula) and/or swallowed, topical corticosteroids. Systemic corticosteroids are reserved for severe symptoms requiring rapid relief or where other treatments have failed. Esophageal dilatation is an option in children with EoE who have esophageal stenosis unresponsive to drug therapy. Maintenance treatment may be required in case of frequent relapse, although an optimal regimen still needs to be determined.

CONCLUSIONS

EoE is a chronic, relapsing inflammatory disease with largely unquantified long-term consequences. Investigations and treatment are tailored to the individual and must not create more morbidity for the patient and family than the disease itself. Better maintenance treatment as well as biomarkers for assessing treatment response and predicting long-term complications is urgently needed.

Meta-analysis: the safety and efficacy of dilation in eosinophilic oesophagitis

BACKGROUND

Oesophageal dilation is one of the most effective options in the management of symptoms of eosinophilic oesophagitis (EoE). However, earlier reports described an increased rate of complications.

AIM

To perform a meta-analysis of population-based studies of the risks associated with dilation and the clinical efficacy and duration of response to dilation in EoE.

METHODS

Using MEDLINE and EMBASE, a systematic search was performed for published articles since 1977 describing cohort or randomised controlled trials of dilation in EoE. Summary estimates, including 95% confidence interval (CI), were calculated for the occurrence of complications associated with dilations (perforations, haemorrhage, chest pain, lacerations) and percentage of patients with symptom improvement following dilation. Heterogeneity was calculated using the I² statistic.

RESULTS

The search resulted in 232 references, of which 9 studies were included in the final analysis. The studies described 860 EoE patients, of whom 525 patients underwent at least one oesophageal dilation and a total of 992 dilations. There were three cases of perforation (95% CI 0-0.9%, I² 0%) and one haemorrhage (95% CI 0-0.8%, I² 0%). Six studies reported postprocedural chest pain in 2% of cases (95% CI 1-3, I² 53%). Clinical improvement from dilation occurred in 75% of patients (95% CI 58-93%, I² 86%).

CONCLUSIONS

Dilation in patients with eosinophilic oesophagitis is a safe procedure with a low rate of serious complications (<1%), and seems to result in at least a short-term improvement of symptoms in the majority of patients.

Eosinophilic gastroenteritis: An unusual type of gastroenteritis

Eosinophilic gastroenteritis (EGE) is a rare disorder characterized by eosinophilic infiltration of the bowel wall with various gastrointestinal manifestations. Till date only 280 cases have been described in the literature. A high index of suspicion, by excluding other causes of peripheral eosinophilia, is a pre requisite for accurate diagnosis. EGE is an uncommon gastrointestinal disease affecting both children and adults. It was first described by Kaijser in 1937. Presentation may vary depending on location as well as depth and extent of bowel wall involvement and usually runs a chronic relapsing course. This condition can respond to low dose steroid therapy, thereby preventing grave complications like ascites and intestinal obstruction that might need surgical intervention. The natural history of EGE has not been well documented. Eosinophilic gastroenteritis is a chronic, waxing and waning condition. Mild and sporadic symptoms can be managed with reassurance and observation, whereas disabling gastrointestinal (GI) symptom flare-ups can often be controlled with oral corticosteroids. When the disease manifests in infancy and specific food sensitization can be identified, the likelihood of disease remission by late childhood is high. GI obstruction is the most common complication. Fatal outcomes are rare.

The management of eosinophilic esophagitis in adults

Eosinophilic esophagitis (EoE), typically a pediatric disease, is becoming more frequently recognized in adults. The optimal treatment of EoE in this population has not yet been established. This paper reviews the literature detailing the treatments for EoE in adults, and provides a treatment strategy. To accomplish this task a comprehensive literature search of Medline was undertaken for studies evaluating the treatment of EoE in adults. High-dose topical corticosteroids and specific elimination diets have been found to improve symptoms, reduce eosinophilic infiltrate in esophageal mucosa, and improve endoscopic markers of inflammation. Dilation therapy does improve symptoms but not underlying inflammation. Other treatments including leukotriene inhibitors and immunomodulatory drugs have been unsuccessful. An effective strategy for treating EoE in adults is using topical corticosteroids and elimination diets for inflammatory disease, and esophageal dilation for fibrotic disease. The conclusion that inflammatory and fibrotic components of EoE respond to different treatment modalities should be evaluated in future clinical trials.

Pathogenesis of allergen-induced eosinophilic esophagitis is independent of interleukin (IL)-13

Several studies have shown that IL-13 is induced in the esophageal biopsies of EoE patients and promotes esophageal eosinophilia in mice following an IL-13 challenge. However, the role of IL-13 has not been clearly investigated in allergen-induced EoE. Accordingly, we tested the hypothesis that IL-13 is required in allergen-induced EoE. Mice deficient in IL-13, STAT (signal transducer and activator of transcription)6 and both IL-4/IL-13 genes with their respective controls were challenged with aspergillus extract and IL-5 gene-deficient with their control were challenged with recombinant IL-13, intranasally The lung and esophageal eosinophils, mast cells and collagen accumulation were examined. Herein, we report that intranasal delivery of IL-13 promotes IL-5 dependent esophageal eosinophilia. However, allergen-induced EoE is not impaired in the IL-13 gene-deficient mice. In addition, wild type and IL-13 gene-deficient mice demonstrated a comparable level of mast cells and collagen accumulation in the esophagus following allergen-induced experimental EoE. Similarly, we found that esophageal eosinophilia in IL-4/IL-13 double gene-deficient and STAT6 gene-deficient mice were also not reduced following allergen-induced experimental EoE. In contrast, lung eosinophilia was significantly reduced in mice deficient in IL-13, both IL-4/IL-13 and STAT6 genes following allergen challenge. In conclusion, our data establish that allergen-induced EoE pathogenesis is independent of IL-13; whereas, IL-13 is required for allergen-induced lung eosinophilia.

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Frequency of eosinophilic esophagitis in patients with esophageal symptoms: a single-center Turkish experience

Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized with symptoms related to esophageal dysfunction and eosinophil-predominant inflammation. There has been a dramatic increase in the diagnosis of this disease in recent years. The primary objective of this study was to determine the frequency of EoE in adult patients who were evaluated by gastroenterologists in our clinic with esophageal symptoms. Between November 2010 and May 2011, 311 adult patients who were evaluated in our clinic with esophageal symptoms were enrolled prospectively. All patients underwent endoscopy and had biopsies taken. Gastroesophageal reflux disease was excluded by either proton pump inhibitory treatment or 24-hour ambulatory pH monitorization. The diagnosis was confirmed by one independent pathologist. Frequency of EoE in patients with esophageal symptoms was 2.6% (n = 8; four men and four women). Mean age at diagnosis was 40.2 ± 8 years. Heartburn was the predominant symptom in patients (75% of the patients), and 87.5% (n = 7) of patients had more than one symptom at diagnosis. Nearly 38% of the patients (n = 3) had a history of allergic disease. Endoscopic findings were as follows: transient/fixed esophageal rings (25%), white exudates (25%), and normal appearance (50%). Median number of circulating eosinophils was 208 (93-659)/mm(3) . Median number of intraepithelial eosinophils in proximal-middle 1/3 part and distal 1/3 part of esophagus were 0 (0-50)/hpf and 37 (16-50)/hpf, respectively. In conclusion, EoE is not rare in Turkey, and it should be considered in the differential diagnosis of patients with esophageal symptoms.

Fluoroscopic findings in pediatric eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EE) is an inflammatory disorder of the esophagus characterized by symptoms such as dysphagia, food sticking and heartburn. Several fluoroscopic findings have been described in EE, but the frequency of these findings is unknown.

OBJECTIVE

To identify the frequency of imaging findings in pediatric-age patients with eosinophilic esophagitis.

MATERIALS AND METHODS

A retrospective study was performed evaluating all upper GI and esophagram studies performed between 2000 and 2008 in patients up to age 21 with a pathological diagnosis of EE. In order to be included in the study, the upper GI or esophagram had to be performed either before EE was diagnosed or within 30 days of the diagnosis. Two pediatric radiologists evaluated each study for the presence or absence of multiple findings of EE. The radiology reports from the time of the study were then read to establish a concurrent diagnosis of esophageal dysmotility or gastroesophageal reflux. Finally, the hospital electronic medical record was evaluated to obtain demographic and pathology information.

RESULTS

Of the 579 patients with biopsy-proven EE, 107 (18%) were included in the study and underwent a total of 112 upper GI or esophagram examinations. The most common finding on these examinations was a normal esophagus (58/112; 52%) followed by gastroesophageal reflux (21/112; 19%) and irregular contractions (17/112; 15%). Less frequent findings included strictures, dysmotility, mucosal irregularity, esophageal rings and filling defects.

CONCLUSION

Fluoroscopic studies are not a sensitive method to diagnose EE because nearly half of the studies are normal. Findings that have been described in the setting of EE such as food impaction, a ringed esophagus, a small-caliber esophagus and esophageal stricture do not occur with a high enough frequency to reliably make a diagnosis.

Esophageal functional impairments in experimental eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is an emerging chronic esophageal disease. Despite the increasing diagnosis of EoE globally, the causes of EoE and other esophageal eosinophilic disorders are not clearly understood. EoE pathology includes accumulation of inflammatory cells (e.g., eosinophils, mast cells), characteristic endoscopic features (e.g., furrows, the formation of fine concentric mucosal rings, exudates), and functional impairments (e.g., esophageal stricture, dysmotility). We hypothesized that the esophageal structural pathology and functional impairments of EoE develop as a consequence of the effector functions of the accumulated inflammatory cells. We analyzed eosinophils (anti-major basic protein immunostaining), esophageal stricture (X-ray barium swallowing), and esophageal motility (isometric force) in two established transgenic murine models of EoE (CD2-IL-5 and rtTA-CC10-IL-13) and a novel eosinophil-deficient model (ΔdblGATA/CD2-IL-5). Herein, we show the following: 1) CD2-IL-5 and doxycycline (DOX)-induced rtTA-CC10-IL-13 mice have chronic eosinophilic and mast cell esophageal inflammation; 2) eosinophilic esophageal inflammation promotes esophageal stricture in both transgenic murine models; 3) the eosinophil-deficient ΔdblGATA/CD-2-IL-5 mice were protected from the induction of stricture, whereas the eosinophil-competent CD2-IL-5 mice develop esophageal stricture; 4) esophageal stricture is not reversible in DOX-induced rtTA-CC10-IL-13 mice (8 wk DOX followed by 8 wk no-DOX); and 5) IL-5 transgene-induced (CD2-IL-5) EoE evidences esophageal dysmotility (relaxation and contraction) that is independent of the eosinophilic esophageal inflammation: CD2-IL-5 and ΔdblGATA/CD2-IL-5 mice have comparable esophageal dysmotility. Collectively, our present study directly implicates chronic eosinophilic inflammation in the development of the esophageal structural impairments of experimental EoE.

Eosinophilic esophagitis: trials and tribulations

Eosinophilic esophagitis (EE) is a recently recognized form of pan-esophagitis, which is characterized by the presence of at least 15 eosinophils per high power field on esophageal histology. EE is closely associated with atopic disorders and occurs predominantly in male patients. Young children are more likely to be sensitized to food allergens whilst aeroallergen sensitization predominates in older children and adults--a pattern reminiscent of the "atopic march". EE presents with a diverse range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or refusal in infancy, in addition to dysphagia and food bolus impaction in older children and adults. The diagnosis may also be ascertained incidentally in patients undergoing gastroscopy for other suspected gastrointestinal conditions, such as gastroesophageal reflux disease or celiac disease. Complications mainly relate to subepithelial remodeling and fibrosis which may result in dysmotility, dysphagia and esophageal strictures. The proportion of EE patients at risk of these complications is unknown due to a paucity of data on the natural history of EE. There are only few randomized controlled trials assessing the efficacy of treatment modalities for EE, which currently either involve food allergen elimination or use of swallowed aerosolized corticosteroids. This article aims to discuss the complex issues of the diagnosis and long-term management that confront clinicians who care for children with EE.

Emerging management concepts for eosinophilic esophagitis in children

Eosinophilic esophagitis (EoE) is a newly recognized condition that appears to be increasing in incidence for as yet unknown reasons. It can occur at any age and presents both to gastroenterologists and allergists. Clinical manifestations range from gastrointestinal symptoms (vomiting, feeding difficulties, dysphagia or food bolus impaction) to co-existing atopic conditions (asthma, allergic rhinitis or eczema). The diagnosis requires demonstration of at least 15 eosinophils per high power field on esophageal histology, usually in the context of resistance to proton pump inhibitor treatment or a normal 24-h esophageal pH monitoring study. The differential diagnosis between EoE and gastroesophageal reflux disease (GERD) can be problematic as there is significant clinical overlap between both conditions. Although difficult-to-manage esophageal strictures are well recognized in patients with long-standing EoE, little is known about risk factors for the development of this complication. There is a paucity of data on both the natural history and optimal long-term management of EoE. Current treatment options include food allergen elimination diets, use of topical aerosolized corticosteroids, or a combination of the two. Pediatric case studies have been provided to illustrate the complexity of decision points that often arise in the management of these patients. This paper aims to discuss the various strategies currently available to clinicians in the management of EoE and highlights gaps in the current evidence base that urgently require further research.

Review article: oesophageal dilation in adults with eosinophilic oesophagitis

BACKGROUND

Eosinophilic oesophagitis is a chronic inflammatory disorder of the oesophagus, characterised by the proton pump inhibitor-refractory accumulation of eosinophils in the oesophageal epithelium (>15 intraepithelial eosinophils/high powered field). Adults present with solid food dysphagia and recurrent food impactions. Oesophageal remodelling produces the characteristic endoscopic feature of adult eosinophilic oesophagitis including strictures, rings and a narrow calibre oesophagus.

AIM

To evaluate the safety and efficacy of oesophageal dilation as the initial therapy for adults with eosinophilic oesophagitis.

METHODS

Medline search from 1975 to November 2010 for all reports of the treatment of patients with eosinophilic oesophagitis using search words: eosinophilic oesophagitis treatment, dilation and eosinophilic oesophagitis, steroids and eosinophilic oesophagitis.

RESULTS

Our systematic review found that 92% of patients treated with oesophageal dilation had improvement in their dysphagia symptoms for up to 1-2 years. Three case series clearly showed clinical resolution of dysphagia symptoms, independent of the degree of eosinophil infiltration, which was unchanged after dilation. Postprocedure pain for several days is common, due to some degree of mucosal tear, but true perforation very rare (<0.1%).

CONCLUSIONS

Oesophageal dilation is an acceptable option for healthy adult eosinophilic oesophagitis patients with anatomic narrowing, possibly followed by a course of topical steroids to reduce inflammation and retard remodelling. Future studies should include a head-to-head comparison of topical steroids and oesophageal dilation, bougie vs through-the-scope balloon dilation and maintenance topical steroids compared with on-demand treatment.

Eosinophilic esophagitis: a case report with a review of the literature

Eosinophilic esophagitis (EE) is an allergic inflammatory condition of the esophagus and is characterized by dense eosinophilic infiltration of the esophagus. There has been a dramatic increase in the diagnosis of EE in Western countries in recent years; however, in Japan, there are very few reports of EE. We present a rare case of EE in a 70-year-old Japanese woman, who had dysphasia for 2 years, but which worsened over a 6-month period. Laboratory examinations showed peripheral eosinophilia (1279/μl). Significant thickening of the esophageal wall was observed on computed tomography scan and many circular rings appeared when an esophagogastroduodenoscopy was carried out. From these circular rings, EE was suspected and a biopsy was then taken from the esophagus. As the histologic findings from the esophageal biopsy showed that >25 eosinophils existed per high-power field, the patient was diagnosed with EE. Oral corticosteroid (prednisolone 30 mg/day) therapy was administered and after 3 days of treatment her symptoms almost disappeared. EE needs to be considered as a differential diagnosis if patients with non-erosive reflux disease have dysphagia but do not respond to high-dose proton pump inhibitor therapy.

Treatment of eosinophilic esophagitis: how should we manage the disease?

Eosinophilic esophagitis (EE) is a chronic clinicopathologic syndrome and is the latest inflammatory disease of the esophagus described in literature. It seems to have a multifactorial etiology. Its causes include exposure to food or airborne allergens that affect individuals who may be genetically predisposed and exposure to the acid could also modulate the inflammatory response at esophageal level. However, we currently do not know how each of these possible etiologic factors contribute to the development of the disease that is essential to define specific treatment. We have used 3 different therapeutic approaches that were effective in patients with EE: various antiinflammatory drugs that are useful in treating asthma, controlling the exposure to allergens, particularly with respect to dietary changes and dilation of the esophagus. Although none of these treatments have absolute advantages, they can efficiently control the symptoms and inflammation in a large number of patients. Each treatment option should be assessed on a case-by-case basis in accordance with the experience of each center, the patients' characteristics, their sensitivity to allergens and their preferences. This article provides the latest information on the different treatment options for patients with EE, analyzing the advantages and disadvantages of each pathology and it offers practical recommendations on how to manage these patients who are being more frequently diagnosed.

Esophageal dilation: simple and effective treatment for adults with eosinophilic esophagitis and esophageal rings and narrowing

The goal of this article is to present the results of the long-term treatment with esophageal dilation of a consecutive series of adults with eosinophilic esophagitis (EoE). EoE in adults is a disease of middle aged white males, with recurrent food impactions and dysphagia. The exact treatment of EoE is unknown due to the uncertainty of the pathogenesis. Currently, the long-term follow-up of adult EoE patients is limited. Sixteen consecutive adult patients (12 males/4 females between ages 27 and 58 years) with EoE underwent a detailed history and baseline upper gastrointestinal endoscopy (EGD) with multiple esophageal biopsies. Thirteen had esophageal dilation. Fifteen were on proton pump inhibitor (PPI) therapy. After dilation, one patient was treated with a restrictive diet. One patient took prn fluticasone. Most of the patients had allergy testing for food and aeroallergens. Follow-up evaluation with similar testing was on average 22 months (range: 12-40 months). Six patients were not available for follow-up. None of the remaining 10 patients had a food impaction; one required further esophageal dilation. Only two patients had intermittent dysphagia. The average dysphagia score decreased from 2.1 to 0.3 (P < 0.002). The average number of eosinophils at follow-up was not significantly different from baseline (120 eosinophils/HPF proximally and 165 eosinophils/HPF distally (P= 0.75). The gross endoscopy findings were unchanged in all patients except one who normalized. A total of 62% and 75% of patients had positive tests for aeroallergens and food allergens, respectively. Over an average of two years, esophageal dilation provided excellent symptomatic relief among 10 adult EoE patients despite no improvement in the mucosal eosinophilia or gross endoscopic appearance.

The small-caliber esophagus: radiographic sign of idiopathic eosinophilic esophagitis

PURPOSE

To evaluate a small-caliber esophagus at barium esophagography with idiopathic eosinophilic esophagitis (IEE) and determine if there is a useful threshold diameter for suggesting this diagnosis.

MATERIALS AND METHODS

The institutional review board approved this retrospective study and waived informed consent. This study was HIPAA compliant. A search of the radiology database (by using the search term small-caliber esophagus) revealed 10 patients with a small-caliber esophagus at barium esophagography who had IEE (defined as more than 20 eosinophils per high-power field in endoscopic biopsy specimens). Images were reviewed to characterize findings and determine the length of narrowing. Luminal diameters were measured at three levels for nine patients and nine control subjects, and mean diameter, range, and standard deviation were determined at each level. An analysis of variance test was performed to determine whether the difference between the range of mean thoracic esophageal diameters in patients with IEE versus that in control subjects was significant.

RESULTS

All 10 patients had long-segment but variable-length narrowing of the thoracic esophagus (mean length, 15.4 cm) with tapered margins. The mean diameter at the aortic arch, carina, and one vertebral body above the gastroesophageal junction was 13.9, 14.3, and 15.1 mm, respectively, for patients with small-caliber esophagus versus 20.2, 30.3, and 28.7 mm for control subjects. The mean overall diameter was 14.7 mm for patients with small-caliber esophagus versus 26.3 mm for control subjects. In the nine patients in whom the luminal diameter was measured, the mean thoracic esophageal diameter was 20 mm or less; all nine control subjects had a mean thoracic esophageal diameter greater than 20 mm. The difference in the range of mean thoracic esophageal diameters between these two groups was highly significant (P < .0001), so 20 mm was a useful threshold diameter for suggesting this diagnosis.

CONCLUSION

The small-caliber esophagus of IEE is characterized at barium esophagography by long-segment but variable-length narrowing of the thoracic esophagus, with a mean length of 15.4 cm, a diameter of 20 mm or less, smooth contours, and tapered margins.

Feline esophagus and gastroesophageal reflux

OBJECTIVE

The purposes of this study were to reassess the relation between a feline esophagus (transient transverse esophageal folds) and gastroesophageal reflux (GER) and to determine whether a feline esophagus is observed more often during swallowing or during reflux of barium.

MATERIALS AND METHODS

A computerized search of double-contrast esophagrams was performed to generate four equal groups of 56 patients with marked, moderate, mild, and no GER. The imaging findings were reviewed to determine the frequency of a feline esophagus in these groups and whether this sign was detected during swallowing or reflux of barium. The presence of a feline esophagus also was correlated with the presence of a hiatal hernia, reflux esophagitis, a peptic stricture, and esophageal dysmotility.

RESULTS

A feline esophagus was detected in 20 of 224 patients (9%). It was detected during reflux of barium in 17 patients (85%), swallowing of barium in two patients (10%), and both in one patient (5%). GER was present in all 20 patients with a feline esophagus and in 148 of the 204 patients (73%) without a feline esophagus (p = 0.0068). A significant relation also was found between a feline esophagus and the presence of a hiatal hernia (p = 0.0116) but not between a feline esophagus and the presence of reflux esophagitis, a peptic stricture, or esophageal dysmotility.

CONCLUSION

All patients with a feline esophagus at barium esophagography had associated GER. These transverse folds were observed mainly during reflux of barium from the stomach rather than during swallowing of barium. When a feline esophagus is detected during barium studies, the patient is extremely likely to have GER whether or not GER is seen at fluoroscopy.

Esophageal dilation in eosinophilic esophagitis: effectiveness, safety, and impact on the underlying inflammation

OBJECTIVES

Esophageal dilation often leads to long-lasting relief of dysphagia in eosinophilic esophagitis (EoE). The aim of this study was to define the effectiveness, safety, and patient acceptance of esophageal dilation in EoE. In addition, we examined the influence of dilation on the underlying esophageal inflammation.

METHODS

Two databases including 681 EoE patients were reviewed. Cohort 1 consisted of patients treated with dilation alone, whereas cohort 2 included patients treated with a combination of dilation and antieosinophilic medication. Patients from cohort 1 underwent a prospective histological reexamination and an evaluation using a questionnaire.

RESULTS

In total, 207 EoE patients were treated with esophageal dilation, 63 in cohort 1 and 144 in cohort 2. Dilation led to a significant increase in esophageal diameter and to an improvement in dysphagia in both the cohorts (P<0.001). After dilation, dysphagia recurred after 23+/-22 months in cohort 1 and 20+/-14 months in cohort 2. No esophageal perforation or major bleeding occurred. Among the patients surveyed, 74% reported retrosternal pain after dilation; however, all were agreeable to repeated dilation if required. Eosinophil peak infiltration, eosinophil load, and EoE-associated histological signs were not significantly affected by esophageal dilation.

CONCLUSIONS

Esophageal dilation is highly effective in providing long-lasting symptom relief and can be performed safely with a high degree of patient acceptance. However, dilation is associated with postprocedural pain in most patients and does not influence the underlying inflammatory process. Symptom improvement despite persistence of inflammation suggests that tissue remodeling contributes substantially to symptom generation in EoE.

Pediatric eosinophilic esophagitis: radiologic findings with pathologic correlation

BACKGROUND

Eosinophilic esophagitis is increasingly recognized as a cause of dysphagia or food impaction in pediatric patients. It has a high male predominance and is often associated with a history of allergy or asthma.

OBJECTIVE

To correlate fluoroscopic findings in eosinophilic esophagitis with the endoscopic and histologic findings.

MATERIALS AND METHODS

We retrospectively reviewed the upper gastrointestinal (UGI) findings of eosinophilic esophagitis and correlated them with the clinical, endoscopic and histologic findings in a series of 17 children (12 boys, 5 girls).

RESULTS

UGI findings were normal in 12 children, including 4 who had a normal UGI exam after endoscopic disimpaction for an obstructing food bolus. Five children had strictures identified on UGI: one was demonstrated with endoscopy. This suggests that the impactions and strictures were due to an esophageal dysmotility rather than a fixed anatomic abnormality.

CONCLUSION

Because the UGI findings are frequently normal in eosinophilic esophagitis, radiologists need to have a high index of suspicion for this disease. In children with a strong clinical history, especially impaction in the absence of an esophageal stricture, endoscopy and biopsy are indicated for further evaluation.

Approach to dysphagia in the young patient in the era of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) has emerged as an important cause of dysphagia and food impactions in young adults. Previously considered a rare condition, an increasing number of cases of EoE have been attributable to a rising incidence and a growing awareness of the condition. Typical endoscopic features include concentric mucosal rings, linear furrowing, white exudates, and a narrow caliber esophagus. Current consensus guidelines define EoE by 1) the presence of characteristic symptoms, especially dysphagia and food impactions in adults, 2) >or= 15 eosinophils per high power field in esophageal tissue, and 3) exclusion of other disorders with similar presentations (eg, gastroesophageal reflux disease). Current knowledge about the pathophysiology implicates food allergens, aeroallergens, and genetic factors. The main treatment options for EoE are proton pump inhibitors, dietary manipulation, and topical or oral glucocorticoids. Endoscopic dilation may be performed in patients who do not respond to medical therapy. This review highlights recent insights into the diagnosis and management of EoE in young adults.