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Yeh PJ, Chen CC, Chao HC, Lai JY, Ming YC, Chen MC, Lai MW. The trends of pediatric duodenal ulcer and predictors of recurrence. J Formos Med Assoc 2024:S0929-6646(24)00211-0. [PMID: 38644127 DOI: 10.1016/j.jfma.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/27/2024] [Accepted: 04/16/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Duodenal ulcer (DU) causes various symptoms in children. The prevalence of Helicobacter pylori (Hp)-associated DU has been reducing in some regions, yet the updated trend in Taiwan is unknown. Risk factors of DU recurrence have not been comprehensively investigated in children. METHODS This retrospective study included children diagnosed with DU to evaluate the demographics, symptoms, diagnostics, treatment, and outcomes. Specific populations (infant, surgery required) were sorted for subgroup analysis. Predictors of DU recurrence was analyzed in patients who received endoscopic follow-ups. RESULTS A total of 488 children were included. Most patients were male (72.5%), school-aged (11.3 ± 4.8 years old), and with varied underlying diseases in one-fifth. The annual incidences were around 3-5%, with a declining trend of case numbers and the Hp-positive proportion. Hp infection, concurrent gastric ulcer, perforation, and mortality were noted in 32.7%, 16%, 1.6%, and 1% of patients. Patients with or without Hp infection showed different clinical features but similar outcomes. The characteristics of subpopulations were depicted respectively. Male sex, lower Hb level, and perforation were independent risk factors associated with recurrence. CONCLUSIONS Hp-positive DU seems to wane. Patients with male sex, lower Hb level, or perforation at diagnosis carried a higher risk of recurrence, which may warrant active surveillance and endoscopic follow-up.
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Affiliation(s)
- Pai-Jui Yeh
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan; Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
| | - Chien-Chang Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsun-Chin Chao
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jin-Yao Lai
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yung-Ching Ming
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Mi-Chi Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan; Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taiwan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan; Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taiwan.
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Papadopoulou A, Amil-Dias J, Auth MKH, Chehade M, Collins MH, Gupta SK, Gutiérrez-Junquera C, Orel R, Vieira MC, Zevit N, Atkins D, Bredenoord AJ, Carneiro F, Dellon ES, Gonsalves N, Menard-Katcher C, Koletzko S, Liacouras C, Marderfeld L, Oliva S, Ohtsuka Y, Rothenberg ME, Strauman A, Thapar N, Yang GY, Furuta GT. Joint ESPGHAN/NASPGHAN Guidelines on Childhood Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2024; 78:122-152. [PMID: 38291684 DOI: 10.1097/mpg.0000000000003877] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 06/13/2019] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis (non-EoE EGIDs) are rare chronic inflammatory disorders of the gastrointestinal (GI) tract. Diagnosis is based on clinical symptoms and histologic findings of eosinophilic inflammation after exclusion of a secondary cause or systemic disease. Currently, no guidelines exist for the evaluation of non-EoE EGIDs. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed a task force group to provide consensus guidelines for childhood non-EoE EGIDs. METHODS The working group was composed of pediatric gastroenterologists, adult gastroenterologists, allergists/immunologists, and pathologists. An extensive electronic literature search of the MEDLINE, EMBASE, and Cochrane databases was conducted up to February 2022. General methodology was used in the formulation of recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to meet current standards of evidence assessment. RESULTS The guidelines provide information on the current concept of non-EoE EGIDs, disease pathogenesis, epidemiology, clinical manifestations, diagnostic and disease surveillance procedures, and current treatment options. Thirty-four statements based on available evidence and 41 recommendations based on expert opinion and best clinical practices were developed. CONCLUSION Non-EoE EGIDs literature is limited in scope and depth, making clear recommendations difficult. These consensus-based clinical practice guidelines are intended to assist clinicians caring for children affected by non-EoE EGIDs and to facilitate high-quality randomized controlled trials of various treatment modalities using standardized, uniform disease definitions.
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Affiliation(s)
- Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, University of Athens, Children's Hospital Agia Sofia, Athens, Greece
| | | | - Marcus Karl-Heinz Auth
- Paediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust and University of Liverpool, Liverpool, UK
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sandeep K Gupta
- Community Health Network; and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University, Indianapolis, IN
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, University Hospital Puerta de Hierro Majadahonda, Autonomous University of Madrid, Madrid, Spain
| | - Rok Orel
- Department of Gastroenterology, Hepatology and Nutrition, Ljubljana University Children's Hospital, Ljubljana, Slovenia
| | - Mario C Vieira
- Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dan Atkins
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Fatima Carneiro
- Centro Hospitalar Universitário de São João (CHUSJ)/Faculty of Medicine of the University of Porto (FMUP) and Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup)/i3S - Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Calies Menard-Katcher
- Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Gastrointestinal Eosinophilic Disease Program, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Sibylle Koletzko
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Chris Liacouras
- Center for Pediatric Eosinophilic Diseases, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Luba Marderfeld
- The Ottawa Hospital, IBD Center, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
| | - Salvatore Oliva
- Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Rome, Italy
| | - Yoshikazu Ohtsuka
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alex Strauman
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, GOS Institute of Child Health, University College London, London, UK
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Guan-Yu Yang
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Glenn T Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Gastrointestinal Eosinophilic Disease Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO
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Tsuge M, Shigehara K, Uda K, Kawano S, Iwamuro M, Saito Y, Yashiro M, Ikeda M, Tsukahara H. Successful use of dupilumab for egg-induced eosinophilic gastroenteritis with duodenal ulcer: a pediatric case report and review of literature. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:103. [PMID: 38053199 DOI: 10.1186/s13223-023-00859-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/10/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Non-esophageal eosinophilic gastrointestinal disorder (non-EoE-EGID) is a rare disease in which eosinophils infiltrate parts of the gastrointestinal tract other than the esophagus; however, the number of patients with non-EoE-EGID has been increasing in recent years. Owing to its chronic course with repeated relapses, it can lead to developmental delays due to malnutrition, especially in pediatric patients. No established treatment exists for non-EoE-EGID, necessitating long-term systemic corticosteroid administration. Although the efficacy of dupilumab, an anti-IL-4/13 receptor monoclonal antibody, for eosinophilic esophagitis, has been reported, only few reports have demonstrated its efficacy in non-EoE EGIDs. CASE PRESENTATION A 13-year-old boy developed non-EoE-EGID with duodenal ulcers, with chicken eggs as the trigger. He was successfully treated with an egg-free diet, proton pump inhibitors, and leukotriene receptor antagonists. However, at age 15, he developed worsening upper abdominal pain and difficulty eating. Blood analysis revealed eosinophilia; elevated erythrocyte sedimentation rate; and elevated levels of C-reactive protein, total immunoglobulin E, and thymic and activation-regulated chemokines. Upper gastrointestinal endoscopy revealed a duodenal ulcer with marked mucosal eosinophilic infiltration. Gastrointestinal symptoms persisted even after starting systemic steroids, making it difficult to reduce the steroid dose. Subcutaneous injection of dupilumab was initiated because of comorbid atopic dermatitis exacerbation. After 3 months, the gastrointestinal symptoms disappeared, and after 5 months, the duodenal ulcer disappeared and the eosinophil count decreased in the mucosa. Six months later, systemic steroids were discontinued, and the duodenal ulcer remained recurrence-free. The egg challenge test result was negative; therefore, the egg-free diet was discontinued. Blood eosinophil count and serum IL-5, IL-13, and eotaxin-3 levels decreased after dupilumab treatment. The serum levels of IL-5 and eotaxin-3 remained within normal ranges, although the blood eosinophil counts increased again after discontinuation of oral prednisolone. CONCLUSIONS Suppression of IL-4R/IL-13R-mediated signaling by dupilumab may improve abdominal symptoms and endoscopic and histologic findings in patients with non-EoE-EGID, leading to the discontinuation of systemic steroid administration and tolerance of causative foods.
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Affiliation(s)
- Mitsuru Tsuge
- Department of Pediatric Acute Diseases, Okayama University Academic Field of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Kenji Shigehara
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Kazuhiro Uda
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Seiji Kawano
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Yukie Saito
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Masato Yashiro
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Masanori Ikeda
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Hirokazu Tsukahara
- Department of Pediatrics, Okayama University Academic Field of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Fujita Y, Tominaga K, Ishida K, Masuyama H, Yoshihara S. Proton Pump Inhibitor to Treat an Eosinophilic Duodenal Ulcer with Esophageal Involvement: A Pediatric Case. TOHOKU J EXP MED 2022; 257:309-313. [PMID: 35661048 DOI: 10.1620/tjem.2022.j045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yuji Fujita
- Department of Pediatrics, Dokkyo Medical University
| | | | - Kazuyuki Ishida
- Department of Diagnostic Pathology, Dokkyo Medical University
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Fujita Y, Tominaga K, Tanaka T, Ishida K, Yoshihara S. Eosinophilic Duodenal Ulcer Exacerbation after Helicobacter pylori Eradication in a 14-Year-Old Boy. TOHOKU J EXP MED 2022; 257:153-156. [PMID: 35444106 DOI: 10.1620/tjem.2022.j031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yuji Fujita
- Department of Pediatrics, Dokkyo Medical University
| | | | - Takanao Tanaka
- Department of Gastroenterology, Dokkyo Medical University
| | - Kazuyuki Ishida
- Department of Diagnostic Pathology, Dokkyo Medical University
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Kubo K, Kimura N, Mabe K, Matsuda S, Tsuda M, Kato M. Eosinophilic Gastroenteritis-associated Duodenal Ulcer Successfully Treated with Crushed Budesonide. Intern Med 2020; 59:2249-2254. [PMID: 32536650 PMCID: PMC7578595 DOI: 10.2169/internalmedicine.4706-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Eosinophilic gastroenteritis (EGE)-associated duodenal ulcer is rare and its endoscopic and pathological features remain poorly described. A 15-year-old boy was referred to our hospital for further examination and treatment of duodenal ulcer. Esophagogastroduodenoscopy (EGD) revealed two A2-stage duodenal ulcers on the duodenal bulb. A biopsy revealed marked infiltration of eosinophils, suggestive of EGE-associated duodenal ulcers. Thus, treatment with crushed budesonide (9 mg/day) was started. EGD revealed healing of the duodenal ulcers seven months after treatment. To our knowledge, this is the first report describing EGE-associated duodenal ulcer successfully treated with crushed budesonide.
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Affiliation(s)
- Kimitoshi Kubo
- Departments of Gastroenterology, National Hospital Organization Hakodate National Hospital, Japan
| | - Noriko Kimura
- Departments of Pathology, National Hospital Organization Hakodate National Hospital, Japan
| | - Katsuhiro Mabe
- Departments of Gastroenterology, National Hospital Organization Hakodate National Hospital, Japan
| | - Soichiro Matsuda
- Departments of Gastroenterology, National Hospital Organization Hakodate National Hospital, Japan
| | - Momoko Tsuda
- Departments of Gastroenterology, National Hospital Organization Hakodate National Hospital, Japan
| | - Mototsugu Kato
- Departments of Gastroenterology, National Hospital Organization Hakodate National Hospital, Japan
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Gastrointestinal Manifestations of Hypereosinophilic Syndromes and Mast Cell Disorders: a Comprehensive Review. Clin Rev Allergy Immunol 2020; 57:194-212. [PMID: 30003499 DOI: 10.1007/s12016-018-8695-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hypereosinophilic syndrome and mastocytosis are relatively rare proliferative diseases encountered in the general population. However, allergists frequently consider these disorders in the differential of patients presenting with gastrointestinal, pulmonary, cutaneous, and allergic symptoms. Gastrointestinal symptoms are some of the most frequent and/or debilitating aspects of both disease states and in many cases lead to poor quality of life and functional limitation for the patient. They are the third most common clinical manifestation in hypereosinophilic syndrome and have been found to be the most distressful aspect of the disorder in those with systemic mastocytosis. Both eosinophils and mast cells play integral parts in normal gut physiology, but when and how exactly their effector functionality translates into clinically significant disease remains unclear, and the available literature regarding their pathophysiology remains sparse. Eosinophils and mast cells even, in fact, may not necessarily function in isolation from each other but can participate in bidirectional crosstalk. Both are affected by similar mediators and can also influence one another in a paracrine fashion. Their interactions include both production of soluble mediators for specific eosinophil and mast cell receptors (for example, eosinophil recruitment and activation by mast cells releasing histamine and eotaxin) as well as direct physical contact. The mechanistic relationship between clonal forms of hypereosinophilia and systemic mastocytosis has also been explored. The nature of gastrointestinal symptomatology in the setting of both hypereosinophilic syndrome and mast cell disease is frequently manifold, heterogeneous, and the lack of better targeted therapy makes diagnosis and management challenging, especially when faced with a substantial differential. Currently, the management of these gastrointestinal symptoms relies on the treatment of the overall disease process. In hypereosinophilia patients, systemic corticosteroids are mainstay, although steroid-sparing agents such as hydroxyurea, IFN-α, methotrexate, cyclosporine, imatinib, and mepolizumab have been utilized with varying success. In mastocytosis patients, anti-mediator therapy with antihistamines and mast cell stabilization with cromolyn sodium can be considered treatments of choice, followed by other therapies yet to be thoroughly studied, including the role of the low-histamine diet, corticosteroids, and treatment of associated IBS symptoms. Given that both eosinophils and mast cells may have joint pathophysiologic roles, they have the potential to be a combined target for therapeutic intervention in disease states exhibiting eosinophil or mast cell involvement.
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Munjal A, Al-Sabban A, Bull-Henry K. Eosinophilic Enteritis: A Delayed Diagnosis. J Investig Med High Impact Case Rep 2017; 5:2324709617734246. [PMID: 29051893 PMCID: PMC5638174 DOI: 10.1177/2324709617734246] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/19/2017] [Indexed: 12/28/2022] Open
Abstract
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.
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