Cases Of Eosinophilic Oesophagitis Research Articles

Development of a model to identify patients who do not need oesophageal biopsies when eosinophilic oesophagitis is suspected.

Predictive models for eosinophilic oesophagitis (EoE) may not fully rule in the diagnosis. To develop a reverse model that predicts against EoE to eliminate the need for oesophageal biopsies. In this two-centre study, a predictive model was developed (Mayo Clinic) and validated (University of North Carolina [UNC]). Cross-sectional data from consecutive adult patients without prior EoE who underwent upper enoscopy with oesophageal biopsies were used. EoE cases had ≥15 eosinophils/high-power field while controls had no eosinophils. Data were collected on patient clinical and endoscopic features. Multiple variable logistic regression was used to identify predictors of non-EoE status while maintaining specificity ≥95%. A secondary model was developed to predict against the need for endoscopy in patients suspected of having EoE without alarm symptoms. The Mayo and UNC cohorts consisted of 345 (EoE = 94, non-EoE = 251) and 297 patients (EoE = 84, non-EoE = 213), respectively. A primary model based on clinical and endoscopic features predicted against EoE with c-statistic 0.92 (95% CI: 0.88-0.96), specificity 95%, and sensitivity 65%. This model was validated (UNC) with c-statistic 0.87 (95% CI: 0.82-0.92). A simplified scoring system was created and a threshold of ≥12 points excluded EoE with 95% specificity and 50% sensitivity. A secondary model based on clinical characteristics alone predicted against EoE with c-statistic 0.86 (95% CI: 0.82-0.90), specificity 95% and sensitivity 39% and validated (UNC) with c-statistic 0.78 (95% CI: 0.71-0.85). A simplified scoring system accurately identified a group of patients with a low likelihood of EoE where unnecessary oesophageal biopsies can be avoided, potentially resulting in resource and cost savings.

Eosinophilic oesophagitis in Denmark: Population‐based incidence and prevalence in a nationwide study from 2008 to 2018

BackgroundEosinophilic oesophagitis (EoE) is a chronic immune‐mediated or antigen‐mediated oesophageal disease characterised by symptoms related to oesophageal dysfunction and eosinophil‐predominant inflammation.ObjectiveWe aimed to estimate the incidence and prevalence of EoE in Denmark during the period 2008–2018.MethodsBased on data from nationwide registers we identified cases of EoE using two definitions: a broad definition based solely on oesophageal biopsies registered in the Danish Pathology Register and a narrow definition also including symptoms of oesophageal dysfunction registered in the Danish National Patient Registry. The annual incidence and prevalence were standardised by sex and age in 5‐year intervals to the 2013 study population.ResultsFrom 2008 to 2011, the standardised incidence of EoE was stable, but from 2011 to 2018 it increased from 3.9 (95% CI 3.3–4.4) to 11.7 (95% CI 10.8–12.6) per 100,000 person‐years. Similar temporal trends were observed when using the narrow EoE definition. The increase in incidence was most pronounced in men and in individuals above 40 years of age. In children, the EoE incidence was a fourth of the incidence in adults aged 40–64 years: 4.4 (95% CI 3.2–5.6) versus 17.6 (95% CI 15.7–19.5) per 100,000 person‐years. The EoE incidence varied substantially across the five regions in Denmark. Overall, the biopsy rate as well as the proportion of oesophageal biopsies with detected eosinophilia increased during the study period.ConclusionThis study of the entire population of Denmark during the period 2008 to 2018 shows that the incidence and prevalence of EoE is not yet plateauing and that EoE could be severely underdiagnosed, especially in children.

Paediatric eosinophilic oesophagitis in New Zealand: A 3-year prospective study.

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. Information on new diagnoses of paediatric EoE was obtained via the New Zealand Paediatric Surveillance Unit, through monthly questionnaires. 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. 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.

Oesophageal food bolus obstruction and eosinophilic oesophagitis.

Eosinophilic oesophagitis (EoE) is now a well-recognised cause of dysphagia and food bolus obstruction (FBO). The diagnosis requires histologic confirmation, and the yield is greatest when at least 4 to 6 oesophageal biopsies are taken from different sites. Previous case reports of FBO have demonstrated a low biopsy rate, and as such cases of EoE may have been missed. In this review, the medical records of 123 patients aged 18 years or older, who had presented with FBO over a 2 year period, were reviewed. EoE was the most common diagnosis, and was found in 81.3% of patients with FBO aged 40 years or less. 45.5% of patients with FBO were biopsied, and of those, 33.9% were confirmed to have had at least 4 biopsies. EoE is a common cause of FBO and requires appropriate oesophageal sampling to confirm the diagnosis. Cases of EoE may otherwise be missed.

A visual analogue scale and a Likert scale are simple and responsive tools for assessing dysphagia in eosinophilic oesophagitis.

While symptom scores have been developed to evaluate dysphagia in eosinophilic oesophagitis (EoE), their complexity may limit clinical use. To evaluate a visual analogue scale (VAS) and a 10-point Likert scale (LS) for assessment of dysphagia severity before and after EoE treatment. We conducted a prospective cohort study enrolling consecutive adults undergoing out-patient endoscopy. Incident cases of EoE were diagnosed per consensus guidelines. At diagnosis and after 8weeks of treatment, symptoms were measured using the VAS, LS and the Mayo Dysphagia Questionnaire (MDQ). The percentage change in scores before and after treatment were compared overall, in treatment responders (<15 eos/hpf) and non-responders, and in patients without baseline dilation. In 51 EoE cases, the median VAS decreased from 3.6 at baseline to 1.4 post-treatment (71% decrease), the LS decreased from 6 to 2 (67%) and the MDQ decreased from 20 to 10 (49%). The VAS correlated with both the LS (R=0.77; P<0.0001) and MDQ (R=0.46, P=0.001). After stratification by histological response, the LS decreased 70% in responders vs. 13% in non-responders (P=0.02). In patients who did not receive baseline dilation, both the VAS and LS decreased significantly more in the histological responders. Both the VAS and LS were responsive to successful treatment as measured by histologic improvement. Because the VAS and LS are simple to administer and are responsive to treatment, they can provide an efficient and objective method for assessing dysphagia severity in EoE in clinical practice.

Primary eosinophilic gastrointestinal disorders in children who have received food oral immunotherapy

BackgroundFood oral immunotherapy (OIT) involves the administration of the food allergen causing the symptoms, in order to induce tolerance. Primary eosinophilic gastrointestinal disorders (PEGDs) are characterised by an eosinophil-rich inflammation affecting different locations of the digestive tract. We present a series of patients with PEGDs in a group of children following OIT with milk and/or egg. Material and methodsA prospective study during the period 2006–2014 was performed in paediatric patients subjected to OIT with milk and/or egg. When these children present persistent gastrointestinal symptoms, they are referred to the Paediatric Gastroenterology Unit for evaluation. ResultsPrimary eosinophilic gastrointestinal disorders were diagnosed in eight of the 128 cases of OIT (6.25%). The time to PEGDs development was variable: two cases showed symptoms during OIT, and the rest with a median time of 29 months (15–48 months). Food treatment discontinuation was not required in four of the five cases of eosinophilic oesophagitis, although food removal was necessary in patients with eosinophilic gastroenteritis. ConclusionsWe report the highest prevalence of PEGDs in children subjected to OIT, and the first cases of eosinophilic gastroenteritis following food OIT.The monitoring of new digestive signs and symptoms after OIT is crucial for the diagnosis of these disorders, and prolonged follow-up is required. The management of such patients and the need or not to eliminate the food should be assessed on an individualised basis, according to the severity of the condition, its evolution and response to different treatment alternatives.

Prospective assessment of serum periostin as a biomarker for diagnosis and monitoring of eosinophilic oesophagitis.

Periostin is highly expressed in eosinophilic oesophagitis (EoE), but has not been extensively studied as a non-invasive biomarker. To assess whether serum periostin distinguished EoE from controls at baseline, had utility for monitoring treatment response, or was associated with IL-13 levels. This was a sub-analysis of a prospective cohort study of adults undergoing out-patient upper endoscopy. Incident cases of EoE were diagnosed per consensus guidelines. Controls were subjects with either GERD or dysphagia without EoE. EoE patients were treated with swallowed/topical steroids and had repeat endoscopy/biopsy. Serum periostin levels for cases and controls were compared at baseline, and pre/post-treatment levels were compared for cases. Serum IL-13 and tissue expression of periostin were also assessed. A total of 61 incident EoE cases and 87 controls were analysed. Despite a marked increase in tissue periostin expression in cases, the median baseline serum periostin level was only slightly higher in cases than controls (22.1 ng/mL vs. 20.7; P = 0.04); there was no change in post-treatment levels. There was also no difference in serum periostin for cases by histologic response or atopic status. There was a strong trend towards higher serum IL-13 levels in cases in the highest periostin quartile (57.1 pg/mL vs. 2.6; P = 0.07). Serum periostin levels were similar in cases and controls, and there were no changes post-treatment. Given elevated IL-13 levels in the EoE patients with the highest periostin levels, future studies could explore periostin as a biomarker in EoE, perhaps in the setting of anti-IL-13 therapy.

OC-041 Eosinophilic oesophagitis – a uk dgh experience

Introduction Eosinophilic oesophagitis (EOE) is an immune/antigen mediated chronic inflammatory disease of the oesophagus. Its incidence and prevalence appears to be increasing and in some studies incidence has been reported to be similar to inflammatory bowel disease. Despite this EOE is largely underdiagnosed. International Guidelines recommend at least 2–4 biopsies from each of the proximal and mid/distal oesophageal segments in patients suspected to have EOE. 1 We retrospectively assessed our practice in investigating patients presenting with dysphagia and food bolus obstruction (FBO) to two district general hospitals (DGH) over a year. Method Patients with history of dysphagia and FBO over 2014 were identified through electronic endoscopy database. 751 patients underwent gastroscopies for above complaints. Patient symptoms, demographics, endoscopic and histological findings were recorded. EOE was defined as the presence of >15 eosinophils per high power field (HPF). Results Patients with oesophageal malignancy (n = 67), Barrett’s oesophagus (n = 68), reflux oesophagitis (n = 154), post-oesophageal surgery complications (n = 6) and PEG insertions (n = 14) were excluded from the final analysis. Of the 442 remaining patients, (255 female, mean age 66; range 17–94, 187 male, mean age 64; range 17–93), oesophageal biopsies were taken from 98 patients giving a biopsy rate of 22% (98/442). 33 patients were suspected of having EOE at timing of endoscopy of which 8 (24%) confirmed cases of EOE (7 male: mean age 37; range 20–50). Endoscopy showed mucosal features in 5/8 (furrowing and corrugated rings seen), 2/8 had mild stricturing or schatzki ring. The remaining patients had Grade A-B reflux oesophagitis. Average number of biopsies taken was 7. Mean number of eosinophils HPF were 27 (range 15–40). Physicians collected more biopsies with 67% (66/98) of cases and suspected EOE in 82% (27/33). Conclusion Only 22% of patients with symptoms conducive with EOE were biopsied, with 24% (8/33) confirmed cases if suspected. Despite recent increasing awareness of EOE, 78% (344/442) of patients did not have biopsies and only a third (31/98) of patients having the recommended number of biopsies. In summary, our DGH experience has shown that EOE detection is likely to improve further if all patients with symptoms conducive with EOE (e.g. solid food dysphagia) routinely trigger an EOE biopsy protocol of ≥4 from the mid/proximal oesophagus regardless of endoscopic findings. 2 Continuous education and improving awareness amongst clinicians who perform upper GI endoscopy will improve identification of EOE patients. Disclosure of interest None Declared. References Dellon ES, Gonsalves N, Hirano I, et al . ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis. Am J Gastroenterol. 2013;108:679–692; doi:10.1038/ajg.2013.71 Kanakala V, Lamb CA, Haigh C, et al . The diagnosis of primary eosinophilic oesophagitis in adults: missed or misinterpreted?. Eur J Gastroenterol Hepatol. 2010;22(7):848–5

The increasing incidence and prevalence of eosinophilic oesophagitis outpaces changes in endoscopic and biopsy practice: national population-based estimates from Denmark.

National population-based medical registries in Denmark offer a unique opportunity to study eosinophilic oesophagitis (EoE) epidemiology. To determine the incidence and prevalence of EoE in Denmark, and evaluate whether an increase in endoscopy with biopsy activity explains changes in these trends. The Danish National Pathology Registry, Danish National Patient Registry and Danish Registry of Medicinal Product Statistics were queried from 1997 to 2012. Using an EoE case-finding algorithm validated for Danish patients, EoE cases were identified during each year of the study period; we also identified all patients with oesophageal eosinophilia. Using the known population of Demark, the annual incidence and prevalence of EoE were determined. We also determined the number of oesophageal biopsies performed each year in Denmark, and compared the change in the incidence rate to the change in biopsy rate. Between 1997 and 2012, 1708 patients had oesophageal eosinophilia, of whom 844 met the case definition of EoE. There were seven new cases of EoE in 1997 and 145 new cases in 2012, corresponding to a 19.5-fold increase in incidence (0.13/100000 to 2.6/100000). There were 769 total cases in 2012 (prevalence of 13.8/100000). Over the same time frame, the oesophageal biopsy rate increased only 1.9 fold, from 91.1/100000 to 175.3/100000. The incidence and prevalence of EoE markedly increased in Denmark over the past 15years. This increase far outpaced the increase in oesophageal biopsy utilisation, indicating that changes in the frequency of EoE are not due to changes in biopsy rates alone.

The rising incidence of eosinophilic oesophagitis is associated with increasing biopsy rates: a population‐based study

Eosinophilic oesophagitis (EoE) has evolved from a supposedly rare entity to one whose incidence rates are approaching that of inflammatory bowel disease. The factors responsible for this apparent increase in the incidence remain obscure. To assess various endoscopist and pathologist factors that might affect the frequency of EoE being detected in a well-defined North American population. Increased endoscopist and pathologist awareness has contributed to the increased clinical recognition of EoE. Cases of EoE were identified systematically using population-based pathology and endoscopy databases from January 2004 to December 2008 in Calgary, Canada (population 1.25 million). EoE frequency was estimated with time trend analysis. Characteristics of individual endoscopists (n = 45) were compared with diagnostic rates. Crude population incidence of EoE increased from 2.1 per 10(5) in 2004 to 11.0 per 10(5) in 2008: an annual increase of 39% (P < 0.0001). The frequency in men was 4.5 times higher than in women (95% CI: 3.51-5.76). In patients presenting with dysphagia oesophageal biopsy rates increased from 17.0% in 2004 to 41.3% of EGDs in 2008: an annual rise of 26% (P < 0.0001). On multivariate regression analysis, those endoscopists with higher biopsy rates were more likely to make the diagnosis of EoE (P = 0.008). To include or exclude the diagnosis, typical histological features of EoE were reported more often by pathologists in 2008 as compared to 2004 (P = 0.01 & P < 0.0001 respectively). The incidence of eosinophilic oesophagitis continues to rise in the general population, in part due to increasing oesophageal biopsy rates and a more detailed histological evaluation of specimens. The biopsy rate of an endoscopist is an indicator for a higher diagnostic yield.

Our cases with eosinophilic oesophagitis, pitfalls and lessons

Introduction: Eosinophilic oesophagitis (EoO) is a rare, increasingly recognised disease, caused by allergens. The authors summarized the diagnostic and therapeutic edifications of their 3 EoO cases.

More than just counting eosinophils: proximal oesophageal involvement and subepithelial sclerosis are major diagnostic criteria for eosinophilic oesophagitis

BackgroundAccording to American Gastroenterological Association Institute criteria, the diagnosis of eosinophilic oesophagitis (EOE) requires clinicopathological correlation. In the appropriate clinical context, a high eosinophil count (HEC, defined as ≥15/HPF) is...