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Dickerson A, Dellon ES, Aceves SS. Future of therapy and monitoring for eosinophilic esophagitis and eosinophilic gastrointestinal diseases. Ann Allergy Asthma Immunol 2025:S1081-1206(25)00242-X. [PMID: 40393554 DOI: 10.1016/j.anai.2025.05.016] [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: 03/14/2025] [Revised: 05/12/2025] [Accepted: 05/14/2025] [Indexed: 05/22/2025]
Abstract
Eosinophilic gastrointestinal disorders, including eosinophilic esophagitis, are chronic Th2 mediated diseases. Establishing a diagnosis and initiating treatment is crucial to limit disease progression that may lead to tissue remodeling and the development of strictures that significantly impact patient quality of life. Expert consensus guidelines provide a framework for treating eosinophilic esophagitis with diet elimination, proton pump inhibitors, swallowed topical steroids, or dupilumab and for monitoring with sedated endoscopy for gross and histologic evaluation. While this provides an established algorithm for treating and monitoring eosinophilic esophagitis, there is less established for the rarer eosinophilic gastrointestinal disorders (eosinophilic gastritis, enteritis, and colitis). Research advancements continue to emerge at a rapid pace, identifying potential biomarkers, therapeutic targets, and monitoring strategies. In this article, we review the current accepted methods for treating and monitoring eosinophilic gastrointestinal disorders with a focus on eosinophilic esophagitis, assess what is currently under investigation, and provide an aspirational vision for future disease management with a streamlined algorithm of personalized medicine and less invasive monitoring.
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Affiliation(s)
- Andrew Dickerson
- Division of Allergy, Immunology, Department of Pediatrics, University of California, San Diego and Rady Children's Hospital, San Diego, California; Division of Gastroenterology, Department of Pediatrics, University of California, San Diego and Rady Children's Hospital, San Diego, California
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology. Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Seema S Aceves
- Division of Allergy, Immunology, Department of Pediatrics, University of California, San Diego and Rady Children's Hospital, San Diego, California; Department of Medicine, University of California, San Diego.
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Authors, Collaborators. S2k guideline Gastroesophageal reflux disease and eosinophilic esophagitis of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1786-1852. [PMID: 39389106 DOI: 10.1055/a-2344-6282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
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Surapaneni D, Azam B, Dasi SC. Eosinophilic Ascites: A Rare Diagnosis With an Even Rarer Etiology. Cureus 2024; 16:e68511. [PMID: 39364509 PMCID: PMC11447649 DOI: 10.7759/cureus.68511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2024] [Indexed: 10/05/2024] Open
Abstract
Eosinophilic ascites (EA) is a rare and often challenging clinical manifestation of eosinophilic gastroenteritis (EGE), a condition characterized by eosinophilic infiltration in various layers of the gastrointestinal tract. EA specifically involves the abnormal accumulation of eosinophils in the peritoneal cavity, which can lead to significant abdominal distension and discomfort. EGE is an inflammatory disorder that can affect the mucosal, muscular, or serosal layers of the gastrointestinal tract, primarily resulting from a combination of genetic predisposition, environmental triggers, and immune responses. This case report discusses a 39-year-old male who presented with persistent abdominal distension, significant weight loss, vomiting, and chronic diarrhea. Clinical evaluation revealed marked eosinophilia and EA, prompting a series of diagnostic tests to differentiate it from other potential causes such as parasitic infections and malignancies. Imaging studies indicated moderate ascites and intestinal wall thickening. The patient was diagnosed with eosinophilic enteritis, and treatment with corticosteroids led to substantial clinical improvement. This case highlights the diagnostic challenges and management strategies associated with both EA and EGE, emphasizing the importance of recognizing these rare manifestations of eosinophilic gastrointestinal disorders.
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Affiliation(s)
- Devipriya Surapaneni
- Internal Medicine, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, IND
| | - Bilal Azam
- Medical Gastroenterology, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, IND
| | - Sharath Chandra Dasi
- Internal Medicine, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, IND
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Amil-Dias J, Oliva S, Papadopoulou A, Thomson M, Gutiérrez-Junquera C, Kalach N, Orel R, Auth MKH, Nijenhuis-Hendriks D, Strisciuglio C, Bauraind O, Chong S, Ortega GD, Férnandez SF, Furman M, Garcia-Puig R, Gottrand F, Homan M, Huysentruyt K, Kostovski A, Otte S, Rea F, Roma E, Romano C, Tzivinikos C, Urbonas V, Velde SV, Zangen T, Zevit N. Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2024; 79:394-437. [PMID: 38923067 DOI: 10.1002/jpn3.12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus characterized by symptoms of esophageal dysfunction and histologically by predominantly eosinophilic infiltration of the squamous epithelium. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published a guideline in 2014; however, the rapid evolution of knowledge about pathophysiology, diagnostic criteria, and therapeutic options have made an update necessary. METHODS A consensus group of pediatric gastroenterologists from the ESPGHAN Working Group on Eosinophilic Gastrointestinal Diseases (ESPGHAN EGID WG) reviewed the recent literature and proposed statements and recommendations on 28 relevant questions about EoE. A comprehensive electronic literature search was performed in MEDLINE, EMBASE, and Cochrane databases from 2014 to 2022. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of evidence and formulate recommendations. RESULTS A total of 52 statements based on the available evidence and 44 consensus-based recommendations are available. A revision of the diagnostic protocol, options for initial drug treatment, and the new concept of simplified empiric elimination diets are now available. Biologics are becoming a part of the potential armamentarium for refractory EoE, and systemic steroids may be considered as the initial treatment for esophageal strictures before esophageal dilation. The importance and assessment of quality of life and a planned transition to adult medical care are new areas addressed in this guideline. CONCLUSION Research in recent years has led to a better understanding of childhood EoE. This guideline incorporates the new findings and provides a practical guide for clinicians treating children diagnosed with EoE.
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Affiliation(s)
- Jorge Amil-Dias
- Pediatric Gastroenterology, Hospital Lusíadas, Porto, Portugal
| | - Salvatore Oliva
- Maternal and Child Health Department, University Hospital - Umberto I, Sapienza - University of Rome, Rome, Italy
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, Children's hospital Agia Sofia, University of Athens, Athens, Greece
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, International Academy for Paediatric Endoscopy Training, Sheffield Children's Hospital, UK
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro Majadahonda, Universidad Autónoma de Madrid, Spain
| | - Nicolas Kalach
- Department of Pediatrics, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University, Lille, France
| | - Rok Orel
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialized Surgery of the University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Sonny Chong
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - Gloria Dominguez Ortega
- Pediatric Gastroenterology and Nutrition Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sonia Férnandez Férnandez
- Pediatric Gastroenterology Unit, Department of Pediatrics, Severo Ochoa University Hospital, Madrid, Spain
| | - Mark Furman
- Royal Free London NHS Foundation Trust, London, UK
| | - Roger Garcia-Puig
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Pediatrics Department, Hospital Universitari MútuaTerrassa, Universitat de Barcelona, Barcelona, Spain
| | | | - Matjaz Homan
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Koen Huysentruyt
- Kindergastro-enterologie, hepatologie en nutritie, Brussels Centre for Intestinal Rehabilitation in Children (BCIRC), Belgium
| | - Aco Kostovski
- University Children's Hospital Skopje, Faculty of Medicine, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Sebastian Otte
- Childrens' Hospital, Helios Mariahilf Hospital, Hamburg, Germany
| | - Francesca Rea
- Endoscopy and Surgey Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Eleftheria Roma
- First Department of Pediatrics, University of Athens and Pediatric Gastroenterology Unit Mitera Children's Hospital, Athens, Greece
| | - Claudio Romano
- Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Christos Tzivinikos
- Paediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Dubai, UAE
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Vaidotas Urbonas
- Vilnius University Medical Faculty Clinic of Children's Diseases, Vilnius, Lithuania
| | | | - Tsili Zangen
- Pediatric Gastroenterology Unit, Wolfson Medical Center, Holon, Israel
| | - Noam Zevit
- Eosinophilic Gastrointestinal Disease Clinic, Institute of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Israel
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de Bortoli N, Visaggi P, Penagini R, Annibale B, Baiano Svizzero F, Barbara G, Bartolo O, Battaglia E, Di Sabatino A, De Angelis P, Docimo L, Frazzoni M, Furnari M, Iori A, Iovino P, Lenti MV, Marabotto E, Marasco G, Mauro A, Oliva S, Pellegatta G, Pesce M, Privitera AC, Puxeddu I, Racca F, Ribolsi M, Ridolo E, Russo S, Sarnelli G, Tolone S, Zentilin P, Zingone F, Barberio B, Ghisa M, Savarino EV. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis-Current Treatment and Monitoring. Dig Liver Dis 2024; 56:1173-1184. [PMID: 38521670 DOI: 10.1016/j.dld.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/11/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
The present document constitutes Part 2 of the EoETALY Consensus Statements guideline on the diagnosis and management of eosinophilic esophagitis (EoE) developed by experts in the field of EoE across Italy (i.e., EoETALY Consensus Group). Part 1 was published as a different document, and included three chapters discussing 1) definition, epidemiology, and pathogenesis; 2) clinical presentation and natural history and 3) diagnosis of EoE. The present work provides guidelines on the management of EoE in two final chapters: 4) treatment and 5) monitoring and follow-up, and also includes considerations on knowledge gaps and a proposed research agenda for the coming years. The guideline was developed through a Delphi process, with grading of the strength and quality of the evidence of the recommendations performed according to accepted GRADE criteria.This document has received the endorsement of three Italian national societies including the Italian Society of Gastroenterology (SIGE), the Italian Society of Neurogastroenterology and Motility (SINGEM), and the Italian Society of Allergology, Asthma, and Clinical Immunology (SIAAIC). The guidelines also involved the contribution of members of ESEO Italia, the Italian Association of Families Against EoE.
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Affiliation(s)
- Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, 00189, Rome, Italy
| | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | | | - Edda Battaglia
- Gastroenterology Unit ASLTO4, Chivasso - Ciriè - Ivrea, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, 27100, Pavia, Italy; First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, 27100, Pavia, Italy
| | - Paola De Angelis
- Digestive Endoscopy Unit - Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ludovico Docimo
- Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Manuele Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa,Genoa,Italy, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Iori
- Gastroenterology and Digestive Endoscopy Unit, 'Santa Chiara' Hospital, Trento, Italy
| | - Paola Iovino
- Gastrointestinal Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84084, Baronissi, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, 27100, Pavia, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa,Genoa,Italy, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Salvatore Oliva
- Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Italy
| | - Gaia Pellegatta
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy; Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Marcella Pesce
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | | | - Ilaria Puxeddu
- Immunoallergology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy Clinic, IRCCS Humanitas Research Hospital, Rozzano - Milan, Italy
| | - Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | - Erminia Ridolo
- Allergy Unit, Department of Internal Medicine, University Hospital of Parma, Parma, Italy
| | - Salvatore Russo
- Gastroenterology and Digestive Endoscopy Unit, Azienda Ospedaliera Universitaria of Modena, Modena, Italy
| | - Giovanni Sarnelli
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Fabiana Zingone
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
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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: 37399187 DOI: 10.1097/mpg.0000000000003877] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [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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Massironi S, Mulinacci G, Gallo C, Elvevi A, Danese S, Invernizzi P, Vespa E. Mechanistic Insights into Eosinophilic Esophagitis: Therapies Targeting Pathophysiological Mechanisms. Cells 2023; 12:2473. [PMID: 37887317 PMCID: PMC10605530 DOI: 10.3390/cells12202473] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease characterized by eosinophilic infiltration of the esophagus. It arises from a complex interplay of genetic predisposition (susceptibility loci), environmental triggers (allergens and dietary antigens), and a dysregulated immune response, mainly mediated by type 2 T helper cell (Th2)-released cytokines, such as interleukin (IL)-4, IL-5, and IL-13. These cytokines control eosinophil recruitment and activation as well as tissue remodeling, contributing to the characteristic features of EoE. The pathogenesis of EoE includes epithelial barrier dysfunction, mast cell activation, eosinophil degranulation, and fibrosis. Epithelial barrier dysfunction allows allergen penetration and promotes immune cell infiltration, thereby perpetuating the inflammatory response. Mast cells release proinflammatory mediators and promote eosinophil recruitment and the release of cytotoxic proteins and cytokines, causing tissue damage and remodeling. Prolonged inflammation can lead to fibrosis, resulting in long-term complications such as strictures and dysmotility. Current treatment options for EoE are limited and mainly focus on dietary changes, proton-pump inhibitors, and topical corticosteroids. Novel therapies targeting key inflammatory pathways, such as monoclonal antibodies against IL-4, IL-5, and IL-13, are emerging in clinical trials. A deeper understanding of the complex pathogenetic mechanisms behind EoE will contribute to the development of more effective and personalized therapeutic strategies.
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Affiliation(s)
- Sara Massironi
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Giacomo Mulinacci
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Camilla Gallo
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Alessandra Elvevi
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (G.M.); (C.G.); (A.E.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20125 Milan, Italy
| | - Edoardo Vespa
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy
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8
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Nguyen PV, Quach DT, Bui MH, Dang TP, Talley NJ. A Clinicopathologic Continuum of Eosinophilic Gastrointestinal Diseases in an Adult With Tuberculosis and Latent Hepatitis B Virus Infection. ACG Case Rep J 2023; 10:e01176. [PMID: 37829167 PMCID: PMC10567028 DOI: 10.14309/crj.0000000000001176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/13/2023] [Indexed: 10/14/2023] Open
Abstract
Eosinophilic gastroenteritis (EGE) is considered distinct from eosinophilic colitis (EC). A 59-year-old man presented with a colonic tumor, who had resolution of pain and diarrhea after surgery, then 7 months later developed proton-pump inhibitor-responsive dysphagia with esophagitis, and 9 months later presented again with pain and diarrhea where EGE with concurrent eosinophilic esophagitis was diagnosed. Review of the resected tumor specimen identified EC with an adenoma. Workup revealed tuberculosis and latent hepatitis B virus requiring treatment before commencing immunosuppressive therapy plus a 6-food elimination diet that led to complete resolution within 3 weeks. EC may precede EGE and eosinophilic esophagitis.
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Affiliation(s)
- Phong V. Nguyen
- Department of Gastroenterology, Nhan Dan Gia Dinh Hospital, Ho Chi Minh, Vietnam
| | - Duc T. Quach
- Department of Gastroenterology, Nhan Dan Gia Dinh Hospital, Ho Chi Minh, Vietnam
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
| | - Minh H.Q. Bui
- Laboratory Department, Vinmec Central Park International Hospital, Ho Chi Minh, Vietnam
- Department of Pathology, Nhan Dan Gia Dinh Hospital, Ho Chi Minh, Vietnam
| | - Thinh P. Dang
- Department of Endoscopy, Nhan Dan Gia Dinh Hospital, Ho Chi Minh, Vietnam
| | - Nicholas J. Talley
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health and NHMRC Centre of Research Excellence Digestive Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
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9
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Kinoshita Y, Sanuki T. Review of Non-Eosinophilic Esophagitis-Eosinophilic Gastrointestinal Disease (Non-EoE-EGID) and a Case Series of Twenty-Eight Affected Patients. Biomolecules 2023; 13:1417. [PMID: 37759817 PMCID: PMC10526434 DOI: 10.3390/biom13091417] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/07/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Eosinophilic gastrointestinal disease (EGID) is divided into eosinophilic esophagitis (EoE) and non-eosinophilic esophagitis eosinophilic gastrointestinal disease (non-EoE-EGID) based on the involved gastrointestinal segments. Reports regarding non-EoE-EGID are limited, in part because of its rarity. The present study was performed to review non-EoE-EGID, including its pathogenesis, diagnosis, treatment, and prognosis. Additionally, details regarding 28 cases of non-EoE-EGID recently diagnosed at our Japanese tertial medical center are presented and compared with 20 EoE cases diagnosed during the same period at the same medical center. Comparisons of the two groups clarified differences regarding age- and gender-dependent prevalence between the two conditions, and also showed that systemic involvement and disease severity were greater in the non-EoE-EGID patients. Notably, diagnosis of non-EoE-EGID is difficult because of its lack of specific or characteristic symptoms and endoscopic findings. The clinical characteristics of EoE and non-EoE-EGID differ in many ways, while they also share several genetic, clinical, laboratory, and histopathological features.
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Affiliation(s)
- Yoshikazu Kinoshita
- Department of Medicine and Gastroenterology, Hyogo Prefectural Harima-Himeji General Medical Center, Himeji 670-8560, Japan
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10
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Uchida AM, Burk CM, Rothenberg ME, Furuta GT, Spergel JM. Recent Advances in the Treatment of Eosinophilic Esophagitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2654-2663. [PMID: 37391018 PMCID: PMC10530275 DOI: 10.1016/j.jaip.2023.06.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/26/2023] [Accepted: 06/13/2023] [Indexed: 07/02/2023]
Abstract
Eosinophilic esophagitis is an increasingly common inflammatory allergic disease of the esophagus characterized by esophageal eosinophilia and symptoms of esophageal dysfunction. The therapeutic landscape has rapidly evolved for this emerging type 2 inflammatory disorder. We review traditional therapies including updates and expert opinions in addition to promising therapies on the horizon and the history of therapies that failed to meet end points and highlight knowledge gaps for future investigations.
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Affiliation(s)
- Amiko M Uchida
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah School of Medicine, Salt Lake City, Utah
| | - Caitlin M Burk
- Food Allergy Center and Division of Pediatric Allergy and Immunology, and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, Mass.
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, Colo
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
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11
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Abstract
Eosinophilic gastrointestinal disorders are a group of rare diseases characterized by the infiltration of eosinophils in the gastrointestinal wall in a greater amount than in homeostatic conditions. 'Non-esophageal eosinophilic gastrointestinal disorders' is the umbrella term for all eosinophilic gastrointestinal disorders outside of the well known eosinophilic esophagitis. This includes eosinophilic gastritis, eosinophilic enteritis and eosinophilic colitis. The clinical presentation is atypical and not very different for the three disorders. The depth of infiltration has a bigger influence on the presenting symptoms than the disease location. Although the frequency of diagnosis and research in this subject is increasing over time, non-esophageal eosinophilic disorders are rare and high quality evidence is limited to date. In this narrative review, we provide an overview of the latest insights in the pathophysiology, diagnostic approach and available treatment options. Transcriptome studies have found the pathogenesis to be T helper type 2 driven. Various laboratory findings can be used to trigger raised suspicion and investigation with endoscopy. As the endoscopic appearance of the mucosa is normal in most cases, multiple biopsies in each segment are needed to quantify the amount of eosinophils in the tissue. Eosinophilic cut-offs for diagnosis are a controversial topic and a consensus is still lacking. A recently developed tissue based diagnostic platform which measures differentially expressed genes might be available in the future to classify patients with intermediate eosinophilic tissue levels under the cut-off. For the treatment, corticosteroids are still the cornerstone of treatment but promising research suggests a role of biologicals, such as Lirentelimab (anti-siglec 8) in particular.
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Affiliation(s)
- J Janssens
- Faculty of Medicine, KULeuven, Leuven, Belgium
| | - T Vanuytsel
- Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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12
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Autorinnen/Autoren, Collaborators:. S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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13
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Li K, Ruan G, Liu S, Xu T, Guan K, Li J, Li J. Eosinophilic gastroenteritis: Pathogenesis, diagnosis, and treatment. Chin Med J (Engl) 2023; 136:899-909. [PMID: 37022943 PMCID: PMC10278761 DOI: 10.1097/cm9.0000000000002511] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Indexed: 04/07/2023] Open
Abstract
ABSTRACT Eosinophilic gastroenteritis (EGE) is a gastrointestinal disorder of unclear etiology that is characterized by eosinophilic infiltration of the stomach and small intestine, and consists of mucosal, muscular, and serosal subtypes. Eosinophilic infiltration of the gastrointestinal tract is a fundamental histopathological characteristic of EGE and is driven by several T-helper type 2 (Th2)-dependent cytokines and induced by food allergy. Due to the lack of a diagnostic gold standard, EGE has a high rate of delayed diagnosis or misdiagnosis. However, several new diagnostic strategies have been developed, such as novel genetic biomarkers and imaging tests. Although dietary therapy and corticosteroids remain the common choices for EGE treatment, recent decades have seen the emergence of novel treatment alternatives, such as biologics that target particular molecules involved in the pathogenic process. Preliminary investigations and clinical trials have demonstrated the efficacy of biologics and provided additional insights for the era of refractory or corticosteroid-dependent EGE biologics.
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Affiliation(s)
- Kaiwen Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
- Key Laboratory of Gut Microbiota Translational Medicine Research, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
| | - Gechong Ruan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
| | - Shuang Liu
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
| | - Tianming Xu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
- Key Laboratory of Gut Microbiota Translational Medicine Research, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
| | - Kai Guan
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
| | - Ji Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
- Key Laboratory of Gut Microbiota Translational Medicine Research, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
| | - Jingnan Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
- Key Laboratory of Gut Microbiota Translational Medicine Research, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100005, China
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14
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Mechanisms and clinical management of eosinophilic oesophagitis: an overview. Nat Rev Gastroenterol Hepatol 2023; 20:101-119. [PMID: 36253463 DOI: 10.1038/s41575-022-00691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/03/2023]
Abstract
Since the first description of eosinophilic oesophagitis (EoE) less than three decades ago, we have observed a striking increase in the number of patients diagnosed with EoE and the understanding of its clinical and immunopathogenic background. Nonetheless, a plethora of open questions await elucidation. In this Review, we discuss the current state of knowledge regarding the underlying mechanisms, particularly environmental factors and their interaction with genetic susceptibility. Subsequently, we discuss how to translate these factors into the diagnostic and therapeutic management of this chronic, immune-mediated disorder. Finally, we dissect the still long list of unmet needs, such as reasons for and handling refractory EoE and atypical clinical presentations. These open questions can guide us through future research steps and potentially foster reconsideration of the diagnostic guidelines of EoE.
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15
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Donnelly SC. Extensive Mucosal Disease: Coeliac Disease and Eosinophilic Enteritis. INTESTINAL FAILURE 2023:161-175. [DOI: 10.1007/978-3-031-22265-8_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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16
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Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R, Morris D, Epstein J, Novelli MR, Hunter H, Cordell A, Hall S, Hayat JO, Kapur K, Moore AR, Read C, Sami SS, Turner PJ, Trudgill NJ. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022; 71:1459-1487. [PMID: 35606089 PMCID: PMC9279848 DOI: 10.1136/gutjnl-2022-327326] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE. METHODS The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance. RESULTS Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research. CONCLUSIONS These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.
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Affiliation(s)
- Anjan Dhar
- Gastroenterology, Darlington Memorial Hospital, Darlington, UK .,Teesside University, Middlesbrough, UK
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea University, Swansea, UK,Department of Gastroenterology, University Hospital Llandough, Llandough, UK
| | | | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK,University of Liverpool, Liverpool, UK
| | - Jason M Dunn
- Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK,Comprehensive Cancer Centre, King's College London, London, UK
| | - Rami Sweis
- Research Department of Tissue and Energy, Division of Surgery & Interventional Science, University College London, London, UK
| | - Danielle Morris
- Department of Gastroenterology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Hannah Hunter
- Department of Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Amanda Cordell
- Trustee & Chair, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sharon Hall
- Department of Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Jamal O Hayat
- Gastroenterology, St George's Healthcare NHS Trust, London, UK
| | - Kapil Kapur
- Gastroenterology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Andrew Robert Moore
- Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Carol Read
- Medical advisor/Patient advocate, EOS Network, Eosinophilic Disease Charity, London, UK
| | - Sarmed S Sami
- Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul J Turner
- National Heart and Lung Institute Section of Allergy and Clinical Immunology, London, UK,Paediatric Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell General Hospital, West Bromwich, UK
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17
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Yamaga Y, Mizuno M, Okae S, Nio-Tamaoki M, Masuo K, Mashimo-Matsuo Y, Tanaka J, Nabeshima M. Eosinophilic enteritis accompanied by cytomegalovirus disease: a case report. BMC Gastroenterol 2022; 22:209. [PMID: 35484485 PMCID: PMC9052655 DOI: 10.1186/s12876-022-02274-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
Background Eosinophilic enteritis is a chronic inflammatory disorder of the intestinal tract that is characterized by eosinophil infiltration. Cytomegalovirus (CMV), a common virus, has a broad infectivity range. CMV is retained in the host body after infection. Impairment of host immune defences may reactivate the latent CMV, leading to symptoms of overt disease. Case presentation A Japanese female in her 70 s was admitted to a hospital due to diarrhoea and then transferred to our hospital. Laboratory data showed hypoalbuminemia. Computed tomography (CT) revealed oedema of the small intestine. Lower gastrointestinal endoscopy revealed oedema of the submucosa, without any remarkable changes in the mucosa of the terminal ileum. Histological examination of the terminal ileum revealed infiltration of > 20 eosinophils per high-power field (HPF). These findings aided in diagnosing eosinophilic enteritis. We administered methylprednisolone (500 mg/day) for three days, followed by tapering prednisolone. However, the patient’s general condition and hypoalbuminemia failed to improve. Immunoglobulin (Ig) G- CMV and IgM-CMV tests were positive. CMV antigenemia was extremely high. Therefore, we administered ganciclovir intravenously, which improved the patient’s condition. Furthermore, azathioprine was administered to taper and discontinue prednisolone without relapse of eosinophilic enteritis. This treatment helped stabilize the patient’s condition for approximately four years. Conclusion We present a case of eosinophilic enteritis accompanied by CMV disease during prednisolone treatment. The patient’s condition improved after administration of ganciclovir. Azathioprine aided in discontinuing prednisolone and stabilizing the patient’s condition for approximately four years.
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Affiliation(s)
- Yuichi Yamaga
- Department of Gastroenterology, Mitsubishi Kyoto Hospital, Kyoto, Japan.
| | - Masahiro Mizuno
- Department of Gastroenterology, Mitsubishi Kyoto Hospital, Kyoto, Japan.,Department of Internal Medicine, Yurin Hospital, Tokyo, Japan
| | - Shunji Okae
- Department of Gastroenterology, Mitsubishi Kyoto Hospital, Kyoto, Japan.,Department of Internal Medicine, Kawabata Hospital, Kyoto, Japan
| | | | - Kenji Masuo
- Department of Gastroenterology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | | | - Junya Tanaka
- Department of Gastroenterology, Mitsubishi Kyoto Hospital, Kyoto, Japan
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18
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Kim SJ, Choi CW, Hwang CS. [Diagnosis and Treatment of Eosinophilic Esophagitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:99-108. [PMID: 35342167 DOI: 10.4166/kjg.2021.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/07/2021] [Accepted: 09/15/2021] [Indexed: 11/03/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated esophageal disease characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. The diagnostic criteria for EoE have changed with our growing knowledge over the past two decades. Esophageal eosinophilia, which responds histologically to a proton pump inhibitor (PPI) is not a distinct disease but a subset of EoE. An endoscopic scoring system that relies on the assessment of exudates, rings, edema, furrows, and strictures is a useful tool for assessing endoscopic severity. PPIs are regarded as safe and effective first-line treatments for EoE. Oral topical corticosteroids or dietary therapy are also options for first-line treatment. Endoscopic dilation is effective for relieving the dysphagia symptoms of a patient with an esophageal stricture.
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Affiliation(s)
- Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheong Su Hwang
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Pathology, Pusan National University School of Medicine, Busan, Korea
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19
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Marabotto E, Giannini EG, Zentilin P, Ziola S, Djahandideh Sheijani A, Savarino E, Savarino V. Pharmacotherapies in eosinophilic esophagitis: state of the art. Minerva Gastroenterol (Torino) 2022; 68:69-76. [PMID: 35302339 DOI: 10.23736/s2724-5985.21.02781-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Eosinophilic esophagitis is a chronic immune-mediated esophageal disease with a Th2 inflammatory response to inhalant and food allergens that cause an eosinophilic infiltration of esophageal mucosa. The diagnosis requires an upper endoscopy with esophageal bioptic samples, in particular the number of eosinophils must be >15 eos/high power field. The main symptoms of EoE in adults are dysphagia and food impaction, and its incidence is growing. Nowadays, the etiology of EoE is not well understood and no standard therapy is available. Therefore, the aim of this review was to analyze the major studies present in literature regarding the various therapeutic approaches to this disease.
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Affiliation(s)
- Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy -
| | - Edoardo G Giannini
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Sebastiano Ziola
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | | | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
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20
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Racca F, Pellegatta G, Cataldo G, Vespa E, Carlani E, Pelaia C, Paoletti G, Messina MR, Nappi E, Canonica GW, Repici A, Heffler E. Type 2 Inflammation in Eosinophilic Esophagitis: From Pathophysiology to Therapeutic Targets. Front Physiol 2022; 12:815842. [PMID: 35095572 PMCID: PMC8790151 DOI: 10.3389/fphys.2021.815842] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/09/2021] [Indexed: 12/11/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation, whose incidence is rising. It significantly affects patients’ quality of life and, if left untreated, results in fibrotic complications. Although broad consensus has been achieved on first-line therapy, a subset of patients remains non-responder to standard therapy. The pathogenesis of EoE is multifactorial and results from the complex, still mostly undefined, interaction between genetics and intrinsic factors, environment, and antigenic stimuli. A deep understanding of the pathophysiology of this disease is pivotal for the development of new therapies. This review provides a comprehensive description of the pathophysiology of EoE, starting from major pathogenic mechanisms (genetics, type 2 inflammation, epithelial barrier dysfunction, gastroesophageal reflux, allergens, infections and microbiota) and subsequently focusing on the single protagonists of type 2 inflammation (involved cells, cytokines, soluble effectors, surface proteins and transcription factors) that could represent present and future therapeutic targets, while summarizing previous therapeutic approaches in literature.
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Affiliation(s)
- Francesca Racca
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- *Correspondence: Francesca Racca,
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Giuseppe Cataldo
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Edoardo Vespa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Digestive Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Elisa Carlani
- Digestive Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Corrado Pelaia
- Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Maria Rita Messina
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Emanuele Nappi
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Digestive Endoscopy Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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21
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Kobayashi S, Tsunoda T, Umetsu S, Inui A, Fujisawa T, Sogo T. Clinical features of pediatric eosinophilic gastroenteritis. Pediatr Int 2022; 64:e15322. [PMID: 36331233 DOI: 10.1111/ped.15322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND No study has analyzed more than100 cases of eosinophilic gastroenteritis (EGE) in children in a single center. We aimed to describe the clinical features of pediatric EGE. METHODS This retrospective study was conducted at a single center. Between April 2007 and December 2017, 860 children between the ages of 1 year and 15 years underwent endoscopy for gastrointestinal symptoms of unknown cause. Among them, 109 (12.7%) were diagnosed with EGE according to the diagnostic criteria for EGE developed by the research group of the Ministry of Health, Labour and Welfare of Japan for eosinophilic gastrointestinal disorder in 2015. We investigated their symptoms, comorbidities, endoscopic findings, pathological findings, treatments, and outcomes. RESULTS Seventy-one boys (65.1%) and 38 girls (34.9%) were diagnosed with EGE. The median age at diagnosis was 11 years (range, 1-15 years). The chief complaints were abdominal pain in 83 (76.1%) and diarrhea in 26 (23.9%). Upper and lower gastrointestinal endoscopies showed normal findings in 32 patients (29.4%). The most common treatment was a combination of elimination of foods suspected of causing EGE and anti-allergic agents in 50 cases (45.9%). The outcomes were symptom disappearance in 43 patients (39.4%) and symptom improvement in 53 patients (48.6%). CONCLUSIONS For gastrointestinal symptoms of unknown cause in children, EGE should be considered as a differential diagnosis. Although the symptoms and endoscopic findings are nonspecific, cracked mucosa may be a specific endoscopic finding for pediatric EGE. An elimination diet and/or anti-allergic drugs were effective in most patients with pediatric EGE.
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Affiliation(s)
- Soya Kobayashi
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama, Kanagawa, Japan
| | - Tomoyuki Tsunoda
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama, Kanagawa, Japan
| | - Shuichiro Umetsu
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama, Kanagawa, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama, Kanagawa, Japan
| | - Tomoo Fujisawa
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama, Kanagawa, Japan
| | - Tsuyoshi Sogo
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama, Kanagawa, Japan
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22
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Barni S, Arasi S, Mastrorilli C, Pecoraro L, Giovannini M, Mori F, Liotti L, Saretta F, Castagnoli R, Caminiti L, Cianferoni A, Novembre E. Pediatric eosinophilic esophagitis: a review for the clinician. Ital J Pediatr 2021; 47:230. [PMID: 34809686 PMCID: PMC8609874 DOI: 10.1186/s13052-021-01178-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 10/27/2021] [Indexed: 12/16/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic clinical-pathologic disease characterized by eosinophilic infiltration of the esophageal epithelium with esophageal dysfunction symptoms.EoE can occur at any age and has different clinical manifestations depending on the age onset.To date, esophago-gastroduodenal endoscopy (EGD) with biopsy is the gold-standard for EoE diagnosis.According to the recent consensus guidelines, proton pump inhibitors, corticosteroids and elimination diets could be a first-line therapy option. The aim of the treatment is clinical and histological remission for preventing long-lasting untreatable fibrosis.A multidisciplinary approach (allergist, gastroenterology, dietitian, and pathologist) is recommended for managing patients affected by EoE, given the complexity of its treatment.This review will provide a practical guide to assist pediatricians treating children with EoE.Moreover, it highlights the unmet needs in diagnosis and treatment that require urgent attention from the scientific community in the aim of improving the management of patients with EoE.
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Affiliation(s)
- Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Stefania Arasi
- Predictive and Preventive Medicine Research Unit, Multifactorial and Systemic Diseases Research Area, Pediatric Allergy Unit, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Carla Mastrorilli
- Pediatric Unit and Emergency, University Hospital Consortium Corporation Polyclinic of Bari, Pediatric Hospital Giovanni XXIII, Bari, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Luca Pecoraro
- Department of Medicine, University of Verona, Policlinico GB Rossi, Verona, Italy
- Pediatric Unit, ASST Mantua, Mantua, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
| | - Lucia Liotti
- Pediatric Unit, Senigallia Hospital, Senigallia, Italy
| | - Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Riccardo Castagnoli
- Department of Pediatrics, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Development Age “Gaetano Barresi”, Allergy Unit, Department of Pediatrics, AOU Policlinico Gaetano Martino, Messina, Italy
| | - Antonella Cianferoni
- Pediatrics Department, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Allergy and Immunology Division, The Children’s Hospital of Philadelphia, Philadelphia, USA
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children’s University Hospital, Florence, Italy
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23
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Chen PH, Anderson L, Zhang K, Weiss GA. Eosinophilic Gastritis/Gastroenteritis. Curr Gastroenterol Rep 2021; 23:13. [PMID: 34331146 DOI: 10.1007/s11894-021-00809-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Eosinophilic gastritis/gastroenteritis (EG/EGE) are rare eosinophilic infiltrative disorders in children and adults that fall under the umbrella term eosinophilic gastrointestinal disorders (EGIDs). EGIDs also include eosinophilic esophagitis (EoE) and eosinophilic colitis. In this article, we present the current literature regarding the clinical presentation, diagnostic criteria, and management of EG/EGE. RECENT FINDINGS The underlying complex pathophysiology remains unknown, yet hypersensitivity response is a central component. Unlike EoE, standardized diagnostic criteria are lacking but, promising research employing tissue-based and blood-based methods of diagnosis have been reported. Non-EoE EGIDs are more challenging to treat than EoE. More than a third of patients may achieve spontaneous remission. Still, most will require dietary elimination and/or pharmaceutical interventions, mainly corticosteroids, but also biologics (monoclonal antibodies against IL-4, IL-5, TNFα, integrin α4β7, and IgE), mast-cell stabilizers, leukotriene (LT)-receptor antagonists, and antihistamines. Promising research suggests the role of AK002, an anti-siglec antibody, in clinical and histological improvement. Given the rarity and underdiagnosis of EG/EGE, different natural progression compared to EoE, heterogeneous clinical manifestations, and probable normal endoscopic appearance, it is vital to maintain a high suspicion index in atopic patients, obtain at least 5-6 random biopsies from each site for gastro/duodenal eosinophilic infiltrate with the subsequent exclusion of inflammatory, allergic and infectious differential diagnoses to increase the yield of an accurate diagnosis. Corticosteroids remain the mainstay of treatment, often requiring long-term use. Steroid-sparing agents remain experimental. Goals of therapy move beyond clinical remission but lack evidence to support histological remission.
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Affiliation(s)
- Phillip H Chen
- David Geffen School of Medicine at UCLA, 100 UCLA Medical Plaza, suite 345, Los Angeles, CA, 90095, USA.,Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lorraine Anderson
- Department of Allergy-Immunology, University of California Los Angeles, Los Angeles, CA, USA
| | - Kuixing Zhang
- Department of Pathology, University of California Los Angeles, Los Angeles, CA, USA
| | - Guy A Weiss
- David Geffen School of Medicine at UCLA, 100 UCLA Medical Plaza, suite 345, Los Angeles, CA, 90095, USA. .,Celiac Disease Program, Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, CA, USA.
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24
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Kumar A, Haider A, Siddiqa A. Organ-Specific Hypereosinophilic Syndrome Presenting as Eosinophilic Gastroenteritis. Cureus 2021; 13:e16021. [PMID: 34258128 PMCID: PMC8257460 DOI: 10.7759/cureus.16021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/05/2022] Open
Abstract
Gastrointestinal (GI) diseases have a substantial impact on the population health and healthcare resources of the United States. They constitute billions of dollars in expenditure and millions of office and hospital visits. With advancing diagnostic and treatment modalities, rare diseases are increasingly recognized and managed. However, after close to 80 years since the first description, eosinophilic GI disorders (EGID) are still uncommon, and only around 300 cases have been reported to date. Hypereosinophilic syndrome (HES) is well studied, but there are still no guidelines to direct management. We report the case of a 56-year-old female who presented with gastroenteritis and a persistent eosinophil count above 7 x 109/L. Imaging was suggestive of bowel wall thickening, and endoscopy revealed normal-appearing mucosa. However, histologic examination revealed eosinophilic infiltration of the GI tract. She was diagnosed with HES and treated with oral prednisone with remarkable improvement of her symptoms.
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Affiliation(s)
- Aneesh Kumar
- Internal Medicine, BronxCare Hospital Center, Bronx, USA
| | - Asim Haider
- Internal Medicine, BronxCare Health System, Bronx, USA
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25
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Biedermann L, Straumann A, Greuter T, Schreiner P. Eosinophilic esophagitis-established facts and new horizons. Semin Immunopathol 2021; 43:319-335. [PMID: 34097125 PMCID: PMC8241662 DOI: 10.1007/s00281-021-00855-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/23/2021] [Indexed: 12/13/2022]
Abstract
Despite dramatic advances in our understanding of the pathogenesis and course of disease in the relatively short timeframe since the discovery and first description of eosinophilic esophagitis (EoE) less than three decades ago, many open questions remain to be elucidated. For instance, we will need to better characterize atypical clinical presentations of EoE and other forms of esophageal inflammatory conditions with often similar clinical presentations, nut fulfilling current diagnostic criteria for EoE and to determine their significance and interrelationship with genuine EoE. In addition, the interrelationship of EoE with other immune-mediated diseases remains to be clarified. Hopefully, a closer look at the role of environmental factors and their interaction with genetic susceptibility often in context of atopic predisposition may enable identifying the candidate substances/agents/allergens and potentially earlier (childhood) events to trigger the condition. It appears plausible to assume that in the end—comparable to current concepts in other immune-mediated chronic diseases, such as for instance inflammatory bowel disease or asthma bronchiale—we will not be rewarded with the identification of a “one-and-only” underlying pathogenetic trigger factor, with causal responsibility for the disease in each and every EoE patient. Rather, the relative contribution and importance of intrinsic susceptibility, i.e., patient-driven factors (genetics, aberrant immune response) and external trigger factors, such as food (or aero-) allergens as well as early childhood events (e.g., infection and exposure to antibiotics and other drugs) may substantially differ among given individuals with EoE. Accordingly, selection and treatment duration of medical therapy, success rates and extent of required restriction in dietary treatment, and the need for mechanical treatment to address strictures and stenosis require an individualized approach, tailored to each patient. With the advances of emerging treatment options, the importance of such an individualized and patient-centered assessment will increase even further.
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Affiliation(s)
- Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.,Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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26
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Kuźmiński A, Przybyszewski M, Przybyszewska J, Bartuzi Z. Eosinophilic esophagitis. What diet? How to treat it? The point of view of a gastroenterologist working in a department of allergology. PRZEGLAD GASTROENTEROLOGICZNY 2021; 16:318-323. [PMID: 34976239 PMCID: PMC8690950 DOI: 10.5114/pg.2021.105163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/21/2021] [Indexed: 11/29/2022]
Abstract
Eosinophilic esophagitis (EoE) belongs to a broad group of allergic gastrointestinal diseases. More narrowly, it is classified as an eosinophilic gastrointestinal disease and is its most common representative. Until recently, this disease was extremely rare, but the last 3 decades have seen a rapid increase in its prevalence to such an extent that in some recent studies it has been named the most common esophageal disease after reflux disease. EoE is an interdisciplinary disorder on the borderline between gastrointestinal and allergologic diseases, requiring cooperation of these two branches of medicine in diagnostics and treatment. Despite the development of medical science it remains a poorly known disease, difficult to diagnose and even more difficult to treat. Recent years have seen the emergence of new studies and guidelines, both American and European, that have radically changed our approach to the diagnosis and treatment of EoE.
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Affiliation(s)
- Andrzej Kuźmiński
- Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Michał Przybyszewski
- Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Justyna Przybyszewska
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Zbigniew Bartuzi
- Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
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27
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Roberts AJ, Day AS, Sinclair J, Dickson N, Porter J, Wellington G, Evans HM. Paediatric eosinophilic oesophagitis in New Zealand: A 3-year prospective study. J Paediatr Child Health 2021; 57:234-238. [PMID: 32918510 DOI: 10.1111/jpc.15183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 06/23/2020] [Accepted: 08/27/2020] [Indexed: 11/30/2022]
Abstract
AIM Eosinophilic oesophagitis (EoE) is a rare, chronic, relapsing immune/antigen-mediated disease characterised by symptoms of oesophageal dysfunction, with a paucity of data among New Zealand (NZ) children. This 3-year prospective study aimed to characterise EoE diagnosed nationally and to describe initial treatment strategies adopted. METHODS Information on new diagnoses of paediatric EoE was obtained via the New Zealand Paediatric Surveillance Unit, through monthly questionnaires. RESULTS From February 2014 to January 2017, 73 new cases (74% male) of EoE were reported, including 74% NZ European, 10% Asian, 7% Māori, 5% Middle-Eastern and 3% Pacific peoples. Median age of symptom onset was 4 years; dysphagia (48%) was the most common, followed by vomiting/regurgitation (40%), food impaction (19%) and epigastric pain (16%). A co-morbid history of other allergic conditions was present in 62% of patients, and 41% had a first degree relative with atopy. Seventy-nine percent of patients had abnormal endoscopic findings, most commonly linear furrows and white plaques; none had strictures. Median eosinophil count per high-powered field was 40 and 50 in the mid and distal oesophagus, respectively. Fifty-four percent of patients were initially managed with dietary manipulation alone (four required elemental feeds, five nasogastric tubes). Fifty-four percent of patients were treated with swallowed corticosteroids and 7% with prednisone. One patient was also treated with a leukotriene receptor antagonist. CONCLUSION This first prospective study on paediatric patients with EoE in NZ finds similar demographics and disease characteristics as in other populations despite our unique ethnic population. Long-term prospective observational data should significantly improve our knowledge of this rare condition.
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Affiliation(s)
- Amin J Roberts
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
| | - Andrew S Day
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
| | - Jan Sinclair
- Department of Paediatric Allergy and Clinical Immunology, Starship Child Health, Auckland, New Zealand
| | - Nigel Dickson
- New Zealand Paediatric Surveillance Unit, University of Otago, Dunedin, New Zealand
| | - Jody Porter
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
| | - Grace Wellington
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
| | - Helen M Evans
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
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28
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Abstract
Eosinophilic esophagitis (EoE) is a relatively recently identified but now frequently encountered antigen/immune-mediated disease which places significant burden on patients and the healthcare system. With its growing prevalence and recognition by healthcare providers in multiple disciplines, substantial progress has been made regarding the diagnostic criteria, clinical evaluation, tools for disease assessment, and immune pathways related to pathogenesis. Current treatment goals focus on the amelioration of inflammation and prevention of remodeling consequences using proton pump inhibitors, swallowed topical steroids, elimination diets, and esophageal dilation. Ongoing research holds promise for more efficacious and targeted therapies as well as a personalized approach to the care of patients with EoE.
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Affiliation(s)
- Ronak V Patel
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA; , ,
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA; , ,
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA; , ,
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29
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Piester T, Liu QY. Gastritis, Gastropathy, and Ulcer Disease. PEDIATRIC GASTROINTESTINAL AND LIVER DISEASE 2021:262-274.e7. [DOI: 10.1016/b978-0-323-67293-1.00026-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
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30
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Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome. Dig Dis Sci 2020; 65:3434-3447. [PMID: 33052498 PMCID: PMC7669680 DOI: 10.1007/s10620-020-06642-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/09/2022]
Abstract
Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of esophageal dysfunction, including dysphagia. While EoE is still considered a rare disease, in practice it seems that more and more cases are diagnosed every week, research in the field is exploding, and the pipeline for treatments contains multiple agents, some of which are quite far along the development pathway. After only scattered cases and small series were published in the late 1970s and 1980, Stephen Attwood, Thomas Smyrk, Tom DeMeester, and James Jones, published in Digestive Diseases and Sciences in 1993 a seminal report that described a clinicopathologic syndrome of esophageal eosinophilia with dysphagia. This review details the origins of this paper and compares and contrast what was observed then and what is known now about multiple aspects of EoE, including the clinical presentation, diagnosis, epidemiology, natural history, and treatments and outcomes. Moreover, it will highlight how the paper presaged a number of controversies in the field that have yet to be resolved, as well as foreshadowed the collaborative, multidisciplinary approach that has led to rapid advances.
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31
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Chen JW. Management of Eosinophilic Esophagitis: Dietary and Nondietary Approaches. Nutr Clin Pract 2020; 35:835-847. [PMID: 32822071 DOI: 10.1002/ncp.10571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an allergen-driven chronic inflammatory condition, characterized by symptoms related to esophageal dysfunction and confirmed histologically by esophageal mucosal eosinophilia. Since its first description in the 1990s, the incidence and prevalence of EoE have been on the rise. It is known to affect all ages of various ethnic backgrounds and both sexes; however, it is most seen in White males. Children with EoE often present with abdominal pain, nausea, vomiting, and failure to thrive, whereas adults with EoE typically present with dysphagia and food impaction. Diagnosis of EoE requires histologic confirmation of elevated esophageal eosinophils in a symptomatic patient, and only after secondary causes have been excluded. Because EoE is a chronic and progressively fibrostenotic disease, treatment goals include resolution of symptoms, induction and maintenance of disease remission, and prevention and possibly reversal of fibrostenotic complications, while minimizing treatment-related adverse effects and improving quality of life. Treatment strategies include the "3 D's"-drugs, diet, and dilation. Standard drug therapies include proton-pump inhibitors and topical corticosteroids. Dietary therapies include elemental diet, allergy testing-directed elimination diet, and empiric elimination diets. Endoscopic esophageal dilation for EoE strictures can alleviate esophageal symptoms but has no effect on mucosal inflammation. Recent progress in EoE research has made possible evidence-based clinical guidelines. Ongoing pharmacologic trials show promise for novel biologic agents in the treatment of refractory EoE.
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Affiliation(s)
- Joan W Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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32
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Chawla K, Alabbas B, Sheth D, Papademetriou M. As Easy as EoE: A Novel and Effective Multidisciplinary Approach to Care of Patients with Eosinophilic Esophagitis in the Age of Biologics. Dig Dis Sci 2020; 65:2196-2202. [PMID: 32519139 DOI: 10.1007/s10620-020-06366-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Karan Chawla
- Department of Internal Medicine, The George Washington University Hospital, Washington, DC, 20037, USA
| | - Bedoor Alabbas
- Division of Hepatology and Gastroenterology, The George Washington University Hospital, Washington, DC, 20037, USA
| | - Dipa Sheth
- Department of Allergy and Immunology, Washington DC Veterans Affairs Medical Center, Washington, DC, 20422, USA
- The George Washington University Hospital, Washington, DC, USA
| | - Marianna Papademetriou
- The George Washington University Hospital, Washington, DC, USA.
- Department of Gastroenterology, Washington DC Veterans Affairs Medical Center, 50 Irving St NW, Washington, DC, 20422, USA.
- Georgetown University Medical Center, Washington, DC, USA.
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33
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Rossetti D, Isoldi S, Oliva S. Eosinophilic Esophagitis: Update on Diagnosis and Treatment in Pediatric Patients. Paediatr Drugs 2020; 22:343-356. [PMID: 32519266 DOI: 10.1007/s40272-020-00398-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disorder characterized by symptomatic esophageal dysfunction and an eosinophil-predominant inflammation of the esophagus. EoE arises from interaction between genetic and environmental factors. In pediatric patients, clinical manifestations vary depending on age, from a gastroesophageal reflux disease (GERD)-like condition to severe dysphagic symptoms. Upper endoscopy is considered the gold standard for diagnosis and monitoring of EoE; however, significant efforts are underway to identify noninvasive diagnostic tools and biomarkers to avoid repetitive invasive procedures. Therapeutic first-line options currently available for EoE are elimination diets, proton pump inhibitors (PPIs), and steroids. The aim of treatment is to improve clinical symptoms while obtaining mucosal healing and avoiding long-term complications. Dietary treatment options comprise different empiric diets or an exclusively amino acid formula. Despite the efficacy of diets, compliance is often challenging. PPIs and topical steroids represent the main pharmacological options for EoE, and both can induce and maintain remission. Topical steroids have been reported as more effective, but data on long-term safety remain insufficient for both these and PPIs. Endoscopic dilations are currently reserved for severe untreated fibrostenotic disease unresponsive to medical therapies. Several biologic agents are available but not yet approved for EoE.
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Affiliation(s)
- Danilo Rossetti
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy
| | - Sara Isoldi
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza University of Rome, viale Regina Elena, 324-00161, Rome, Italy.
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34
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Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical review on the management of eosinophilic esophagitis: a report from the AGA institute and the joint task force on allergy-immunology practice parameters. Ann Allergy Asthma Immunol 2020; 124:424-440.e17. [PMID: 32336463 PMCID: PMC8171057 DOI: 10.1016/j.anai.2020.03.021] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
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Affiliation(s)
- Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona
| | - Rajiv N Sharaf
- Division of Gastroenterology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Division of Allergy Immunology Center for Immunity, Infection, and Inflammation, University of California, San Diego Rady Children's Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M Spergel
- Division of Allergy-Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland Veterans Affairs Medical Center and University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, Falck-Ytter YT, Dellon ES. Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters. Gastroenterology 2020; 158:1789-1810.e15. [PMID: 32359563 PMCID: PMC9473155 DOI: 10.1053/j.gastro.2020.02.039] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus. Many new studies have been reported recently that describe EoE management. An expert panel was convened by the American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters to provide a technical review to be used as the basis for an updated clinical guideline. This technical review was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Eighteen focused EoE management questions were considered, with 15 answered using the GRADE framework and 3 with a narrative summary. There is moderate certainty in the evidence that topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over a short-term treatment period of 4-12 weeks, but very low certainty about the effects of using topical glucocorticosteroids as maintenance therapy. Multiple dietary strategies may be effective in reducing esophageal eosinophil counts to <15 per high-power field over a short-term treatment period, with moderate certainty for elemental diets, low certainty for empiric 2-, 4-, and 6-food elimination diets, and very low certainty that allergy-based testing dietary eliminations have a higher failure rate compared to empiric diet elimination. There is very low certainty for the effect of proton pump inhibitors in patients with esophageal eosinophilia. Although esophageal dilation appears to be relatively safe, there is no evidence that it reduces esophageal eosinophil counts. There is very low certainty in the effects of multiple other medical treatments for EoE: anti-interleukin-5 therapy, anti-interleukin-13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy.
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Affiliation(s)
- Matthew A. Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo
Clinic, Scottsdale, Arizona
| | - Ravi N. Sharaf
- Division of Gastroenterology, Donald and Barbara
Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Glenn T. Furuta
- Digestive Health Institute, Children’s
Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of
Colorado School of Medicine, Aurora, Colorado
| | - Seema S. Aceves
- Division of Allergy Immunology Center for Immunity,
Infection, and Inflammation, University of California, San Diego Rady
Children’s Hospital, San Diego, California
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children’s
Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M. Spergel
- Division of Allergy-Immunology, Children’s
Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania,
Philadelphia, Pennsylvania
| | - Yngve T. Falck-Ytter
- Division of Gastroenterology and Hepatology, Cleveland
Veterans Affairs Medical Center and University Hospitals, Case Western Reserve
University School of Medicine, Cleveland, Ohio
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of
Gastroenterology and Hepatology, University of North Carolina School of Medicine,
Chapel Hill, North Carolina
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Abstract
Eosinophilic gastrointestinal disorders (EGID) are a group of disorders characterized by pathologic eosinophilic infiltration of the esophagus, stomach, small intestine, or colon leading to organ dysfunction and clinical symptoms (J Pediatr Gastroenterol Nutr; Spergel et al., 52: 300-306, 2011). These disorders include eosinophilic esophagitis (EoE), eosinophilic gastritis (EG), eosinophilic gastroenteritis (EGE), eosinophilic enteritis (EE), and eosinophilic colitis (EC). Symptoms are dependent not only on the location (organ) as well as extent (layer invasion of the bowel wall). Common symptoms of EoE include dysphagia and food impaction in adults and heartburn, abdominal pain, and vomiting in children. Common symptoms of the other EGIDs include abdominal pain, nausea, vomiting, early satiety, diarrhea, and weight loss. These disorders are considered immune-mediated chronic inflammatory disorders with strong links to food allergen triggers. Treatment strategies focus on either medical or dietary therapy. These options include not only controlling symptoms and bowel inflammation but also on identifying potential food triggers. This chapter will focus on the clinical presentation, pathophysiology, and treatment of these increasingly recognized disorders.
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Affiliation(s)
- Nirmala Gonsalves
- Feinberg School of Medicine, Northwestern University, 676 N St. Claire St, Suite 1400, Chicago, IL, 60614, USA.
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37
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Kumar S, Choi S, Gupta SK. Eosinophilic Esophagitis-A Primer for Otolaryngologists. JAMA Otolaryngol Head Neck Surg 2020; 145:373-380. [PMID: 30789641 DOI: 10.1001/jamaoto.2018.4177] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Eosinophilic esophagitis (EoE) is a chronic, inflammatory condition of the esophagus. Prevalence of EoE is on the rise and, owing to its associated extragastrointestinal manifestations and comorbidities, otolaryngologists are increasingly encountering this condition in their practice. Observations Symptoms of EoE are vague and vary greatly based on patient's age. The gastrointestinal symptoms include dysphagia, food impaction, feeding difficulties, symptoms mimicking gastroesophageal reflux, abdominal pain, vomiting, and failure to thrive. Several otolaryngologic symptoms are associated with EoE including rhinosinusitis, chronic cough, recurrent croup, hoarseness, and other aerodigestive symptoms refractory to gastroesophageal reflux therapy. Eosinophilic esophagitis is also frequently associated with other atopic conditions, such as asthma, eczema, and food allergies. The diagnosis is made on endoscopy with biopsies that reveal eosinophil-predominant esophageal inflammation. There are 3 major treatment approaches to EoE, commonly referred to as the 3 Ds: diet, drugs, and dilation. Untreated inflammation of esophagus from EoE can result in irreversible structural damage to the esophagus, leading to fibrosis, strictures, and impaired esophageal function. Conclusions and Relevance Eosinophilic esophagitis is now a fairly prevalent condition with considerable morbidity. Otolaryngologists should be familiar with the various clinical presentations of this condition in different age groups. Early diagnosis and treatment of this condition is a key for avoiding or postponing its complications.
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Affiliation(s)
- Sanjay Kumar
- Pediatric Gastroenterologist, Ascension St John Providence Children's Hospital, Detroit, Michigan
| | - Sukgi Choi
- Department of Otolaryngology and Communication Enhancement, Harvard Medical School, Boston, Massachusetts
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine at Peoria, Peoria.,Children's Hospital of Illinois, Peoria, Illinois
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Mari A, Tsoukali E, Yaccob A. Eosinophilic Esophagitis in Adults: A Concise Overview of an Evolving Disease. Korean J Fam Med 2020; 41:75-83. [PMID: 32062959 PMCID: PMC7093678 DOI: 10.4082/kjfm.18.0162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disease that encompasses esophageal symptoms along with eosinophilic infiltration of the esophageal epithelium. EoE is an evolving disease that has been a subject of interest to many researchers since the first studies recognized this condition as a new and distinct clinicopathological entity 25 years ago. Clinical presentation in adult patients may include dysphagia, food impaction, vomiting, and reflux symptoms. The diagnosis of EoE is based on the combination of clinical history suggestive of esophageal dysfunction, endoscopic features indicative of the disease, and histology revealing eosinophilic infiltration of the esophageal epithelium that persists after a trial of proton pump inhibitor therapy along with the exclusion of other disorders that may be associated with esophageal tissue eosinophilia. The interplay between EoE and gastroesophageal reflux disease (GERD) is complex, and differentiating these two conditions continues to be difficult and challenging in clinical practice. The mainstay treatment includes dietary modification, topical steroids, and/or endoscopic dilation. The primary care physician (PCP) plays an important role in improving patient care and quality of life by ensuring early referral and participating in management and follow-up. This article provides an overview of the current knowledge base regarding the disease including epidemiology, genetics, pathogenesis, common clinical presentations, the interplay between EoE and GERD, diagnostic approaches, and therapeutic options available to the PCP.
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Affiliation(s)
- Amir Mari
- Gastroenterology Institute, Nazareth EMMS Hospital, Nazareth, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | - Emmanouela Tsoukali
- Gastroenterology and Hepatology Department, Evangelismos General Hospital of Athens, Athens, Greece
| | - Afif Yaccob
- Gastroenterology and Liver Disease Department, Rambam Healthcare Campus, Haifa, Israel
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Mari A, Abu Baker F, Mahamid M, Khoury T, Sbeit W, Pellicano R. Eosinophilic esophagitis: pitfalls and controversies in diagnosis and management. Minerva Med 2020; 111:9-17. [PMID: 31755670 DOI: 10.23736/s0026-4806.19.06322-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Formerly considered a rare disorder, eosinophilic esophagitis (EoE) has emerged as a leading cause of feeding problems in children and an increasingly recognized cause of dysphagia and food impaction in adults. Our understanding of EoE and its complex interplay with gastro-esophageal reflux disease (GERD) has evolved over the past decade and culminated in the introduction of proton pump inhibitor (PPI) responsive EoE as a distinct entity which has added to this complexity. It is now clear that this entity is on the same spectrum as the original EoE, and that PPIs should be considered as part of treatment protocol and should not be recommended as a diagnostic tool. As such, removing the PPI trial from the diagnostic algorithm has been encouraged recently. Recent guidelines and reviews thoroughly address various aspects in EoE pathogenesis and diagnostic workup as well as management endpoints, treatment options and novel therapies. However, despite the recent extensive study and the advances in our knowledge of this disease, unmet needs and pitfalls in diagnostic workup and management of these patients are still to be clarified and will be under focus in this review.
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Affiliation(s)
- Amir Mari
- Gastroenterology Unit, Nazareth Hospital EMMS, Faculty of Medicine, Bar Ilan University, Safed, Israel -
| | - Fadi Abu Baker
- Gastroenterology Unit, Hillel Yaffe MC, Technion, Haifa, Israel
| | - Mahmud Mahamid
- Gastroenterology Unit, Nazareth Hospital EMMS, Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Tawfik Khoury
- Gastroenterology Unit, Nazareth Hospital EMMS, Faculty of Medicine, Bar Ilan University, Safed, Israel
- Department of Gastroenterology, Galilee MC, Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Wisam Sbeit
- Department of Gastroenterology, Galilee MC, Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Rinaldo Pellicano
- Gastroenterology Unit, Molinette-San Giovanni Antica Sede Hospitals, Turin, Italy
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40
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Chan MQ, Balasubramanian G. Esophageal Dysphagia in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:534-553. [PMID: 31741211 DOI: 10.1007/s11938-019-00264-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia. RECENT FINDINGS Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.
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Affiliation(s)
- Megan Q Chan
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA
| | - Gokulakishnan Balasubramanian
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA.
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Gómez-Aldana A, Jaramillo-Santos M, Delgado A, Jaramillo C, Lúquez-Mindiola A. Eosinophilic esophagitis: Current concepts in diagnosis and treatment. World J Gastroenterol 2019; 25:4598-4613. [PMID: 31528089 PMCID: PMC6718043 DOI: 10.3748/wjg.v25.i32.4598] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/13/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic esophagitis is an immune-allergic pathology of multifactorial etiology (genetic and environmental) that affects both pediatric and adult patients. Its symptoms, which include heartburn, regurgitation, and esophageal stenosis (with dysphagia being more frequent in eosinophilic esophagitis in young adults and children), are similar to those of gastroesophageal reflux disease, causing delays in diagnosis and treatment. Although endoscopic findings such as furrows, esophageal mucosa trachealization, and whitish exudates may suggest its presence, this diagnosis should be confirmed histologically based on the presence of more than 15 eosinophils per high-power field and the exclusion of other causes of eosinophilia (parasitic infections, hypereosinophilic syndrome, inflammatory bowel disease, among others) for which treatment could be initiated. Currently, the 3 "D"s ("Drugs, Diet, and Dilation") are considered the fundamental components of treatment. The first 2 components, which involve the use of proton pump inhibitors, corticosteroids, immunosuppressants and empirical diets or guided food elimination based on allergy tests, are more useful in the initial phases, whereas endoscopic dilation is reserved for esophageal strictures. Herein, the most important aspects of eosinophilic esophagitis pathophysiology will be reviewed, in addition to evidence for the various treatments.
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Affiliation(s)
- Andrés Gómez-Aldana
- Departament of Internal Medicine, Section of Gastroenterology, Santa Fe Foundation of Bogotá (Fundación Santa Fe de Bogotá), Bogotá 220246, Colombia
- University of Los Andes, Bogotá 111711, Colombia
| | - Mario Jaramillo-Santos
- Department of Endoscopy, Caldas University, Manizales 275, Colombia
- Department of Endoscopy, Surgeons’ Union SAS (Joint stock company) (Union de cirujanos SAS), Manizales 170001661, Colombia
| | - Andrés Delgado
- Departament of Internal Medicine, Section of Gastroenterology, Santa Fe Foundation of Bogotá (Fundación Santa Fe de Bogotá), Bogotá 220246, Colombia
| | - Carlos Jaramillo
- Department of Endoscopy, Caldas University, Manizales 275, Colombia
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42
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Pharmacotherapies for the Treatment of Eosinophilic Esophagitis: State of the Art Review. Drugs 2019; 79:1419-1434. [DOI: 10.1007/s40265-019-01173-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Alterio T, Cardile S, Trayers C, Valenti S, Loddo I, Mardare R, Mosca A, Nobili V. Eosinophilic esophagitis in children: current knowledge to open new horizons. Scand J Gastroenterol 2019; 54:822-829. [PMID: 31535579 DOI: 10.1080/00365521.2019.1641214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Eosinophilic Esophagitis (EoE) is a chronic immune/antigen-mediated condition which is also driven by genetic and environmental factors. It has been deeply investigated over the last years and its incidence is widely increasing in childhood. Although atopic diseases are closely linked with EoE, it does not recognize a classical IgE-mediate immune pathogenesis but it is rather a T helper type 2 inflammatory process. Familial clustering supports genetic predisposition in EoE and recent advances in understanding the genetic basis for EoE may eventually translate into targeted management of the disease. EoE diagnosis is based on clinical symptoms, micro, and macroscopic findings along with exclusion of gastroesophageal reflux disease (GERD) evidence. Management of the disease encompasses both dietary and pharmacological solutions that need to be specifically targeted on patients' history, clinical symptoms, and diagnostic evaluations. New therapies, currently not available in children, may represent the basis for future therapeutic options in the next years.
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Affiliation(s)
- Tommaso Alterio
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy
| | - Sabrina Cardile
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy
| | - Claire Trayers
- Department of Paediatric and Perinatal Pathology, Cambridge University Hospitals (CUH), Addenbrooke's Hospital , Cambridge , UK
| | - Simona Valenti
- Department of Pediatrics, University of Messina , Messina , Italy
| | - Italia Loddo
- Department of Laboratory Medicine and Advanced Biotechnologies, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT) - IRCCS , Palermo , Italy
| | - Roxana Mardare
- Department of Pediatrics, Cambridge University Hospitals (CUH), Addenbrookes Hospital , Cambridge , UK
| | - Antonella Mosca
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy
| | - Valerio Nobili
- Hepatology, Gastroenterology and Nutrition Unit, IRCCS "Bambino Gesù" Children's Hospital , Rome , Italy.,Department of Pediatrics, University "La Sapienza" , Rome , Italy
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Sunkara T, Rawla P, Yarlagadda KS, Gaduputi V. Eosinophilic gastroenteritis: diagnosis and clinical perspectives. Clin Exp Gastroenterol 2019; 12:239-253. [PMID: 31239747 PMCID: PMC6556468 DOI: 10.2147/ceg.s173130] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 04/26/2019] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Tagore Sunkara
- Division of Gastroenterology and Hepatology, Mercy Medical Center, Des Moines, IA 50314, USA.,Division of Gastroenterology, St. Barnabas Hospital Health System, New York, NY, 10457, USA
| | - Prashanth Rawla
- Department of Internal Medicine, Sovah Health, Martinsville, VA, 24112, USA
| | - Krishna Sowjanya Yarlagadda
- Division of Gastroenterology and Hepatology, Mercy Medical Center, Des Moines, IA 50314, USA.,Division of Gastroenterology, St. Barnabas Hospital Health System, New York, NY, 10457, USA
| | - Vinaya Gaduputi
- Division of Gastroenterology, St. Barnabas Hospital Health System, New York, NY, 10457, USA
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Pérez-Martínez I, Rodrigo L, Lucendo AJ. Esofagitis eosinofílica: aproximación al diagnóstico y tratamiento desde la evidencia. Med Clin (Barc) 2019; 152:444-449. [DOI: 10.1016/j.medcli.2018.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/12/2018] [Accepted: 10/16/2018] [Indexed: 01/07/2023]
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Carr S, Chan ES, Watson W. Correction to: Eosinophilic esophagitis. Allergy Asthma Clin Immunol 2019; 15:22. [PMID: 31007687 PMCID: PMC6456987 DOI: 10.1186/s13223-019-0336-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an atopic condition of the esophagus that has become increasingly recognized over the last 15 years. Diagnosis of the disorder is dependent on the patient’s clinical manifestations, and must be confirmed by histologic findings on esophageal mucosal biopsies. Patients with EoE should be referred to an allergist for optimal management, which may include dietary modifications and pharmacologic agents such as proton pump inhibitors (PPI) and corticosteroids, and for the diagnosis and management of comorbid atopic conditions. Mechanical dilation of the esophagus may also be necessary. The epidemiology, pathophysiology, diagnosis, treatment, and prognosis of EoE are discussed in this review.
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Affiliation(s)
- Stuart Carr
- 1Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - Edmond S Chan
- 2Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC Canada.,3EoE Clinic, BC Children's Hospital, Vancouver, BC Canada
| | - Wade Watson
- 4Division of Allergy, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, NS Canada
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Fan YC, Steele D, Kochar B, Arsene D, Long MD, Dellon ES. Increased Prevalence of Esophageal Eosinophilia in Patients with Inflammatory Bowel Disease. Inflamm Intest Dis 2019; 3:180-186. [PMID: 31111034 DOI: 10.1159/000497236] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/19/2019] [Indexed: 12/14/2022] Open
Abstract
Background The overlap between eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD) has not been extensively examined. We aimed to assess the prevalence of esophageal eosinophilia in patients with IBD. Methods We conducted a retrospective cohort study using diagnostic codes to identify adults with EoE and IBD between 2008 and 2016 at a tertiary care center. Electronic medical records were reviewed to extract clinical, endoscopic, and treatment data. Patients with esophageal eosinophilia and IBD were compared to EoE cases without IBD. Results Of 621 EoE patients and 4,814 IBD patients identified, 35 had a code for both diseases and 12 were confirmed to have overlapping IBD and esophageal eosinophilia. The prevalence of esophageal eosinophilia in IBD was 12/4814 (0.25%), and the prevalence of confirmed EoE in IBD was 5/4,814 (0.10%). There were no substantial clinical, endoscopic, or histologic differences between EoE patients with and without IBD. IBD was diagnosed before esophageal eosinophilia 92% of the time, with an average time between diagnoses of 9.6 years. Of the IBD patients, 71% were started on biologic anti-tumor necrosis factor-α therapy an average of 7.6 years prior to developing esophageal eosinophilia. Conclusions The prevalence of esophageal eosinophilia in IBD is 5 times higher than expected in the general population (0.25 vs. 0.05%) and EoE in IBD is 2 times higher than expected (0.10 vs. 0.05%). Upper gastrointestinal (GI) symptoms in patients with IBD should merit evaluation not only for upper GI Crohn's disease, but also for esophageal eosinophilia.
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Affiliation(s)
- Y Claire Fan
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - David Steele
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Bharati Kochar
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Diana Arsene
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Millie D Long
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Iuliano S, Minelli R, Vincenzi F, Gaiani F, Ruberto C, Leandro G, Bizzarri B, Nouvenne A, Di Mario F, De'Angelis GL. Eosinophilic esophagitis in pediatric age, state of the art and review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:20-26. [PMID: 30561413 PMCID: PMC6502212 DOI: 10.23750/abm.v89i8-s.7866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Indexed: 02/06/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated relapsing disease caused by eosinophilic infiltration of the esophageal mucosa which is normally lacking these cells. EoE belongs to the group of the so called Eosinophilic Gastrointestinal Disorders (EGIDs). From a rare and unusual disease, EoE has become an emerging entity and in recent years its incidence and prevalence have increased all over the world, also in children. The pathogenesis is very complex and still not completely clear. Esophageal disfunction symptoms (e.g. dysphagia and food impaction) represent the typical manifestation of EoE and this condition could be difficult to recognize, more in pediatric age than in adults. Moreover, symptoms can often overlap with those of gastro-esophageal reflux disease (GERD), leading to a delayed diagnosis. EoE is often related to atopy and an allergological evaluation is recommended. Untreated EoE could provoke complications such as strictures, esophageal rings, narrowing of the esophagus. Diagnosis is confirmed by the demonstration in biopsy specimens obtained through upper endoscopy of eosinophilic inflammation (>15 for high powered field) of the esophageal mucosa and other histological features. Other tests could be useful not specifically for the diagnosis, but for the characterization of the subtype of EoE. Since EoE incidence and knowledge about physiopathology and natural history have increased, the goal of the review is to provide some helpful tools for the correct management in pediatric age together with an overview about epidemiology, pathogenesis, clinical, diagnosis and treatment of the disease.
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Affiliation(s)
- Silvia Iuliano
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
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Wong S, Ruszkiewicz A, Holloway RH, Nguyen NQ. Gastro-oesophageal reflux disease and eosinophilic oesophagitis: What is the relationship? World J Gastrointest Pathophysiol 2018; 9:63-72. [PMID: 30386667 PMCID: PMC6209579 DOI: 10.4291/wjgp.v9.i3.63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/17/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic oesophagitis (EoE) and gastro-oesophageal reflux disease (GORD) are the most common causes of chronic oesophagitis and dysphagia associated with oesophageal mucosal eosinophilia. Distinguishing between the two is imperative but challenging due to overlapping clinical and histological features. A diagnosis of EoE requires clinical, histological and endoscopic correlation whereas a diagnosis of GORD is mainly clinical without the need for other investigations. Both entities may exhibit oesophageal eosinophilia at a similar level making a histological distinction between them difficult. Although the term proton-pump inhibitor responsive oesophageal eosinophilia has recently been retracted from the guidelines, a relationship between EoE and GORD still exists. This relationship is complex as they may coexist, either interacting bidirectionally or are unrelated. This review aims to outline the differences and potential relationship between the two conditions, with specific focus on histology, immunology, pathogenesis and treatment.
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Affiliation(s)
- Stephanie Wong
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Andrew Ruszkiewicz
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Anatomical Pathology, SA Pathology, Adelaide SA 5000, Australia
| | - Richard H Holloway
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Nam Q Nguyen
- Discipline of Medicine, University of Adelaide, Adelaide SA 5000, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide SA 5000, Australia
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Durrani SR, Mukkada VA, Guilbert TW. Eosinophilic Esophagitis: an Important Comorbid Condition of Asthma? Clin Rev Allergy Immunol 2018; 55:56-64. [PMID: 29455359 DOI: 10.1007/s12016-018-8670-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Eosinophilic esophagitis and asthma are frequently found as comorbid conditions in children and adults along with other manifestations of atopic diathesis. These two conditions have similar T helper 2 responses-driven pathophysiology and share common management strategies such as using systemic corticosteroids and targeted anti-cytokine biologic therapies. Review of the literature finds that asthma is often a comorbid condition in eosinophilic esophagitis in both children and adults; however, the EoE-asthma relationship remains poorly characterized mechanistically and clinically. EoE and asthma commonly share several comorbid conditions such as allergic rhinitis and gastroesophageal reflux disease; therefore, addressing these comorbid conditions has the potential to improve and/or maintain control in both diseases. Similar to asthma, patients with EoE frequently demonstrate elevations in serum markers of atopy, including serum IgE levels, peripheral eosinophil counts, and T helper 2-related cytokines. Gastroesophageal reflux disease is thought to affect asthma through microaspirations, airway hyperresponsiveness, and increased vagal tone. The understanding of the relationship between gastroesophageal reflux and EoE is still evolving but seems to be bidirectional and interactive. In terms of treatment, similar classes of medications have been used in both EoE and asthma. In both children and adults, EoE remission can be achieved by food trigger avoidance and use of corticosteroids and biologic therapies. Asthma control is mostly achieved through inhaled corticosteroids, and long but biologic therapies are increasingly used in severe subsets of the disease. Significant clinical and mechanistic work needs to be accomplished to better understand the relationship between asthma, EoE, and their interaction with other allergic diseases. Understanding whether shared mechanisms exist can lead to the development of new diagnostic and therapeutic strategies. The following review examines the existing literature regarding prevalence, common comorbidities, and potential therapeutic approach and identifies gaps in knowledge and future directions.
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Affiliation(s)
- Sandy R Durrani
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA. .,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Vincent A Mukkada
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Theresa W Guilbert
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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