Dense Eosinophilia Research Articles

Eosinophilic esophagitis: current perspectives from diagnosis to management

Eosinophilic esophagitis (EoE) is a chronic antigen-mediated immune disease of the esophagus characterized by symptoms related to esophageal dysfunction, as well as significant esophageal eosinophilia. Although dense eosinophilia is the hallmark of EoE, other characteristic histologic features have been described that may help distinguish EoE from other competing diagnoses, although none are specific to EoE. One or more foods and, at times, environmental allergens trigger EoE. Left untreated, esophageal inflammation in EoE may lead to esophageal remodeling and stricture formation. Symptoms in EoE vary with age, as they relate to the progression of the disease from an inflammatory to a fibrostenotic phenotype over time. There are currently no U.S. Food and Drug Administration-approved therapies for EoE. Current options include various dietary-restriction therapies, topical corticosteroids, and esophageal dilations. Several emerging therapies aiming at restoring the esophageal barrier function or targeting various inflammatory cells or their mediators are under investigation.

Mo1842 Comparison of Inflammatory Versus Fibrostenotic Phenotype in Eosinophilic Esophagitis

Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory condition which causes esophageal remodeling and stricture formation over time. Aim: To explore the natural course of symptoms, endoscopic findings to include stricture development, and histology in EoE patients. Methods: EoE adult patients (age > 18 years) were prospectively enrolled from databases of two medical centers (Walter Reed and Mayo Clinic Jacksonville). All EoE patients were diagnosed per recent consensus guidelines. All patients completed index and follow-up symptom surveys. Endoscopic features (rings, furrows, plaques, strictures) and histology from index and follow-up endoscopies were recorded. Disease behavior was classified as inflammatory if endoscopic findings demonstrated furrows or white plaques and classified as fibrostenotic if endoscopic findings included rings or strictures. Results: 165 EoE patients were identified, mean age 42 ± 14 years; 88.5% Caucasian and 70% male. Median (range) duration of symptoms prior to EoE diagnosis was 66 months (0.1-425). Median follow-up time was 19.2 months (0.9-120). At index, the majority (124/165, 75%) presented with fibrostenotic EoE and 25% (41/165) presented with inflammatory disease. Patients who presented with a stricture had a significantly longer duration of symptoms prior to diagnosis (130 vs 86 months, p=0.011). Patients with fibrostenotic features had more food allergies than those with inflammatory disease (23.4% vs. 4.9%, p=0.010); otherwise, other allergic conditions were similar. At index endoscopy, significantly more patients with fibrostenotic disease had dense proximal eosinophilia (>15 eos/hpf) than patients with inflammatory disease (81.1% vs. 64.3%, p=0.015), but were similar in degree of distal eosinophilia (86.4% vs. 85.3%, p=0.415). Over time, disease behavior remained unchanged in the majority (87.3%, 144/165) of patients. Of the 41 patients presenting with inflammatory disease, 21 patients (51%) developed fibrostenotic features with 15 of these developing a stricture at follow-up endoscopy. Patients who developed fibrostenosis had more dense eosinophilia on biopsies (proximal 68.4% vs. 20.0%, p=0.015; distal 68.2% vs. 36.8%, p=0.049) than those who maintained inflammatory features. The majority of patients (68%) reported improved symptoms over time regardless of their disease behavior. Conclusions: The majority of patients with EoE present with or develop fibrostenotic disease. Duration of symptoms was significantly greater in patients presenting with stricture. Dense proximal esophageal eosinophilia is associated with the presence of fibrostenosic disease and higher levels of eosinophilia may predict transformation from inflammatory to fibrostenotic disease.

Mo1843 Mast Cell Densities on Esophageal Mucosal Biopsies Were Higher in Eosinophilic Esophagitis Versus Proton Pump Inhibitor-Responsive Esophageal Eosinophilia in Adults

Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory condition which causes esophageal remodeling and stricture formation over time. Aim: To explore the natural course of symptoms, endoscopic findings to include stricture development, and histology in EoE patients. Methods: EoE adult patients (age > 18 years) were prospectively enrolled from databases of two medical centers (Walter Reed and Mayo Clinic Jacksonville). All EoE patients were diagnosed per recent consensus guidelines. All patients completed index and follow-up symptom surveys. Endoscopic features (rings, furrows, plaques, strictures) and histology from index and follow-up endoscopies were recorded. Disease behavior was classified as inflammatory if endoscopic findings demonstrated furrows or white plaques and classified as fibrostenotic if endoscopic findings included rings or strictures. Results: 165 EoE patients were identified, mean age 42 ± 14 years; 88.5% Caucasian and 70% male. Median (range) duration of symptoms prior to EoE diagnosis was 66 months (0.1-425). Median follow-up time was 19.2 months (0.9-120). At index, the majority (124/165, 75%) presented with fibrostenotic EoE and 25% (41/165) presented with inflammatory disease. Patients who presented with a stricture had a significantly longer duration of symptoms prior to diagnosis (130 vs 86 months, p=0.011). Patients with fibrostenotic features had more food allergies than those with inflammatory disease (23.4% vs. 4.9%, p=0.010); otherwise, other allergic conditions were similar. At index endoscopy, significantly more patients with fibrostenotic disease had dense proximal eosinophilia (>15 eos/hpf) than patients with inflammatory disease (81.1% vs. 64.3%, p=0.015), but were similar in degree of distal eosinophilia (86.4% vs. 85.3%, p=0.415). Over time, disease behavior remained unchanged in the majority (87.3%, 144/165) of patients. Of the 41 patients presenting with inflammatory disease, 21 patients (51%) developed fibrostenotic features with 15 of these developing a stricture at follow-up endoscopy. Patients who developed fibrostenosis had more dense eosinophilia on biopsies (proximal 68.4% vs. 20.0%, p=0.015; distal 68.2% vs. 36.8%, p=0.049) than those who maintained inflammatory features. The majority of patients (68%) reported improved symptoms over time regardless of their disease behavior. Conclusions: The majority of patients with EoE present with or develop fibrostenotic disease. Duration of symptoms was significantly greater in patients presenting with stricture. Dense proximal esophageal eosinophilia is associated with the presence of fibrostenosic disease and higher levels of eosinophilia may predict transformation from inflammatory to fibrostenotic disease.

Esofagite eosinofílica e alergia alimentar: há ou não relação estabelecida? Caso clínico

IntroductionEosinophilic esophagitis (EE) is an entity characterized by esophageal symptoms with the presence of dense eosinophilia, in the absence of reflux disease excluded by pHmetry or lack of response to treatment with proton pump inhibitor. Various guidelines try to establish diagnostic criteria. Clinical caseTeenager, 14 years old. A history of low birth weight from 19 months (p5) and asthma since age of 3. Started symptoms of intermittent dysphagia, being placed reflux disease hypothesis, he did prolonged treatment with PPI with no success. The patient was refered to the Digestive Pathology enquiry, because of persistence of complaints, now with dysphagia for solids and impact feeding episodes. In HDE the progression of the endoscope was not possible by the existence of stenosis, in a mucosa with traqueiform rings. A biopsy confirmed the diagnosis. Were performed allergens tests with positivity for food and inhalant allergens (hazelnut, wheat). Started fluticasonewith with slight improvement. Later, started eviction of food he had allergy, showing clinical improvement, which resulted in weight gain (p10‐25). ConclusionThe pathogenesis of EE is related to atopy. The goal of treatment is to improve the quality of life of the patient. As illustrated by this case, the control of the disease with a dietary component led to greater clinical improvement.

Su1873 Eosinophilic Esophagitis in Patients Presenting With Dysphagia–a Prospective Analysis

Introduction Eosinophilic oesophagitis (EO) is a chronic relapsing,immune/antigen mediated disease of the oesophagus with rapidly increasing incidence and prevalence; however EO often remains under-diagnosed. Early detection and appropriate therapy improves quality of life and may prevent development of chronic oesophageal changes. A diagnosis can only be made when a dense eosinophilia is confirmed on histology in the context of typical symptoms (e.g.solid food dysphagia) 1 .We prospectively assessed the prevalence of EO in patients presenting to endoscopy at a tertiary referral centre with solid food dysphagia over 2 years. Methods Between Jan 2010 and Dec 2011,746 patients with dysphagia (including food bolus obstruction)had high definition white light endoscopy performed. Patient demographics,symptomatology,endoscopic and histological findings were recorded.EO was defined as the presence of > 15 eosinophils per high power field Results Patients with oesophageal malignancy (n = 65),barrett’s oesophagus(n = 48) and post-oesophageal surgery complications (n = 16) were excluded. Of the 628 remaining patients,388(62%) (254 male; mean age 59; range 18–88) had mid-oesophageal biopsies taken.23/388 (5.9%)were diagnosed with EO 19 male; mean age 40; range 26–56).Endoscopy showed mucosal pathology in 12/23 (52%)patients with confirmed EO; oesophagitis (n = 3),red furrows (n = 3),distal narrowing (n = 2),corrugated rings (n = 2),mucosal tear (n = 1) and white exudates (n = 1).250 of the remaining patients had grade A or B oesophagitis. Overall 17 patients had food bolus obstruction.11/17 patients had biopsies taken and 5/11(46%) showed histological evidence of EO.4/5 patients with bolus obstruction had distal oesophagitis on endoscopy but EO was confirmed following ≥4 mid-oesophageal biopsies. There was a trend towards those with EO having had a greater number of biopsies taken (mean 6.14; range 2–12) compared to those without EO (mean 5.02; range 2–8; p = 0.082).28% and 51% had ≤3 and ≤4 biopsies collected respectively. The mean (±SD) number of eosinophils/hpf in the EO group was 64.3 (51.3). Conclusion Mid-oesophageal biopsies can diagnose EO in at least 1 in 16 cases of patients with unexplained solid food dysphagia.However,1/3 of patients in whom EO should have been considered (including 6 with food bolus obstruction)did not have biopsies collected.Furthermore, 1/4 had less than the recommended minimum 4 mid-oesophageal biopsies. In summary, our experience has shown that EO detection is likely to improve further if all patients with symptoms conducive with EO (e.g.solid food dysphagia) routinely trigger an EO biopsy protocol of ≥4 from the mid-oesophagus regardless of endoscopic findings. Disclosure of Interest None Declared Reference Liacouras CA, Furuta GT et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128(1):3–20 e6.

Eosinophilic gastrointestinal diseases—clinically diverse and histopathologically confounding

Eosinophilic gastrointestinal diseases are a group of chronic diseases characterized by a range of symptoms caused by eosinophilic inflammation of various parts of the gastrointestinal tract. Other causes for eosinophilia need to be ruled out prior to making the diagnosis of EGIDs. The most common form of EGID is eosinophilic esophagitis (EoE), an antigen-driven disease that afflicts children and adults and has been identified across the world. Histological features include dense eosinophilia of the esophageal mucosa, eosinophil degranulation, eosinophil microabscess formation, and other features of epithelial inflammation including basal zone hyperplasia and rete pege elongation. Treatments include dietary exclusions and topical corticosteroids.

Feeding Difficulties in Children With Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a recently recognized inflammatory disease that is characterized by upper intestinal symptoms and dense eosinophilia of the esophageal mucosa. Food refusal, dysphagia, and reduced volume and variety of intake are common symptoms associated with eosinophilic esophagitis in children (Furuta et al., 2007; Spergel, 2007). Accurate diagnosis of eosinophilic esophagitis is frequently missed as many of its features are similar to other gastrointestinal diseases (Aceves, Furuta, & Spechler, 2008). Oftentimes, before this diagnosis is made, a feeding specialist is the first contact for these children in response to their eating difficulties. Gastroenterologists, allergists, feeding specialists, dietitians, psychologists, and social workers are now collaborating to provide integrated, comprehensive care for optimal diagnosis and treatment of children with eosinophilic esophagitis. In the general population, feeding difficulties are present in 25% of typically developing children and in 75-80% of children with developmental disabilities (Eicher, 1997; Iwata, Riordan, Wohl, & Finney, 1982; Kedesky & Budd, 1998; Kerwin, Ahearn, Eicher, & Burd, 1995; Lefton-Greif & Arvedson, 2007). Although prevalence numbers for feeding issues in children with eosinophilic esophagitis are unknown, it is anticipated that the prevalence will fall closer to that of children with developmental disabilities.

Estenosis esofágica en una esofagitis eosinofílica

Eosinophilic esophagitis is a rare, recently discovered disease, characterized by esophageal symptoms, such as dysphagia and food impaction, associated with dense eosinophilia on endoscopic biopsy of the esophagus. Other entities such as gastroesophageal reflux disease are absent and there is a lack of response to proton pump inhibitor therapy. This disease mainly affects the pediatric population but is becoming more prevalent in adults. There are several theories on the etiopathogenesis of this entity, which may involve allergies and atopy. In advanced disease, complications such as esophageal stenosis can appear. Treatment is based on dietary elimination, corticosteroids and endoscopic dilatation. We report a case of eosinophilic esophagitis with esophageal stenosis.