Summary
Background
Oesophageal dilation is frequently used as an adjunct treatment to alleviate symptoms that develop from fibrostenotic remodelling in eosinophilic oesophagitis (EoE). Earlier ...reports described an increased risk of complications associated with dilation.
Aim
Perform a systematic review and meta‐analysis to assess the efficacy and safety of endoscopic dilation in children and adults with EoE.
Methods
Professional librarians searched MEDLINE, EMBASE, the Cochrane library, Scopus, and Web of Science for articles in any language describing studies of dilation in EoE through December 2016. Studies were selected and data were ed independently and in duplicate. Random effects modelling was used to generate summary estimates for clinical improvement and complications (haemorrhage, perforation, hospitalisation, and death).
Results
The search resulted in 3495 references, of which 27 studies were included in the final analysis. The studies described 845 EoE patients, including 87 paediatric patients, who underwent a total of 1820 oesophageal dilations. The median number of dilations was 3 (range: 1‐35). Clinical improvement occurred in 95% of patients (95% CI: 90%‐98%, I2: 10%, 17 studies). Perforation occurred in 0.38% (95% CI: 0.18%‐0.85%, I2: 0%, 27 studies), haemorrhage in 0.05% (95% CI: 0%‐0.3%, I2: 0%, 18 studies), and hospitalisation in 0.67% (95% CI: 0.3%‐1.1%, I2: 44%, 24 studies). No deaths occurred (95% CI: 0%‐0.2% I2: 0%, 25 studies).
Conclusions
Endoscopic dilation is consistently effective in children and adults with EoE, resulting in improvement in 95% of patients with very low rates (<1%) of major complications.
Linked ContentThis article is linked to Moaward et al and Kia and Hirano papers. To view these articles visit https://doi.org/10.1111/apt.14216 and https://doi.org/10.1111/apt.14213.
Summary
Background
Several measures have been used to assess the health‐related quality of life (HRQoL) of patients with eosinophilic oesophagitis (EoE).
Aims
To systematically review these HRQoL ...measures, to appraise measurement properties of specific instruments and to evaluate determinant factors influencing HRQoL in paediatric and adult EoE patients.
Methods
We searched the PubMed, Embase, Scopus, Web of Science (WOS) and PsycINFO databases for documents providing original information on the development of measurement tools and/or evaluation of HRQoL outcomes in EoE patients of all ages.
Results
Of the 596 references identified, data was collected from 34 studies (with only 16 of them being published as full papers) including a total of 1,689 individual patients. Three disease‐specific HRQoL measures in EoE covering different aspects of patients’ lives and developed in English, were scored positive regarding measurement properties. The PedsQL inventory (including parent and child report forms) and the Peds‐QoL EoE module were the generic and specific instruments respectively used in children, while the SF‐36 and EoE‐QoL‐A were the most used questionnaires in adults. Patients with EoE show an impaired HRQoL compared to controls, which greatly depends on symptom severity and disease duration. Severity of endoscopic features and female gender may also determine an impaired HRQoL. The effect of treatments on HRQoL requires further assessment.
Conclusions
HRQoL is a relevant outcome that should be considered in clinical practice and research of EoE. Further validation studies in several languages and populations are required to support the use of disease‐specific HRQoL measures.
Summary
Background
Noncoeliac gluten sensitivity (NCGS) is a controversial emerging disorder. Despite reported symptoms related to the ingestion of gluten, NCGS remains a diagnosis based on the ...exclusion of coeliac disease, given the absence of reliable biomarkers.
Aim
To evaluate the prevalence, diagnostic exclusion of coeliac disease and the efficacy of a gluten‐free diet (GFD) for NCGS patients.
Methods
A PubMed search was performed up to December 2014. According to consensus diagnostic criteria, NCGS was defined as self‐reported gluten intolerance, negative coeliac serology and absence of villous atrophy. Studies evaluating the impact of a GFD on patients with irritable bowel syndrome (IBS) were also included.
Results
Prevalence rates of NCGS (0.5–13%) differed widely. Seventeen studies, including 1561 patients (26 children), met the inclusion criteria for NCGS. HLA haplotypes could not be linked to histology normal or lymphocytic enteritis (LE) in 1123 NCGS patients. HLADQ2/DQ8 haplotypes were present in 44% of NCGS patients. After advanced diagnostic techniques in 189 NCGS patients combining LE and HLADQ2/DQ8 haplotypes, 39 (20%) were reclassified as coeliac disease. There was a higher than expected family history of coeliac disease and autoimmune disorders in NCGS patients. A GFD resulted in variable results for variable, but significantly improved stool frequency in HLADQ2 positive diarrhoea‐predominant IBS patients.
Conclusions
Prevalence rates for NCGS are extremely variable. A subset of NCGS patients might belong in the so‐called ‘coeliac‐lite’ disease. The benefit of a GFD for NCGS patients is currently controversial. HLADQ2 positive diarrhoea‐type IBS patients might gain symptom improvement from a GFD.
Summary
Background
Recent advances in eosinophilic oesophagitis (EoE) have confirmed the existence of a new disease phenotype, proton pump inhibitor (PPI)‐responsive oesophageal eosinophilia ...(PPI‐REE).
Aim
To summarise evidence supporting the use of PPI therapy in patients with suspected EoE (oesophageal dysfunction plus >15 eos/HPF in oesophageal biopsies).
Methods
A literature search was conducted through MEDLINE, using the MeSH search terms ‘eosinophilic oesophagitis’, ‘proton pump inhibitors’ and ‘oesophageal eosinophilia’. Relevant articles and their reference lists were identified through manual review.
Results
Ten articles, including 258 patients with suspected EoE (152 children, 106 adults) undergoing clinico‐histological re‐evaluation after PPI therapy, were identified. In children, clinical response ranged from 78% to 86% and histological remission from 23% to 40%. In adults, symptom response ranged from 25% to 80% and histological remission from 33% to 61%. Among PPI‐REE patients with oesophageal pH‐monitoring, 35 showed pathological and 10 normal studies. PPI‐REE was significantly commoner with documented gastro‐oesophageal reflux disease (GERD) when compared to patients with negative pH monitoring (70% vs. 29%, P < 0.001). Symptom improvement/resolution occurred in 50–85% of patients without histological remission on PPI therapy. Six PPI‐REE patients demonstrated clinico‐histological relapse on PPI therapy.
Conclusions
At least one third of patients with suspected EoE achieve clinico‐histological remission on PPI therapy. Response is more limited in children compared with that in adults. pH monitoring does not accurately predict response to PPI therapy, albeit histological remission is significantly higher, up to 70%, upon documented GERD. Symptom improvement is common with PPI therapy despite persistent eosinophilic infiltration.
Summary
Background
The molecular basis and effects of proton pump inhibitor (PPI) therapy on PPI‐responsive oesophageal eosinophilia (PPI‐REE) and eosinophilic oesophagitis (EoE) remain unknown.
Aim
...To compare symptom‐histological and cytokine gene expression in PPI‐REE and EoE patients, at baseline and after specific treatment.
Methods
In consecutive adult patients with an EoE phenotype (dysphagia/food impaction, typical endoscopic findings and > 15 eos/HPF), gene expression of eotaxin‐3, IL‐13, and IL‐5 were determined in distal and proximal oesophagus, at baseline and after omeprazole 40 mg b.d. for 8 weeks. PPI‐REE was defined by clinicohistological response. PPI nonresponders (EoE) were offered treatment with topical steroids.
Results
Fifty three patients were re‐evaluated on PPI therapy. 23 patients (43%) had PPI‐REE and 30 patients (57%) had EoE. At baseline, eotaxin‐3/IL‐13/IL‐5 gene expression was indistinguishable between EoE and PPI‐REE, excepting increased IL‐5 expression in proximal oesophagus (12.54 vs. 57, P = 0.029). PPI therapy significantly decreased eotaxin‐3/IL‐13 in PPI‐REE, at both oesophageal sites (P ≤ 0.008), and IL‐5 in distal (P = 0.016), but not in proximal oesophagus. Patients with steroid‐responsive EoE also showed a significant decrease in eotaxin‐3/IL‐5 expression at both oesophageal sites. In EoE patients, initial PPI trial significantly decreased distal oesophageal eosinophilia (63.78 to 41.79 eos/HPF, P = 0.025) and led to symptom remission in 16%, but did not influence Th2 markers.
Conclusions
Baseline cytokine gene expression in PPI‐REE was nearly indistinguishable from EoE. PPI therapy significantly downregulated oesophageal eotaxin‐3/Th2‐cytokine gene expression in PPI‐REE, similarly to that seen in steroid‐responsive EoE. A subset of EoE patients showed clinicohistological improvement on PPI therapy.
Summary
Background
Proton pump inhibitor‐responsive oesophageal eosinophilia (PPI‐REE) is common in patients with suspected eosinophilic oesophagitis (EoE). However, the long‐term efficacy of PPIs ...and the best maintenance doses are yet to be defined.
Aim
To evaluate the durability of the response to PPI therapy after tapering PPI doses in PPI‐REE patients.
Methods
Prospective study conducted on PPI‐REE patients. Upon complete remission on high‐dose PPI therapy (omeprazole 40 mg b.d. for 8 weeks), PPI doses were tapered followed by an endoscopic procedure after each dose reduction. The primary outcomes were sustained clinical and histological remission (<15 eos/HPF) after decreasing PPI doses.
Results
From a total of 121 patients with suspected EoE, 40 (33%) achieved complete remission on high‐dose PPIs and were given a diagnosis of PPI‐REE. No patient in histological remission showed symptom relapse, but half of patients with relapsing oesophageal inflammation were in clinical remission. After reduction to omeprazole 40 mg once daily, 38/31 (81%) remained in complete remission. Among these latter patients, 15/18 (83%) were kept in remission with omeprazole 20 mg once daily. As for side effects, only asymptomatic hypertransaminasemia and oesophageal candidiasis were observed in two patients while receiving high doses of omeprazole.
Conclusions
Most PPI‐responsive oesophageal eosinophilia patients show sustained clinical and histological remission with daily PPI doses equal to or below 40 mg of omeprazole. As adverse effects only appeared with the highest dose of omeprazole, it would be advisable to individualise the dose of PPIs for each patient, lowering it to the minimum capable of maintaining the disease controlled.
Linked ContentThis article is linked to Moaward et al and Kia and Hirano papers. To view these articles visit https://doi.org/10.1111/apt.14216 and https://doi.org/10.1111/apt.14123.
Summary
Background
The most commonly used second‐line Helicobacter pylori eradication regimens are bismuth‐containing quadruple therapy and levofloxacin‐containing triple therapy, both offering ...suboptimal results. Combining bismuth and levofloxacin may enhance the efficacy of rescue eradication regimens.
Aims
To evaluate the efficacy and tolerability of a second‐line quadruple regimen containing levofloxacin and bismuth in patients whose previous H. pylori eradication treatment failed.
Methods
This was a prospective multicenter study including patients in whom a standard triple therapy (PPI–clarithromycin–amoxicillin) or a non‐bismuth quadruple therapy (PPI–clarithromycin–amoxicillin–metronidazole, either sequential or concomitant) had failed. Esomeprazole (40 mg b.d.), amoxicillin (1 g b.d.), levofloxacin (500 mg o.d.) and bismuth (240 mg b.d.) was prescribed for 14 days. Eradication was confirmed by 13C‐urea breath test. Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by questionnaires.
Results
200 patients were included consecutively (mean age 47 years, 67% women, 13% ulcer). Previous failed therapy included: standard clarithromycin triple therapy (131 patients), sequential (32) and concomitant (37). A total of 96% took all medications correctly. Per‐protocol and intention‐to‐treat eradication rates were 91.1% (95%CI = 87–95%) and 90% (95%CI = 86–94%). Cure rates were similar regardless of previous (failed) treatment or country of origin. Adverse effects were reported in 46% of patients, most commonly nausea (17%) and diarrhoea (16%); 3% were intense but none was serious.
Conclusions
Fourteen‐day bismuth‐ and levofloxacin‐containing quadruple therapy is an effective (≥90% cure rate), simple and safe second‐line strategy in patients whose previous standard triple or non‐bismuth quadruple (sequential or concomitant) therapies have failed.
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