Clinical Presentation Of Eosinophilic Esophagitis Research Articles

Differences in Clinical Presentation of Eosinophilic Esophagitis in Pediatric Patients With Ulcerative Colitis and Crohn Disease

Significance: Eosinophilic esophagitis (EoE) is an inflammatory condition characterized by T helper-2 (TH2) cytokines. Ulcerative colitis (UC) and Crohn disease (CD) are inflammatory conditions with different clinical presentations and immune profiles. UC is associated with TH2 cytokines and CD with TH1 cytokines. We investigated potential differences in the association of EoE with UC and CD because of these different immune profiles. Methods: We utilized ICD-9 and ICD-10 codes to find patients with inflammatory bowel disease (IBD) and EoE. We defined EoE as any esophageal biopsy with >15 eosinophils. We collected demographic, clinical, laboratory, endoscopic, and histological data. Results: Thirty patients had both EoE and IBD. 14.9% of UC patients had EoE and 5.7% of CD patients had EoE. 64.7% of UC patients presented with UC and EoE at the same time, whereas 76.9% of CD patients presented with EoE at follow up. Ten of 13 CD patients were on anti-tumor necrosis factor (TNF) at EoE diagnosis. No UC patients were on anti-TNF at EoE diagnosis. Eighty-three percent of CD patients had mild disease or were in remission, whereas 50% of UC patients had moderate to severe disease at the time of EoE diagnosis. Conclusion: A higher percentage of UC than CD patients had EoE. EoE was more likely to be present at the initial diagnosis of UC than CD. EoE was more likely after diagnosis and treatment of CD with anti-TNF, when CD activity was mild or in remission. The difference in presentation suggests that anti-TNF or it’s impact on inflammation may differentially impact the association of EoE with CD and UC.

Eosinophilic esophagitis: A review of the pediatric population and consideration of upcoming therapies

Eosinophilic esophagitis (EoE) is a disease entity that has become increasingly recognized in the pediatric population over the last decade and was first recognized as early as 1990. EoE is a clinicopathologic diagnosis with signs and symptoms varying between age groups. The clinical presentation of EoE is variable ranging from milder nonspecific symptoms, such as abdominal pain, vomiting, and dyspepsia, to more severe presentations such as failure to thrive, dysphagia and even food impaction and is dependent on age of diagnosis 2. There is growing body of evidence with regards to the pathophysiology, diagnostic modalities, and treatment options for EoE in the past decade. In this review article, we aim to discuss the disease burden, pathophysiology, diagnostic strategies, and currently available treatment options for EoE based on existing literature.

Clinical presentation of eosinophilic esophagitis in the pediatric age

Clinical presentation of eosinophilic esophagitis in the pediatric age

S3135 Online CME on Eosinophilic Esophagitis Improves Knowledge and Competence Among Gastroenterologists

INTRODUCTION: Eosinophilic esophagitis (EoE) is a chronic immune-mediated esophageal disease characterized clinically by esophageal dysfunction and food impactions, and pathologically by eosinophilic infiltration of the esophageal mucosa. The goal of this study was to examine the effect of online CME on improving knowledge, competence, and confidence in evidence-based management of patients with EoE. METHODS: Gastroenterologists (N = 206) participated in an online audio and slide-based CME activity that highlighted key educational points from a live symposium.1 Effectiveness was analyzed using 3 multiple-choice and 1 self-efficacy question, presented as pre-/post-CME repeated pairs. The online CME activity launched on November 22, 2019 and participant results were collected through January 21, 2020. Chi-square test assessed changes in responses to questions from pre- to post-CME. Cramer’s V effect size was calculated using the change in proportion of learners who answered questions correctly from pre- to post-CME. RESULTS: In pre to post-CME assessments, there was an overall 11% relative improvement in correct responses from 62% to 69% pre/post (P < .01; Cramers V =0 .08). There was a 12% relative increase in knowledge regarding the most common trigger of EoE (67% to 75% pre/post; P = .08). Despite high baseline knowledge regarding the clinical presentation of EoE in adults, learners still demonstrated a 5% relative increase following participation in online education (85% to 89% pre/post; P = .24). In a case-based scenario there was a 33% relative improvement in competence regarding selection of guideline-based treatment (33% to 44% pre/post; P < .05). Learners also had a 7% average increase in confidence in their ability to manage patients with EoE based on clinical guidelines and best available evidence, with 24% and 71% having increased and maintained confidence, respectively, following participation. CONCLUSION: An online CME audio module with synchronized slides on evidence-based management of EoE resulted in increased knowledge, competence, and confidence among gastroenterologists. Further case-based education would be beneficial in closing remaining gaps in competence.

Eosinophilic Esophagitis: the Potential Role of Biologics in its Treatment.

Eosinophilic esophagitis (EoE) is a chronic, relapsing inflammatory disease of the esophagus, characterized by the presence of significant esophageal mucosal eosinophilic infiltrates. The clinical presentation of EoE in childhood may include failure to thrive and feeding intolerance. The complication of food impaction is often related to the presence of strictures or narrow caliber esophagus. Over the last decade, there has been tremendous progress in the field of eosinophilic disorders, particularly eosinophilic esophagitis. Conventional treatment of eosinophilic esophagitis involves topical swallowed steroids, systemic steroids, elimination diets, and/or esophageal dilation. However, treatment outcomes with the above modalities are not satisfactory for all patients with EoE and alternative treatments are clearly needed. There has been ongoing research targeting the treatment-refractory population of patients with EoE and the population with long-term consequences of the disease and its treatment. With the significant eosinophilic infiltration that characterizes EoE, anti-IL-5 therapies designed to target eosinophilic inflammation have been some of the most studied anti-inflammatory biologic therapies in EoE. In the studies published to date, while various IL-5 inhibitors have decreased the numbers of esophageal eosinophils, they have not depleted them to the levels consistent with histologic remission of EoE. As additional biologics that modulate Th2-mediated immunity are trialed for the treatment of EoE, we stand to learn more about the inflammatory factors mediating this challenging condition. In this review, we discuss the alternative modes of therapy in EoE that have emerged, with a focus on anti-IL-5 therapies and other biologics, their variation of success, and ultimately, the future of treatment in this field.

Esophageal Dilation Demonstrates That the Majority of Esophageal Strictures Are Located in the Distal Esophagus in Adults With Eosinophilic Esophagitis

Introduction: Dysphagia caused by esophageal stricture is the most common clinical presentation of eosinophilic esophagitis (EoE) in adults. Esophageal dilation is an accepted therapeutic modality to manage strictures that persist in spite of medical therapy. Mucosal disruption following dilation not only provides evidence of an effective dilation but also identifies the site of dominant stricture formation Methods: We conducted a retrospective chart review for EoE adults receiving care from a single provider at an urban university based medical center. Patients from 2000 to 2017 who had undergone esophageal dilation for their EoE symptoms were identified. Demographic and clinical information and endoscopic features and results of dilation were collected. Location of mucosal disruption after dilation was recorded in all cases. Disruptions located between 15-27.5 cm from the incisors were defined as proximal strictures, and those above 27.5 cm from the incisors as distal strictures. A disruption was considered proximal and distal if there were multiple mucosal lacerations identified with one localized proximally and another distally, or from a disruption in the mid-esophagus spanning above and below 27.5 cm. Major complications of esophageal perforation or GI bleeding requiring hospitalization or blood transfusion were assessed. Results: Of 640 EoE patients identified, 250 patients had undergone 718 dilations. The average number of dilations per patient was 2.87 ± 2.62 dilations. Among the 718 dilations, 152 (23%) had proximal disruptions, 118 (18%) had both proximal and distal, 317 (47%) had distal only, 110 (16%) had no disruptions. Among 250 patients receiving dilation, 150 (52%) had only disruptions in the distal esophagus. 58 (23%) had disruptions in both the proximal and distal esophagus, and 25 (10%) had only proximal disruptions. Overall, distal esophageal strictures were present in 75% whereas proximal strictures were present in 33% of patients. A single complication of a contained esophageal perforation occurred (0.14%) that was managed conservatively with antibiotics. No major bleeding complications were identified. Conclusion: (1) The results of the largest single center experience of esophageal dilation in EoE affirm that dilation is a safe procedure with low risk of major complications. (2) The majority of strictures in EoE occur in the distal rather than proximal esophagus. (3) We speculate that factors including gastroesophageal reflux may influence stricture formation in EoE.324_A Figure 1 No Caption available.324_B Figure 2 No Caption available.

Eosinophilic Esophagitis Is an Underlying Cause for Gastrointestinal Concerns in Children.

Eosinophilic esophagitis (EoE) is a chronic immune antigen-mediated disorder characterized by symptoms of esophageal dysfunction in combination with dense esophageal eosinophilia. The clinical presentation of EoE can vary depending on children's age and their ability to report symptoms, therefore a high index of suspicion for EoE is required because children and teenagers may develop coping strategies around eating. The development of symptoms measurement tools in EoE assists in not only assessing symptoms, but also coping strategies children may have developed. While the diagnosis of EoE requires endoscopic evaluation with histologic assessment of esophageal mucosal biopsy samples, several emerging methods to assess and survey the esophageal mucosa have been developed. Advances in the field to better understand the natural history, clinical and molecular features of phenotypes in EoE will be important in considering novel therapeutic options and assessing outcomes.

Proposed criteria to differentiate heterogeneous eosinophilic gastrointestinal disorders of the esophagus, including eosinophilic esophageal myositis.

AIMTo define clinical criteria to differentiate eosinophilic gastrointestinal disorder (EoGD) in the esophagus.METHODSOur criteria were defined based on the analyses of the clinical presentation of eosinophilic esophagitis (EoE), subepithelial eosinophilic esophagitis (sEoE) and eosinophilic esophageal myositis (EoEM), identified by endoscopy, manometry and serum immunoglobulin E levels (s-IgE), in combination with histological and polymerase chain reaction analyses on esophageal tissue samples.RESULTSIn five patients with EoE, endoscopy revealed longitudinal furrows and white plaques in all, and fixed rings in two. In one patient with sEoE and four with EoEM, endoscopy showed luminal compression only. Using manometry, failed peristalsis was observed in patients with EoE and sEoE with some variation, while EoEM was associated with hypercontractile or hypertensive peristalsis, with elevated s-IgE. Histology revealed the following eosinophils per high-power field values. EoE = 41.4 ± 7.9 in the epithelium and 2.3 ± 1.5 in the subepithelium; sEoE = 3 in the epithelium and 35 in the subepithelium (conventional biopsy); EoEM = none in the epithelium, 10.7 ± 11.7 in the subepithelium (conventional biopsy or endoscopic mucosal resection) and 46.8 ± 16.5 in the muscularis propria (peroral esophageal muscle biopsy). Presence of dilated epithelial intercellular space and downward papillae elongation were specific to EoE. Eotaxin-3, IL-5 and IL-13 were overexpressed in EoE.CONCLUSIONBased on clinical and histological data, we identified criteria, which differentiated between EoE, sEoE and EoEM, and reflected a different pathogenesis between these esophageal EoGDs.

Gender is a determinative factor in the initial clinical presentation of eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease resulting in symptoms of esophageal dysmotility. Abnormalities include dysphagia, food impaction and reflux. Although men appear to comprise a majority of the EoE population, few studies have directly assessed gender-associated clinical differences. The aim of this study is to identify the effect of gender on the initial clinical presentation of adult-onset EoE patients. We reviewed our electronic medical record database from January 2008 to December 2011 for adults diagnosed with EoE per the 2011 updated consensus guidelines. Patient demographics, presenting symptoms, endoscopy findings and complications were recorded. Proportions were compared using chi-squared analysis, and means were compared using the Student's t-test. A total of 162 patients met the inclusion criteria and 71 (44%) were women. Women were more likely to report chest pain (P = 0.03) and heartburn (P = 0.06), whereas men more commonly reported dysphagia (P = 0.04) and a history of food impaction (P = 0.05). Endoscopic findings were similar between groups. No patients suffered esophageal perforations. These data suggest that men report more fibrostenotic symptoms and women report more inflammatory symptoms at the time of diagnosis. There was no difference in endoscopic findings between genders. This is one of the only reviews comparing differences in clinical presentation, endoscopic findings and complications between gender for EoE. The current recommended guidelines state that any patient with symptoms of esophageal dysfunction should be biopsied for EoE. Our findings support biopsying patients with typical and atypical symptoms of dysmotility including heartburn and chest pain.

Racial Differences in the Clinical Presentation of Pediatric Eosinophilic Esophagitis

Analysis of current data suggests that 80% to 90% of children diagnosed with eosinophilic esophagitis are white. Little data exist regarding the presentation of eosinophilic esophagitis and potential clinical differences in minority children. This study compared the clinical presentation of eosinophilic esophagitis in African American children with white children treated at an urban allergy referral center. At an urban allergy clinic, a 2-year retrospective chart review was performed of 50 consecutive pediatric patients diagnosed with eosinophilic esophagitis. Presenting symptoms, age at diagnosis, coexisting atopic disease, and laboratory parameters were compared between races. Most of the 50 children identified were boys (74%), as previously described. However, unlike prior literature, most were nonwhite (42% white, 42% African American, 4% Asian, and 12% other). African American children compared with white children had (1) a significantly higher frequency of failure to thrive (P < .01) and vomiting (P < .01) as presenting symptoms, (2) a higher frequency of comorbid atopic dermatitis (P < .01), (3) a younger mean age of symptom presentation and formal diagnosis (3.7 vs 9.1 years; P < .01), and (4) a trend toward a longer interval between symptom onset and formal diagnosis. However, after adjusting for confounding variables of age and insurance type, several of these racial differences were no longer significant. African American children in this series had a larger burden of eosinophilic esophagitis than previously described as well as differences in clinical presentation compared with white patients. Analysis of these findings suggests that providers be aware of this potential diagnosis in young, atopic African American children with symptoms of esophageal dysfunction.

Eosinophilic Esophagitis among Children at King Hussein Medical Center

Objective: Eosinophilic esophagitis is a clincopathologic entity characterized by esophageal symptoms in association with a dense eosinophilic infiltrate, the aim of this study is to describe the clinical presentation, laboratory, endoscopic and histopathologic results in children diagnosed with eosinophilic esophagitis. Methods: This is a retrospective review of the medical records for 38 children with histologic diagnosis of eosinophilic esophagitis performed at King Hussein Medical Center, during the period between January 2001 to February 2011, with the cut off biopsy diagnosis ≥20/HPF eosinophilic infiltrate. Patients were excluded if gastric or duodenal biopsies showed prominent eosinophilic infiltrate. Patients medical records were reviewed regarding age at presentation, gender, clinical presentation, associated disease. Laboratory, endoscopic and histologic results were also reviewed. Results: A total 38 patients with histological diagnosis of eosinophilic esophagitis were included in this study. Thirty-one (82%) were males and 7 (18%) were females. Their ages ranged between 2-14 years. Mean age 8 years. The most commonly clinical presentation of eosinophilic esophagitis was vomiting which occurred among 26 children (68%), however, rash was presented in only one child (2%). Peripheral eosinophilia >(0.5×10/L) was found in 45%. High serum IgE level (>100 IU/ml) was found in 39%. Positive radio allergo sorbent testing in 39%. The most frequent endoscopic findings were loss of normal vascularity found in 19 (50%) children, however, white exudates were found in 2(5%) children. Mean eosinophil count was 70 (20-120), eosinophilic degranulation, and bazal zone hyperplasia reported in 18 children (47%). Conclusion: Eosinophilic esophagitis in Jordan displays similar clinical, endoscopic and pathologic features to those described in other countries. Endoscopic and histologic feature remain the gold standard for diagnosis of eosinophilic esophagitis Key word: clinical presentation, Eosinophilic esophagitis, Endoscopic and histopathologic features.

Race May Play a Role in the Clinical Presentation of Eosinophilic Esophagitis

Moawad, Fouad J MD1; Veerappan, Ganesh R MD1; Dias, Johnny A DO1; Maydonovitch, Corinne L BS1; Wong, Roy KH MD1 Author Information

Vitamin D deficiency, eosinophilic esophagitis, and health literacy

To review the recent literature on three topics that are important in pediatric office practice: vitamin D deficiency, eosinophilic esophagitis, and health literacy. Review of current literature will help pediatricians understand the prevalence of vitamin D deficiency, its potential negative health effects, and vitamin D supplementation guidelines. This article also provides practitioners with current knowledge of the evaluation and treatment of eosinophilic esophagitis. The article concludes with a summary of recent literature on health literacy and available techniques to improve patient education. Vitamin D deficiency in pediatric and adolescent patients is extremely common and has potential negative skeletal and extra-skeletal effects. Eosinophilic esophagitis is an increasingly recognized problem. Pediatric patients benefit from early recognition and treatment of the disease. There are effective techniques that improve patient health literacy. Vitamin D deficiency, eosinophilic esophagitis, and poor health literacy are three important problems that potentially negatively impact the lives of children and adolescents. Pediatricians should regularly counsel their patients regarding appropriate vitamin D intake. Practitioners should be aware of the clinical presentation of eosinophilic esophagitis. Pediatricians should utilize strategies to improve patient education with the goal of improving health outcomes.

Demographic Data and Symptoms of Eosinophilic Esophagitis in Adults

The clinical presentation of eosinophilic esophagitis in adults is varied but most often starts with some form of dysphagia. These patients often may be diagnosed incorrectly as having gastroesophageal reflux disease or functional disease, given the paucity of objective endoscopy and radiographic findings in some patients, even though symptoms often are severe and persistent. A careful history with attention to detail and a compilation of compatible characteristics is key to the clinician's diagnosing eosinophilic esophagitis in an adult.