Eosinophilic esophagitis in children from Western saudi arabia: relative frequency, clinical, pathological, endoscopic, and immunological study

Adherence to clinical guidelines for the evaluation and management of eosinophilic esophagitis among gastroenterologists in the Arab countries

Background

The practice patterns of eosinophilic esophagitis (EoE) remain poorly characterized. Few studies investigated the variability of clinical patterns among gastroenterologists, mainly in the United States.

Objectives

We assessed the practice patterns of gastroenterologists in the Arab countries regarding the diagnosis and management of EoE, and their concordance with the European 2017 guidelines and the Proceedings of the AGREE Conference published in 2018.

Methods

We conducted a cross-sectional, self-administered, online survey of practicing gastroenterologists in the Arab countries (April to December 2022). The survey consisted of 23 questions and was designed to assess the respondents' practice characteristics, knowledge and practice on diagnosis and treatment of EoE.

Results

A total of 190 participants responded to the survey (118 pediatric gastroenterologists and 72 adult gastroenterologists). Thirty-six percent and 31% saw ≥6 new patients with EoE annually, 55% were 'very familiar' with the most recent EoE guidelines, and 49% attended ≥3 E-E-related educational activities during the 3 years prior to the survey. The majority of the respondents (72%) did not require a trial of a proton-pump inhibitor (PPI) prior to making the diagnosis of EoE and 66% obtain biopsies from multiple esophageal levels. While 90% of the respondents considered eosinophil-predominant inflammation on esophageal biopsies necessary for the diagnosis of EoE, only 27% felt that symptoms of esophageal dysfunction are necessary for the diagnosis, and only half of the participants considered exclusion of other etiologies of esophageal eosinophilia necessary for the diagnosis of EoE. For first-line treatment, only 16% used PPI monotherapy, 12.6% topical steroids, and 63.5% treat with a variable combination of PPIs, topical steroids, and dietary elimination. Sixty percent would repeat upper endoscopy to determine histologic improvement and 72% use maintenance therapy in responders. Compared to pediatric gastroenterologists, significantly fewer adult gastroenterologists reported taking biopsies from proximal and distal esophagus (34% vs. 66%) and gastric and duodenal biopsies (67% vs. 90%) when EoE was suspected (P < 0.001).

Conclusion

There is significant variability in adherence to EoE guidelines among gastroenterologists in the Arab countries. Our results highlight areas of need for continuous education and form the basis to assess implementation efforts in the future.

Dupilumab in children with eosinophilic esophagitis: a retrospective multicenter study

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. Dupilumab is a human monoclonal antibody that targets both IL-4 and IL-13 signaling. It is currently indicated for the treatment of asthma, atopic dermatitis, and EoE. This study aimed to describe children with EoE that is difficult to treat using conventional treatment and to identify symptomatic, histological, and endoscopic improvements after dupilumab treatment.

MATERIALS AND METHODS

We conducted a retrospective multicenter study in children with confirmed EoE and performed a chart review of patients prescribed dupilumab for EoE. Demographic information, symptoms, and medications including dupilumab treatment were collected. The endoscopic findings, histopathological features, and treatment results were analyzed. We calculated the change in EoE endoscopic reference scoring system (EREFS) scores from the baseline to 3 months.

RESULTS

Eleven patients were included in this study. The study population comprised seven boys (64%) and four girls (36%). The median age at presentation was 11.6 years (8-13 years). Dupilumab at a dose of 200-300 mg was administered to all patients as second-line therapy for children with EoE refractory to conventional therapy (proton pump inhibitors, corticosteroids, and dietary restrictions). Dupilumab efficacy regarding symptom relief, and endoscopic and histological improvements was 82%, 73%, and 90%, respectively. The mean EoE endoscopic reference scoring system scores changed from a baseline of 6.9 (before dupilumab) to 0.3 (after dupilumab). In addition to the improvement in EoE, the use of corticosteroids in EoE and inhaled corticosteroids in asthma was decreased for all patients, suggesting that dupilumab may be effective in patients with multiple concurrent atopic conditions. Dupilumab had a well-tolerated safety profile, except for one patient who developed conjunctivitis.

CONCLUSION

This pediatric study demonstrates the effectiveness of dupilumab as a second-line therapy for symptom relief, and endoscopic and histological improvements of EoE that is refractory to current treatment. A longitudinal, large prospective study is necessary to guide the initiation of dupilumab treatment for childhood EoE, and long-term follow-up data on dupilumab are required.

CLINICAL TRIAL NUMBER

Not applicable.

Temporal Trend of Incidence and Prevalence of Eosinophilic Esophagitis in Asia: A Systematic Review and Meta-Analysis

INTRODUCTION

There are limited epidemiological studies on eosinophilic esophagitis (EoE) in Asia. We studied the temporal trend of EoE in Asia, the presenting symptoms, and association with atopic diseases.

METHODS

Literature search on PubMed, Embase, MEDLINE, Scopus, and Web of Science was performed to retrieve studies published between 1980 and 2023 that reported the prevalence or incidence of EoE in Asia. We used a random-effects model to estimate the pooled incidence and prevalence. I2 index and Cochran Q test were used to assess heterogeneity. Subgroup analyses were conducted for study types, different regions, years of examination, and age groups. The proportion of atopic diseases among patients with EoE was presented.

RESULTS

Twenty-five studies from Asia were included. The pooled prevalence of EoE was 33.5 cases per 100,000 inhabitants in population-based studies and 11.0 cases per 1,000 patients/visitors in hospital-based studies. The incidence rate among children was 12.3 cases per 1,000 patients/visitors, whereas for adults, it was only 0.2 cases per 1,000 patients/visitors. Among population-based studies, there was an increase in prevalence from 19.8 per 100,000 individuals in 2005-2009 to 73.0 per 100,000 individuals in 2015-2019. A similar upward trend was observed in hospital-based studies conducted during the same period. Patients with EoE commonly presented with dysphagia (36.3%) and nausea and vomiting (34.6%). History of atopy was reported in 57.2% of patients with EoE in Asia.

DISCUSSION

The prevalence and incidence of EoE in Asia have been rising over the past decades. Because of the limited number of Asian studies and variations in patient sources, caution should be exercised when interpreting these results.

Eosinophilic esophagitis: Current concepts in diagnosis and management

ABSTRACT

Eosinophilic esophagitis is an antigen-mediated chronic inflammatory disorder that has risen in incidence and prevalence over the past 2 decades. The clinical presentation is variable and consists of mainly esophageal symptoms such as dysphagia, heartburn, food impaction, and vomiting. Current management relies on dietary elimination, proton-pump inhibitors, and topical corticosteroids with different response rates and relapses after treatment discontinuation. With a better understanding of the underlying pathophysiology, many molecules emerged recently as targeted treatment including dupilumab (IL4/IL13 blocker), as the first FDA-approved biological treatment, which has changed the management paradigm.

Prevalence of Esophageal Eosinophilia, Eosinophilic Esophagitis, and Lymphocytic Gastritis in Children with Celiac Disease: A Saudi Tertiary Center Experience

Background

Celiac disease (CD) is an immune-mediated enteropathy that has been associated with other immune-related gastrointestinal disorders, such as eosinophilic esophagitis (EoE) and lymphocytic gastritis (LG). To our knowledge, this is the first study in Saudi Arabia that has described such an association.

Aim

To evaluate the prevalence of EoE and LG in children and adolescents with CD.

Methods

This was a retrospective cross-sectional study of all pediatric patients (aged 0-18 years) with CD following up at King Abdulaziz University Hospital, between January, 2014, and December, 2021. The study examined clinical, demographic, endoscopic, and histopathological data.

Results

Seventy-five patients with CD were included in the analysis. The median age was 12 years (range, 2-18 years). Male constituted 54.7% of the overall cohort (n = 41). The most common clinical symptoms were short stature (54.7%), weight loss (34.7%), abdominal pain (33.3%), abdominal distension (29.3%), anorexia (29.3%), diarrhea (24%), and vomiting (21.3%). The esophageal biopsy results reported were basal cell hyperplasia in 24 patients (32.9%), esophageal eosinophilia in 23 patients (31.5%), and EoE in 3 patients (4.1%). The gastric biopsy results were normal in 40 patients (53.3%). The most common abnormality was chronic inactive gastritis with no Helicobacter pylori (HP) infection (16%). LG was found in 3 patients (4%).

Conclusions

The prevalence of EoE in this cohort of patients with CD was lower than the prevalence recorded in a number of other studies. Further studies are needed to determine the effects of a gluten-free diet (GFD) on EOE and LG.

Descriptive Analysis of Pre-existing Data on Eosinophilic Esophagitis and Associated Morbidities in Cleveland Clinic Abu Dhabi, United Arab Emirates

BACKGROUND

Data on eosinophilic gastrointestinal disorders (EGIDs) are limited in the United Arab Emirates.

OBJECTIVE

This study aimed to describe the distribution of eosinophilic gastritis/gastroenteritis (EoG/EGE) and eosinophilic esophagitis (EoE) among patients whose data are recorded on the Cleveland Clinic Abu Dhabi (CCAD) systems.

METHODS

Anonymized aggregate data were obtained from the Clinerion Patient Network Explorer (PNEx®) network installed at the CCAD on patients diagnosed with EoG/EGE (n=17, of whom 11 (64.7%) were females) or with EoE (n=118, of whom 35 (29.7%) were females) between 2015 and 2022; 63 (53.4%) were diagnosed between 2020 and 2022.

RESULTS

The vast majority of EoE patients visited the gastroenterology clinic (111, 94.1%), followed by the primary care (70, 59.3%), the emergency medicine (60, 50.8%), and the immunology (59, 50%) units. A total of 84 patients with EoE also presented with another type-2 inflammatory condition including allergic rhinitis, food allergy, and atopic dermatitis. Proton pump inhibitors and corticosteroids were widely prescribed, and four patients with EoE have been commenced on biologics since 2020. However, heterogeneity of medication use was identified, warranting local clinical practice guidelines.

CONCLUSION

A referral network could be established with local and regional reach, which relies on a multidisciplinary approach for the management of EoE and associated type 2 co-morbidities. More studies are needed to better depict the clinical picture of patients with EGIDs in general and EoE, in particular, in terms of diagnosis, pharmacological treatment, non-medical interventions, disease course, and patient-reported outcomes.

Incidence of Pediatric Eosinophilic Esophagitis and Characterization of the Stricturing Phenotype in Alberta, Canada

Limited work has been done to characterize the stricturing pediatric eosinophilic esophagitis (EoE) phenotype. We aimed to determine, in pediatric EoE: the local incidence, the frequency of esophageal stricturing, and the safety of mechanical dilations.

Methods

We retrospectively identified all new cases of EoE at our center from 2015 to 2018 using esophageal biopsy reports, EoE clinic lists, and a local OR database of esophageal dilatations. Electronic medical records (EMRs) were reviewed to confirm EoE diagnosis. Clinical data were captured from the outpatient EMR and gastroscopy/pathology reports. Scope adverse event data were captured from multiple sources. The 2016 census data were used to calculate incidence rates.

Results

One hundred eighty-five new cases of EoE were diagnosed during the study period. For patients <15 years old living in Edmonton, the incidence over the 4 years was 11.1 cases per 100,000 person years. Eight of 185 (4%) patients had endoscopically confirmed esophageal strictures, 4 of which required mechanical dilation. Eleven of 185 (5.9%) patients had more subtle signs of esophageal narrowing, but no focal strictures. No perforations or episodes of significant bleeding were reported. Pain was reported after 15% of all scopes, including 50% of the 28 scopes with focal strictures. No unexpected admissions or emergency department visits occurred within 72 hours of a gastroscope with esophageal narrowing.

Conclusions

Edmonton zone has one of the highest incidences of pediatric EoE reported. In this cohort, 4% had focal esophageal strictures, and 6% had more subtle narrowing. Mechanical dilation of esophageal strictures was associated with no significant adverse events.

Clinico-pathological characteristics of eosinophilic esophagitis in Jordanian children

Introduction

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disorder manifested by symptoms of impaired esophageal function and hypereosinophilic esophageal inflammation. It is believed that the number of patients being diagnosed globally is increasing.

Aim

To describe the frequency and clinicopathological features of EoE in Jordanian children.

Material and methods

A retrospective review of all paediatric patients with eosinophilic esophagitis diagnosed and followed up at our paediatric gastroenterology service at King Abdullah University Hospital between January 2015 and January 2020.

Results

During the study period, 21 patients were diagnosed with EoE out of 700 diagnostic endoscopic procedures. Only 1 (4.8%) female was diagnosed. The average age at presentation was 9.5 years (age range: 1-16 years). The most common manifestation was solid food dysphagia (15, 71.4%), followed by food impaction and vomiting (11, 52.4% and 6, 28.6%, respectively). Atopy was diagnosed in 10 (47.6%) patients. Four (19.0%) had food allergy, 3 (14.3%) had respiratory allergy, and 3 (14.3%) had combined. Linear furrows and circular rings were the most common endoscopic features - 17 (81.0%) and 10 (47.6%), respectively, while papillary elongation, basal zone hyperplasia, and eosinophilic infiltrate were the most common reported histopathological features. Almost all patients received proton pump inhibitors (19, 90.5%). Steroids were used in 18 (85.7%) patients; local steroids in 11 (52.4%), and oral steroids in 7 (33.3%). Out of the 4 (19%) patients with esophageal strictures, 2 (9.5%) required pneumatic dilatation.

Conclusions

Eosinophilic esophagitis is not uncommon in our community. Clinical and histological parameters point to delayed referral and diagnosis. Increasing awareness of this problem will lead to early diagnosis and will decrease complications.

Trend, clinical presentations and diagnosis of eosinophilic esophagitis in Saudi children

Objectives:

To observe the frequency of eosinophilic esophagitis (EoE), pattern of clinical presentation and diagnosis among Saudi children at 2 tertiary care hospitals in Riyadh, Saudi Arabia.

Methods:

The database of children admitted or seen, and aged less than 18 years over 5 years period and diagnosed with EoE was collected and reviewed. Patients with esophagitis other than EoE were excluded. Patients who had eosinophils count more than 15/high power field (HPF) on esophageal biopsies were given the diagnosis of EoE. Demographic database, clinical parameters, and diagnostic modalities were analyzed by using the Statistical Package for Social Sciences version 22.

Results:

A total of 37 children with the diagnosis of EoE were gathered from 398 upper gastrointestinal endoscopic procedures with the frequency of 9.3%. There were 22 (59.4%) males with a mean±SD age of 9.6±2.3 years and all were Saudi nationals. Dysphagia was the leading presentation in 21 (56.7%) children followed by vomiting in 18 (48.6%), impaction of food bolus in 8 (21.6%) and foreign body in 3 (8.1%). Allergic symptoms were present in 13 (35.1%) children in the form of asthma, 11 (29.7%) multiple food allergies and 5 (13.5%) eczema. Peripheral eosinophil count and immunoglobulin E were raised more than normal in 6 and 5 children respectively. The pH measurements were carried out in 16 (43.2%) and ruled out the reflux. Contrast studies with barium (n=6; 16.2%) and endoscopic findings were significant (n=27; 72.9%).

Conclusion:

Eosinophilic esophagitis is an emerging disease and have a rising trend in Saudi children. Dysphagia, vomiting, and food impaction are the more common presenting features in older children and recurrent vomiting in younger children in addition to associated allergic conditions.

Eosinophilic Esophagitis From an Allergy Perspective: How to Optimally Pursue Allergy Testing & Dietary Modification in the Adult Population

Eosinophilic esophagitis (EoE) is a clinicopathologic condition characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. In adults, the three most common treatment options are swallowed steroids, elimination diets, and periodic esophageal dilations. Many different elimination diets have been studied in adults, including elemental diets, allergy testing-directed diets, and empiric elimination diets. This article will review the existing data on these dietary therapies and will propose an approach to dietary management in adult EoE.

Savary Dilation Is Safe and Effective Treatment for Esophageal Narrowing Related to Pediatric Eosinophilic Esophagitis

OBJECTIVES

Data on management of esophageal narrowing related to eosinophilic esophagitis (EoE) in children are scanty. The aim of the present study is to assess the safety and effectiveness of esophageal dilation in pediatric EoE from the largest case series to date.

METHODS

Children diagnosed with EoE during 2004 to 2015 were reviewed for the presence of esophageal narrowing. Esophageal narrowing was categorized as short segment narrow caliber, long segment narrow caliber, and single short stricture. The characteristics of the narrowed esophagus, therapeutic approach, clinical outcome, and complications were reviewed.

RESULTS

Of the 50 EoE cases diagnosed during the study period, 11 cases (9 boys; median age 9 years, range 4-12) were identified with esophageal narrowing (22%). Six had short segment narrow caliber esophagus and 5 had long segment narrow caliber esophagus (median length of the narrowing was 4 cm, range 3-20 cm). Three cases with narrow caliber esophagus also had esophageal stricture 2 to 3 cm below the upper esophageal sphincter. Nineteen dilation sessions were performed in 10 cases using Savary dilator. Esophageal size improved from median 7 mm to median 13.4 mm. Good response was obtained in all cases. Following the dilation procedure, longitudinal esophageal mucosal tear occurred in all cases without esophageal perforation or chest pain.

CONCLUSIONS

Esophageal dilation using Savary dilator is safe and highly effective in the management of esophageal narrowing related to EoE in children. Dilation alone does not improve the inflammatory process, and hence a combination with dietary or medical intervention is required.

Meta-Analysis-Based Guidance for Dietary Management in Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a prevalent chronic esophageal disorder, triggered and maintained by immunologically mediated responses against dietary antigens. EoE represents the most recent form of food allergy, and its control by avoiding offending foods has increasingly appeared as a therapeutic alternative to achieve and maintain remission. Dietary therapies have proved equally effective in pediatric and adult EoE patients, among whom various types of interventions to eliminate or reduce food antigens exposure have been evaluated. A recent meta-analysis showed elemental diet as the most effective option to induce disease remission, but with a limited application in clinical practice. Inconsistency and wide variability in results from skin allergy testing-directed food restriction contributed to dissatisfaction with implementation of this option, which subsequently was displaced by empiric elimination of common food allergens. Such empiric elimination of common food allergens is now recognized as the best alternative for dietary treatment, with moderate-to-high efficiency and reproducible results. This review provides evidence-based insights into the dietary management of EoE.

Systematic review with meta-analysis: the incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies

BACKGROUND

The recognition of eosinophilic oesophagitis (EoE) has risen sharply, but its current epidemiology is still under debate.

AIM

To estimate accurately the prevalence and incidence rates of EoE, by a systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE and SCOPUS databases were searched for population-based studies on the epidemiology of EoE. Pooled incidence and prevalence rates, male:female and children:adult ratios, and geographical and temporal variations were calculated with random-effects models.

RESULTS

The search yielded 1334 references; the final quantitative summary included 13 population-based studies from North America, Europe and Australia, with the results showing high heterogeneity. The pooled EoE incidence rate was 3.7/100 000 persons/year [95% confidence interval (CI): 1.7-6.5] and was higher for adults (7; 95% CI: 1-18.3) than for children (5.1; 95% CI: 1.5-10.9). The pooled prevalence of EoE was 22.7 cases/100 000 inhabitants (95% CI: 12.4-36), rising to 28.1 (95% CI: 13-49) when studies with a lower risk of bias were considered; prevalence was higher in adults than in children (43.4; 95% CI: 22.5-71.2 vs. 29.5; 95% CI: 17.5-44.7, respectively), and in American compared to European studies. A steady rise in EoE incidence and prevalence rates was observed upon comparison of studies conducted before and after 2008. No significant publication bias was found.

CONCLUSIONS

Eosinophilic oesophagitis is an increasingly common diagnosis in North America and Europe. The population-based incidence and prevalence of eosinophilic oesophagitis vary widely across individual studies, probably due to variations in diagnosis and risk of bias of research. More prospective, large-scale, multicenter studies are needed to evaluate reported data.

Clinical features of eosinophilic esophagitis: differences between Asian and Western populations

The prevalence and incidence of eosinophilic esophagitis (EoE) have been rapidly increasing in Western countries. It is thought to be more common among Caucasians than other racial or ethnic groups, but epidemiological studies have not been fully evaluated in Asian populations, and its clinical manifestation is rarely documented. In this review, recent reports regarding EoE in Asian countries have been collected, and differences in the clinical features, including symptoms and endoscopic findings, between Asian and Western populations have been evaluated. In Asia, EoE is still much less prevalent than in Western countries. Baseline values for average age, male/female ratio, and personal history of allergic disease were comparable to those in Western populations. Predominant symptoms were dysphagia, and food impaction was extremely rare among Asian patients. Although the frequency of abnormal endoscopic findings varies among studies, over 90% of patients with EoE have shown abnormal findings such as linear furrow, which is the most common findings, in recent prospective studies in Asia. There are few reports regarding the treatment of EoE and no prospective studies evaluating drugs or elimination diet in patient with EoE have been reported in Asia. Overall, EoE had similar clinical characteristics in Asian populations. Because the incidence of EoE could increase in the future with the increase in allergic disorders in Asian countries, large-scale, nationwide prospective studies should be performed to more fully understand the epidemiology and pathophysiology of EoE in Asian populations.