Abstract
Proton pump inhibitors (PPIs) are the pharmacological cornerstone for acid-related peptic disorders, especially gastroesophageal reflux disease (GERD), on account of their powerful suppression of gastric acid secretion. GERD is the most common esophageal disease, with approximately 10-20% of adult Western population affected, mainly males between 20 and 50 yrs-old. Eosinophilic esophagitis (EoE) is an emerging immuno/antigen-mediated disorder, characterized by esophageal symptoms and eosinophil-predominant inflammation. It is an allergic condition of growing recognition and prevalence, so much so that it is currently recognized as the second cause of chronic esophagitis after GERD. EoE usually presents in allergic males under 40 yrs-old, so GERD and EoE coexist frequently in adult patients. Initially, both disorders were distinguished since EoE was, by definition, unresponsive to PPIs. However, case reports and small series since 2006 have progressively shown patients with clinical, endoscopic and histological data consistent with EoE having complete remission on PPIs. Notwithstanding the fact that these patients have been historically classified as having mislabelled GERD, recent evidence has made way for a new potential phenotype of EoE (PPI-responsive esophageal eosinophilia), even in patients with normal acid exposure. Furthermore, more confusion has been added to the debate since GERD has been recently redefined as a cytokinemediated disorder rather than acid-injury mediated. As such, PPIs might also affect GERD-related or EoE-related esophageal eosinophilia through immunomodulatory mechanisms beyond acid suppression. This report intends to update the available evidence on PPI-responsive esophageal eosinophilia and briefly review the mechanisms whereby PPIs might exert potential anti-inflammatory effects on allergic diseases such as EoE.
Highlights
Proton pump inhibitors (PPIs) are the pharmacological cornerstone for acid-related peptic disorders, especially gastroesophageal reflux disease (GERD), on account of their powerful suppression of gastric acid secretion
Excluding patients with a GERD profile, we observed that even 50% of Eosinophilic esophagitis (EoE) profile patients were PPI-responders
PPIs are the treatment of choice for all acid-related disorders including peptic ulcer disease, gastroesophageal reflux disease (GERD), eradication of Helicobacter pylori, prevention of ulcers associated with non-steroidal anti-inflammatory drugs (NSAIDs) and ZollingerEllison syndrome
Summary
Citation: Molina-Infante J, Zamorano J, Rivas MD, Fernandez-Bermejo M (2011) Proton Pump Inhibitors Therapy for Eosinophilic Esophagitis. J Aller Ther S8:002. doi:10.4172/2155-6121.S8-002 furrows, exudates) and histological (>20 eo/HPF) data consistent with EoE which fully reverted to normal after PPI therapy [6]. The authors concluded that these patients were likely to have mislabelled GERD and that large number of eosinophils can be found related to peptic esophagitis. In agreement with this study, Rodrigo et al reported in 2008 a retrospective series of 40 out of 3648 patients with esophageal eosinophilia (>20 eo/HPF) [7]. 28 patients (70%) had a final diagnosis of GERD after careful evaluation of clinical, endoscopic, manometric and pH monitoring information. The main conclusion drawn was that esophageal eosinophilia was not specific of EoE. In 2009, Dranove et al published an interesting retrospective series of 43 pediatric patients with esophageal eosinophilia (>15 eo/HPF) who received PPI therapy [8]. In this report, 17 patients (40%) achieved clinical and histological (< 5 eo/ HPF) remission on PPIs. Interestingly, PPI-response was identified in 45% and 41% of patients with normal and abnormal pH esophageal monitoring, respectively, thereby questioning the role of esophageal acid exposure to predict response to PPI therapy. These findings raised the possibility of a PPI-responder phenotype different from EoE among patients with esophageal eosinophilia. In 2009, Sayej et al reported a retrospective series of 69 pediatric patients with ≥ 15 eo/HPF, of whom 36 (52%) were treated with high-dose PPI therapy [9]. 14 out of those 36 patients (39%) had clinical and histological remission (< 5 eo/HPF) on PPIs, emphasizing the existence of a significant proportion of PPI-responders among patients with suspected EoE. It was in 2010 that it was published the first randomized controlled trial comparing esomeprazole (40 mg a day) and topical fluticasone (440 mcg bid) in 30 adult patients with ≥ 15 eo/HPF[10]. There were no differences regarding improvement in average dysphagia score or eosinophilic infiltration between both groups. Partial histological response (
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