Eosinophilic esophagitis (EoE) is a new disease. It is caused by a T-helper type 2 cell response to food antigens in contact with the esophageal mucosa. Although no single feature defines EoE, a ...constellation of compatible demographic, clinical, endoscopic, and histologic findings establish the diagnosis. Children present with symptoms and endoscopic patterns characteristic of inflammation, whereas adolescents and adults have manifestations of fibrosis and gross esophageal strictures. Clinical and endoscopic scoring systems have helped to standardize diagnosis. There is controversy in EoE research over the optimal endpoint for treatment. Although the most common endpoint is a reduced number of eosinophils in biopsies, changes in symptoms and endoscopic features are becoming important targets of therapy. We should improve our understanding of EoE progression and the need for maintenance therapy, and continue development of diagnostic tools that avoid endoscopy and biopsy analyses to more easily monitor disease activity.
Background & Aims Gene expression profiling provides an opportunity for definitive diagnosis but has not yet been well applied to inflammatory diseases. Here we describe an approach for diagnosis of ...an emerging form of esophagitis, eosinophilic esophagitis (EoE), which is currently diagnosed by histology and clinical symptoms. Methods We developed an EoE diagnostic panel (EDP) comprising a 96-gene quantitative polymerase chain reaction array and an associated dual-algorithm that uses cluster analysis and dimensionality reduction using a cohort of randomly selected esophageal biopsy samples from pediatric patients with EoE (n = 15) or without EoE (non-EoE controls, n = 14) and subsequently vetted the EDP using a separate cohort of 194 pediatric and adult patient samples derived from both fresh or formalin-fixed, paraffin-embedded tissue: active EoE (n = 91), control (non-EoE and EoE remission, n = 57), histologically ambiguous (n = 34), and reflux (n = 12) samples. Results The EDP identified adult and pediatric patients with EoE with approximately 96% sensitivity and approximately 98% specificity, and distinguished patients with EoE in remission from controls, as well as identified patients exposed to swallowed glucorticoids. The EDP could be used with formalin-fixed, paraffin-embedded tissue RNA and distinguished patients with EoE from those with reflux esophagitis, identified by pH-impedance testing. Preliminary evidence showed that the EDP could identify patients likely to have disease relapse after treatment. Conclusions We developed a molecular diagnostic test (referred to as the EDP) that identifies patients with esophagitis in a fast, objective, and mechanistic manner, offering an opportunity to improve diagnosis and treatment, and a platform approach for other inflammatory diseases.
Aims
To explore the utility of an IgG4 immunohistochemical stain to help distinguish eosinophilic oesophagitis from gastroesophageal reflux disease.
Methods and results
We examined 21 cases of ...eosinophilic oesophagitis and 25 cases of gastroesophageal reflux disease. The diagnosis of eosinophilic oesophagitis was based on the presence of oesophageal dysfunction, >15 eosinophils per high‐power field, and a lack of response to proton pump inhibitors. Gastroesophageal reflux disease showed intraepithelial eosinophils, but a clinical and/or histological response to proton pump inhibitor therapy. We also evaluated an additional cohort of 22 cases with intraepithelial eosinophils. Immunohistochemical staining for IgG4 was performed. Sixteen of 21 (76%) eosinophilic oesophagitis cases showed intrasquamous extracellular IgG4 deposits, whereas all 25 gastroesophageal reflux disease cases were negative. Mucosal IgG4‐positive plasma cells were identified in eosinophilic oesophagitis and gastroesophageal reflux disease cases in 58% and 40% of cases, respectively. Eosinophilic oesophagitis patients receiving treatment were less likely to be positive for intraepithelial IgG4 deposits (88% versus 53%). In the validation cohort, the sensitivity and specificity for eosinophilic oesophagitis were 88% and 100%, respectively.
Conclusions
The presence of intrasquamous IgG4 deposits is a useful adjunctive marker in the distinction between eosinophilic oesophagitis and gastroesophageal reflux disease.
Eosinophilic Esophagitis Furuta, Glenn T; Katzka, David A
The New England journal of medicine,
10/2015, Letnik:
373, Številka:
17
Journal Article
Recenzirano
Eosinophilic esophagitis is an increasingly common diagnosis among children evaluated for feeding problems and among adults with dysphagia and food impaction. This review considers the diagnostic ...criteria, pathophysiology, clinical features, and treatment of this disease.
Once considered a rare condition, eosinophilic esophagitis is now one of the most common conditions diagnosed during the assessment of feeding problems in children and during the evaluation of dysphagia and food impaction in adults.
1
The entity exists worldwide but has been most extensively studied in Western countries, where its prevalence has been estimated to be 0.4% among all children and adults.
2
Whether eosinophilic esophagitis is truly a new disease or simply a recently recognized one is uncertain.
3
In this review, we consider the diagnostic criteria, pathophysiological and clinical features, and treatment of this increasingly prevalent disease.
Definition and Differential . . .
Infectious Esophagitis in Children O’Donnell, Jonathan E. M.; Krishnan, Usha
Journal of pediatric gastroenterology and nutrition,
November 2022, 2022-11-01, 2022-11-00, 20221101, Letnik:
75, Številka:
5
Journal Article
Recenzirano
Infectious esophagitis is the third most common cause of esophagitis after gastroesophageal reflux disease and eosinophilic esophagitis (EoE) and should always be considered in the differential of ...patients with dysphagia and odynophagia. The most common organisms causing disease are candida, Herpes simplex virus (HSV) and cytomegalovirus (CMV). It is well recognized that an impaired local or systemic immune system is a risk factor for disease; however, esophageal dysmotility and disruptions in esophageal homeostasis and the esophageal milieu are likely to represent additional risk factors in disease pathogenesis.
Eosinophilic Esophagitis: A Review Muir, Amanda; Falk, Gary W
JAMA : the journal of the American Medical Association,
10/2021, Letnik:
326, Številka:
13
Journal Article
Recenzirano
IMPORTANCE: Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disease of the esophagus that affects an estimated 34.4/100 000 people in Europe and North America. EoE affects ...both children and adults, and causes dysphagia, food impaction of the esophagus, and esophageal strictures. OBSERVATIONS: EoE is defined by symptoms of esophageal dysfunction, such as vomiting, dysphagia, or feeding difficulties, in a patient with an esophageal biopsy demonstrating at least 15 eosinophils per high-power field in the absence of other conditions associated with esophageal eosinophilia such as gastroesophageal reflux disease or achalasia. Genetic factors and environmental factors, such as exposure to antibiotics early in life, are associated with EoE. Current therapies include proton pump inhibitors; topical steroid preparations, such as fluticasone and budesonide; dietary therapy with amino acid formula or empirical food elimination; and endoscopic dilation. In a systematic review of observational studies that included 1051 patients with EoE, proton pump inhibitor therapy was associated with a histologic response, defined as less than 15 eosinophils per high-power field on endoscopic biopsy, in 41.7% of patients, while placebo was associated with a 13.3% response rate. In a systematic review of 8 randomized trials of 437 patients with EoE, topical corticosteroid treatment was associated with histologic remission in 64.9% of patients compared with 13.3% for placebo. Patients with esophageal narrowing may require dilation. Objective assessment of therapeutic response typically requires endoscopy with biopsy. CONCLUSIONS AND RELEVANCE: EoE has a prevalence of approximately 34.4/100 000 worldwide. Treatments consist of proton pump inhibitors, topical steroids, elemental diet, and empirical food elimination, with esophageal dilation reserved for patients with symptomatic esophageal narrowing.
Eosinophilic esophagitis (EoE) has emerged over the past 2 decades as a major cause of upper gastrointestinal morbidity. Over this time, the epidemiology of EoE has also rapidly evolved. EoE has ...transformed from a rare case-reportable condition to disease that is commonly encountered in the gastroenterology clinic, hospital emergency room, and endoscopy suite. The incidence and prevalence are increasing at rates that outpace increased disease recognition. Current incidence estimates range from 5 to 10 cases per 100,000, and current prevalence estimates range from 0.5 to 1 case per 1000. We review the data and potential reasons behind this increase, examine risk factors, and identify important areas for research into disease etiology. The article also discusses the progression of EoE from an inflammatory to fibrostenotic phenotype. An accurate view of the natural history of EoE is central to discussions with patients regarding disease prognosis and decisions about long-term use of medical, endoscopic, and diet therapies. Progressive remodelling appears to be gradual, but not universal, and the duration of untreated disease is the best predictor of stricture risk. Ultimately, prospective, long-term outcome studies focusing on multiple aspects of disease activity are needed to fully understand the natural history of EoE.
Management Guidelines of Eosinophilic Esophagitis in Childhood Papadopoulou, A.; Koletzko, S.; Heuschkel, R. ...
Journal of pediatric gastroenterology and nutrition,
January 2014, 2014-January, 2014-Jan, 2014-01-00, 20140101, Letnik:
58, Številka:
1
Journal Article, Conference Proceeding
Recenzirano
Odprti dostop
ABSTRACT
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.
Patient symptom reporting often does not correlate with the pathophysiological markers of esophageal disease, including eosinophilic esophagitis (EoE). Esophageal hypervigilance and symptom-specific ...anxiety are emerging as important considerations in understanding symptom reporting. As such, we aimed to conduct the first study of these constructs in EoE.
A retrospective review of an EoE patient registry was conducted and included eosinophils per high power field (from esophagogastroduodenoscopy biopsy: proximal, distal), endoscopic reference score, distal distensibility plateau (functional luminal imaging probe), Brief Esophageal Dysphagia Questionnaire, Visual Dysphagia Question of EoE Activity Index, Northwestern Esophageal Quality of Life scale, and the Esophageal Hypervigilance and Anxiety Scale. Correlational and regression analyses evaluated relationships of hypervigilance and anxiety with Brief Esophageal Dysphagia Questionnaire, Visual Dysphagia Question of EoE Activity Index, and Northwestern Esophageal Quality of Life scale when controlling for histology and endoscopic severity.
One hundred and three patients had complete data, 69.9% were male, and the mean (SD) age was 40.66 (13.85) years. Forty-one percent had elevated dysphagia and 46% had elevated hypervigilance and anxiety. Esophageal symptom–specific anxiety emerged as the most important predictor of Brief Esophageal Dysphagia Questionnaire severity (44.8% of the variance), Visual Dysphagia Question of EoE Activity Index severity (26%), and poor health-related quality of life (HRQoL) (55.3%). Hypervigilance was also important, but to a lesser extent. Pathophysiological variables did not significantly predict symptoms or HRQoL. Recent food impaction can predict symptom-specific anxiety and proton pump inhibitor use can reduce hypervigilance.
Hypervigilance and symptom-specific anxiety are important for our understanding of self-reported patient outcomes in EoE. These processes outweigh endoscopic and histologic markers of EoE disease activity across dysphagia, difficulty eating, and HRQoL. Clinicians should assess hypervigilance and anxiety, especially in patients with refractory symptoms and poor HRQoL.
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The amount of attention a patient's brain pays to symptoms of eosinophilic esophagitis, and how upsetting symptoms are, may be more important in explaining their severity than medical testing.
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