Treatment Of Eosinophilic Esophagitis Research Articles

Age-based Differences in the Diagnosis and Management of Esophageal Eosinophilia

Eosinophilic esophagitis (EoE) is hallmarked by esophageal eosinophilia, >15 eosinophils(eos)/high-powered field (hpf), unresponsive to acid inhibition, and varied symptomatology. EoE consensus guidelines do not discriminate based on age for initiating treatment. To evaluate if age-related differences exist in managing esophageal eosinophilia and EoE within a university population. In a retrospective cohort study from a referral center, the medical records of 426 pediatric and adult patients with at least 1 presenting symptom of esophagitis, reflux, or upper gastrointestinal dysfunction, who underwent esophageal biopsy between 2009 and 2011 were analyzed for age-based differences in care in diagnosing and managing esophageal eosinophilia. For these patients, 79.6% (336/426) had ≥15 eos/hpf in biopsy specimens, which was not associated with age. Significantly fewer adults than children with ≥15 eos/hpf were diagnosed with EoE (P < .001), referred for allergy evaluation (P < .001), started on swallowed steroid therapy (P < .001), or underwent repeated biopsy (P < .001). Increasing age, atopy, and increasing biopsy peak eos count moderated these effects, but the adjusted predicted probabilities for these outcomes were significantly lower among adults. Restriction for an 8-week prebiopsy proton-pump inhibitor trial did not alter the age-based relationships for an allergy referral or repeated biopsy. Numerous age-based differences in the management of symptomatic patients with esophageal eosinophilia existed in this cohort. Adults were significantly less likely than children to receive a clinical diagnosis of EoE, allergy referral, or steroid treatment, or to have a repeated biopsy. Even when stratified for an 8-week prebiopsy proton-pump inhibitor trial, advancing age was associated with lower odds of referral or repeated biopsy. Further study is necessary to better understand why discrepancies exist and their potential ramifications.

Efficacy of Topical Corticosteroids in the Treatment of Eosinophilic Esophagitis: A Meta-Analysis and Systematic Review of Placebo Controlled Randomized Clinical Trials

Efficacy of Topical Corticosteroids in the Treatment of Eosinophilic Esophagitis: A Meta-Analysis and Systematic Review of Placebo Controlled Randomized Clinical Trials

P-085: Resolution of factor XI (FXI) deficiency in refractory ulcerative colitis (UC) after surgery: a case report

s of the 3rd International Symposium on Pediatric Inflammatory Bowel Disease S425 (perianal disease, ileal and/or colonic stenosis with or without abscess with respective resections). In multivariate analysis, no association with age, gender, inflammatory and serologic markers was detected. Conclusion: IBD is rare in our country, however extensive forms predominate and rates of surgery are high, especially in CD (40% by the final visit), with important resections, reflecting the severity of IBD. Family history and positivity of ANCA and ASCA are low; therefore, other factors have to be involved in this aggressive phenotype. P-084 Eosinophilic gastroenteropathy from diet to colectomy A. Karoliny1 *, J.B. Kovacs1, A. Nagy1, N. Lasztity1, K. Meichelbeck1, L. Karsza1, G. Hegyi1, B. Lestar2, G. Veres3, M. Lorincz1. 1Pal Heim Children’s Hospital, Budapest, Hungary, 2Hungarian Defence Forces Med. Center, Dept. of Surgery, Budapest, Hungary, 31st Dept. of Pediatrics, Semmelweis University, Budapest, Budapest, Hungary Background: Incidence of eosinophilic gastrointestinal disorders is increasing worldwide, however, precise pathomechanism, diagnostic criteria and therapy, in severe cases, is not well known. While there are well documented publications and guidelines about the clinical manifestation and treatment of eosinophilic oesophagitis the incidence, clinical manifestation and treatment of primary eosinophilic gastroenterocolitis is less well known. Case report: A 4-year-old male patient was presented with massive haematochesia and diarrhoea. Upper and lower endoscopy showed gastritis, duodenitis and ulcerative pancolitis, respectively. Histology confirmed eosinophilic gastroenteropathy (>100 eosinophils/HPF in duodenum and colon). 5-ASA, systemic corticosteroid, leukotriene receptor antagonist and azathioprine treatment combined with elimination diet did not achieve remission. Due to further deterioration and increased transfusion demand nasogastric feeding with amino acid based formula was introduced. After two years of unsuccessful conventional therapy infliximab was given, but due to severe bloody diarrhoea total colectomy was needed. After 12 months of follow-up, the patients is symptom free, growing well with no hematochezia. None of the upper and lower endoscopies, biopsies, and colectomy specimens showed any signs of Inflammatory Bowel Disease (IBD), but high number of eosinophils. Conclusion: IBD and eosinophilic colitis may share a common phenomenon resulting differencial diagnostic difficulties. Here, we presented a patient with severe form of eosinophilic gastroenteritis causes life-threatening hematochezia. Biological treatment and colectomy for this indication is rarely indicated. P-085 Resolution of factor XI (FXI) deficiency in refractory ulcerative colitis (UC) after surgery: a case report A. Angelakopoulou1 *, K. Lindley2, M. Mathias2, S. McCartney3, A. Windsor3, F. Kiparissi1. 1Great Ormond Street Hospital NHS Trust, London, United Kingdom, 2Great Ormond Street Hospital, London, United Kingdom, 3University College London Hospital NHS Trust, London, United Kingdom Introduction: Coagulation abnormalities in acute inflammatory conditions such as sepsis are well recognised. Chronic inflammatory conditions, such as Inflammatory Bowel Disease, have the potential to induce a coagulopathic or procoagulant state with potential devastating consequences. Aim: To report the resolution of severe FXI deficiency in severe UC post colectomy and restorative surgery. Methods: We present the case of a 14-year-old male with severe UC, FXI deficiency and an acute, thrombotic cerebrovascular event. Results: The patient presented with two-week history of headache, vomiting, altered consciousness and left leg weakness, one year after diagnosis of severe UC refractory to combination immunosuppressive therapy. MRI changes in keeping with Right Middle Cerebral Artery ischaemic stroke. Cerebral/visceral angiography excluded systemic vasculitis. Investigations revealed APTT of 67.3s (26 38s) and low FXI (13 IU/dl; 50 150). Platelet count showed a drop post stroke (lowest 76) with subsequent gradual recovery. Congenital FXI deficiency was excluded by patient genetic and parental FXI testing. Lifelong aspirin anticoagulation was commenced. No neurological sequelae were observed. UC remained uncontrolled despite escalation to non-conventional immunosuppression; he underwent subtotal colectomy and ileostomy formation with good results. Lowest FXI levels were documented pre-operatively (8 IU/dl) and treated with FXI concentrate. FXI showed spontaneous normalisation within 2 years of surgery (FXI >50 IU/dl) with no further complications. Conclusion: Clinicians should recognise the haematological implications of UC, especially in cases refractory to medical therapy. In our patient, FXI deficiency was secondary to uncontrollable gastrointestinal inflammation and normalised after definitive surgical treatment. P-086 Total colectomy in pediatric ulcerative colitis: a cohort study from a tertiary center in Greece K. Dimakou, S. Fessatou, M. Maragoudaki, I. Panayotou, E. Roma-Giannikou*, G. Chouliaras. University of Athens, “Aghia Sophia” Children’s Hospital, Athens, Greece Introduction: Pharmacological interventions may induce and maintain clinical remission in children with ulcerative colitis (UC). Nevertheless a significant proportion of these patients may, ultimately, undergo total colectomy (TC) due to refractory disease. Aim: To assess the observed rate of colectomy in pediatric UC in Greece. Patients were classified according to period of diagnosis (1981 1989, 199

P-084: Eosinophilic gastroenteropathy – from diet to colectomy

s of the 3rd International Symposium on Pediatric Inflammatory Bowel Disease S425 (perianal disease, ileal and/or colonic stenosis with or without abscess with respective resections). In multivariate analysis, no association with age, gender, inflammatory and serologic markers was detected. Conclusion: IBD is rare in our country, however extensive forms predominate and rates of surgery are high, especially in CD (40% by the final visit), with important resections, reflecting the severity of IBD. Family history and positivity of ANCA and ASCA are low; therefore, other factors have to be involved in this aggressive phenotype. P-084 Eosinophilic gastroenteropathy from diet to colectomy A. Karoliny1 *, J.B. Kovacs1, A. Nagy1, N. Lasztity1, K. Meichelbeck1, L. Karsza1, G. Hegyi1, B. Lestar2, G. Veres3, M. Lorincz1. 1Pal Heim Children’s Hospital, Budapest, Hungary, 2Hungarian Defence Forces Med. Center, Dept. of Surgery, Budapest, Hungary, 31st Dept. of Pediatrics, Semmelweis University, Budapest, Budapest, Hungary Background: Incidence of eosinophilic gastrointestinal disorders is increasing worldwide, however, precise pathomechanism, diagnostic criteria and therapy, in severe cases, is not well known. While there are well documented publications and guidelines about the clinical manifestation and treatment of eosinophilic oesophagitis the incidence, clinical manifestation and treatment of primary eosinophilic gastroenterocolitis is less well known. Case report: A 4-year-old male patient was presented with massive haematochesia and diarrhoea. Upper and lower endoscopy showed gastritis, duodenitis and ulcerative pancolitis, respectively. Histology confirmed eosinophilic gastroenteropathy (>100 eosinophils/HPF in duodenum and colon). 5-ASA, systemic corticosteroid, leukotriene receptor antagonist and azathioprine treatment combined with elimination diet did not achieve remission. Due to further deterioration and increased transfusion demand nasogastric feeding with amino acid based formula was introduced. After two years of unsuccessful conventional therapy infliximab was given, but due to severe bloody diarrhoea total colectomy was needed. After 12 months of follow-up, the patients is symptom free, growing well with no hematochezia. None of the upper and lower endoscopies, biopsies, and colectomy specimens showed any signs of Inflammatory Bowel Disease (IBD), but high number of eosinophils. Conclusion: IBD and eosinophilic colitis may share a common phenomenon resulting differencial diagnostic difficulties. Here, we presented a patient with severe form of eosinophilic gastroenteritis causes life-threatening hematochezia. Biological treatment and colectomy for this indication is rarely indicated. P-085 Resolution of factor XI (FXI) deficiency in refractory ulcerative colitis (UC) after surgery: a case report A. Angelakopoulou1 *, K. Lindley2, M. Mathias2, S. McCartney3, A. Windsor3, F. Kiparissi1. 1Great Ormond Street Hospital NHS Trust, London, United Kingdom, 2Great Ormond Street Hospital, London, United Kingdom, 3University College London Hospital NHS Trust, London, United Kingdom Introduction: Coagulation abnormalities in acute inflammatory conditions such as sepsis are well recognised. Chronic inflammatory conditions, such as Inflammatory Bowel Disease, have the potential to induce a coagulopathic or procoagulant state with potential devastating consequences. Aim: To report the resolution of severe FXI deficiency in severe UC post colectomy and restorative surgery. Methods: We present the case of a 14-year-old male with severe UC, FXI deficiency and an acute, thrombotic cerebrovascular event. Results: The patient presented with two-week history of headache, vomiting, altered consciousness and left leg weakness, one year after diagnosis of severe UC refractory to combination immunosuppressive therapy. MRI changes in keeping with Right Middle Cerebral Artery ischaemic stroke. Cerebral/visceral angiography excluded systemic vasculitis. Investigations revealed APTT of 67.3s (26 38s) and low FXI (13 IU/dl; 50 150). Platelet count showed a drop post stroke (lowest 76) with subsequent gradual recovery. Congenital FXI deficiency was excluded by patient genetic and parental FXI testing. Lifelong aspirin anticoagulation was commenced. No neurological sequelae were observed. UC remained uncontrolled despite escalation to non-conventional immunosuppression; he underwent subtotal colectomy and ileostomy formation with good results. Lowest FXI levels were documented pre-operatively (8 IU/dl) and treated with FXI concentrate. FXI showed spontaneous normalisation within 2 years of surgery (FXI >50 IU/dl) with no further complications. Conclusion: Clinicians should recognise the haematological implications of UC, especially in cases refractory to medical therapy. In our patient, FXI deficiency was secondary to uncontrollable gastrointestinal inflammation and normalised after definitive surgical treatment. P-086 Total colectomy in pediatric ulcerative colitis: a cohort study from a tertiary center in Greece K. Dimakou, S. Fessatou, M. Maragoudaki, I. Panayotou, E. Roma-Giannikou*, G. Chouliaras. University of Athens, “Aghia Sophia” Children’s Hospital, Athens, Greece Introduction: Pharmacological interventions may induce and maintain clinical remission in children with ulcerative colitis (UC). Nevertheless a significant proportion of these patients may, ultimately, undergo total colectomy (TC) due to refractory disease. Aim: To assess the observed rate of colectomy in pediatric UC in Greece. Patients were classified according to period of diagnosis (1981 1989, 199

Esophageal dilations in eosinophilic esophagitis: a single center experience.

To diagnose the clinical and histologic features that may be associated with or predictive of the need for dilation and dilation related complications; examine the safety of dilation in patients with eosinophilic esophagitis (EoE). The medical records of all patients diagnosed with EoE between January 2002 and July 2010 were retrospectively reviewed. Esophageal biopsies were reexamined by an experienced pathologist to confirm the diagnosis (≥ 15 eos/hpf per current guidelines). Patients were divided into 2 groups: patients who did not receive dilation therapy and those who did. Demographics, clinical history, the use of pharmacologic therapy, endoscopic and pathology findings, and the number of biopsies and dilations carried out, if any, and their locations were recorded for each patient. The dilation group was further examined based on the interval between diagnosis and dilation, and whether or not a complication occurred. Sixty-one patients were identified with EoE and 22 (36%) of them underwent esophageal dilations for stricture/narrowing. The peak eos/hpf was significantly higher in patients who received a dilation (P = 0.04). Four (18% of pts.) minor complications occurred: deep mucosal tear 1, and small mucosal tears 3. There were no cases of esophageal perforations. Higher peak eos/hpf counts were not associated with increased risk of complications. Esophageal dilation appears to be a safe procedure in EoE patients, carrying a low complication rate. No correlation was found between the peak of eosinophil count and complication rate. Complications can occur independently of the histologic features. The long-term outcome of EoE treatment, with or without dilation, needs to be determined.

Swallowed topical corticosteroids reduce the risk for long-lasting bolus impactions in eosinophilic esophagitis.

Long-lasting food impactions requiring endoscopic bolus removal occur frequently in patients with eosinophilic esophagitis (EoE) and harbor a risk for severe esophageal injuries. We evaluated whether treatment with swallowed topical corticosteroids is able to reduce the risk of occurrence of this complication. We analyzed data from the Swiss EoE Cohort Study. Patients with yearly clinic visits, during which standardized assessment of symptoms, endoscopic, histologic, and laboratory findings was carried out, were included. A total of 206 patients (157 males) were analyzed. The median follow-up time was 5years with a total of 703 visits (mean 3.41visits/patient). During the follow-up period, 33 patients (16 % of the cohort) experienced 42 impactions requiring endoscopic bolus removal. We evaluated the following factors regarding the outcome 'bolus impaction' by univariate logistic regression modeling: swallowed topical corticosteroid therapy (OR 0.503, 95%-CI 0.255-0.993, P=0.048), presence of EoE symptoms (OR 1.150, 95%-CI 0.4668-2.835, P=0.761), esophageal stricture (OR 2.832, 95%-CI 1.508-5.321, P=0.001), peak eosinophil count >10eosinophils/HPF (OR 0.724, 95%-CI 0.324-1.621, P=0.433), blood eosinophilia (OR 1.532, 95%-CI 0.569-4.118, P=0.398), and esophageal dilation (OR 1.852, 95%-CI 1.034-3.755, P=0.017). In the multivariate model, the following factors were significantly associated with bolus impaction: swallowed topical corticosteroid therapy (OR 0.411, 95%-CI 0.203-0.835, P=0.014) and esophageal stricture (OR 2.666, 95%-CI 1.259-5.645, P=0.01). Increasing frequency of use of swallowed topical steroids was associated with a lower risk for bolus impactions. Treatment of EoE with swallowed topical corticosteroids significantly reduces the risk for long-lasting bolus impactions.

Steroids versus dietary therapy for the treatment of eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a condition characterized by dense mucosal eosinophilia in conjunction with symptoms of esophageal dysfunction. Since both the incidence and prevalence of EoE are on the rise in both children and adults, understanding the various treatment options available is imperative in choosing the proper treatment for each patient. This article will highlight the major strides in both medical and dietary treatment of EoE in the past year. Whereas prior studies have shown that medical therapy with topical corticosteroids is effective in treating EoE, this more recent literature highlights some of the limitations of this approach, raising awareness that development of better drug delivery models is greatly needed. The review also describes the recent advances in the field of dietary therapy for this disease, particularly in adults, and further supports the notion that the pathophysiology of this disease in children and adults is similar, with food antigens driving this disease. Both medical and dietary therapy are effective for treating adults and children with EoE. Choosing the optimal treatment approach should be individualized based both on patient goals and on available local resources. Future prospective clinical trials comparing these two treatment modalities are needed to help understand comparable effectiveness as well as to help understand potential predictors of response to treatment and identify optimal therapeutic endpoints.

Mo1840 Most Patients Demonstrate Correlation Between Symptoms, Endoscopic Findings, and Histology in Response to Topical Steroid Treatment in Eosinophilic Esophagitis

G A A b st ra ct s major basic protein. These genetic products have not been previously used to differentiate between the two phenotypes of EoE. Methods We prospectively entered patients from 2012 who presented to the USF Joy McCann Swallowing Center. Informed consent was obtained to acquire 6 additional biopsies from the proximal and distal esophagus. These tissue samples were stored in an EoE tissue bank. EoE phenotype was classified as time of their first endoscopy by luminal diameter. Fibrostenotic disease was defined as a luminal diameter less than 17 mm based on resistance to passage of the smallest diameter bougie and inflammatory as 17 mm or above. Expression analysis of the complete genome using the Affymetrix U133 Plus 2.0 array was then performed to compare fibrostenotic to inflammatory phenotypes. Results Ten patients with EoE (4 fibstenotic and 6 inflammatory) were evaluated by gene expression microarray analysis. Inflammatory EoE was used as control during analysis. A total of 54,676 probe sets representing the entire transcriptome were analyzed. Of these, 825 were genes that had a greater than 2-fold difference and an ANOVA p-value of <.05. (Figure 1). The genes previously reported in the pediatric population, including TGF-beta 1, IL-15, eotaxin-3, TSLP, periostin, and MBP, did not demonstrate a significant difference. Discussion Following microarray analysis of 10 patients with EoE, subtle differences were seen between the two groups, but not in genes that have been associated with the disease previously. The majority of genes reviewed did not have a significant difference between the two phenotypes. This may be because factors contributing to fibrostenotic EoE disease are not genetic, but rather due to duration of the chronic eosinophilic inflammation.

429 Maturational Changes in Esophageal Fibroblasts: Implications Upon the Natural History and Treatment of Eosinophilic Esophagitis

429 Maturational Changes in Esophageal Fibroblasts: Implications Upon the Natural History and Treatment of Eosinophilic Esophagitis

Su1756 Endoscopic Ultrasound (EUS): a Proposed Role in Pediatric Eosinophilic Esophagitis (EoE)

Previously, EUS has documented increased esophageal (esph) total wall thickening (TWT) in Pediatric Eosinophilic Esophagitis (EoE) compared to children with gastroesophageal reflux (GER) and decreased TWT in adults who responded to EoE treatment. This report describes EUS data obtained in a longitudinal study on the evolution of Pediatric EoE .

Practical approach to implementing dietary therapy in adults with eosinophilic esophagitis: the Chicago experience

Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated esophageal disease characterized by esophageal dysfunction and esophageal mucosal eosinophilia. Diet therapy is effective in the treatment of EoE in both children and adults. The role of food allergens is well established in the pathogenesis and treatment of eosinophilic esophagitis. Empiric elimination with a six-food elimination diet (avoiding milk, wheat, egg, soy, peanuts/tree nuts, and fish/shellfish) demonstrates remission in over 70% of adults with this disease. Dietary therapy in adult EoE is becoming more accepted by both patients and clinicians. Dietary therapy can be effectively implemented in clinical practice with appropriate dietary education, patient resources, and close communication with physician and clinical staff. The ability to identify specific food triggers to help tailor dietary therapy for long-term management allows for a return to consumption of most table foods. Furthermore, the diet approach avoids the need for chronic topical corticosteroid use and possible long-term side effects of these medications. The decision to proceed with dietary therapy should be decided by patient preference and available resources. A collaborative and multidisciplinary approach including gastroenterologists, allergists, nurses, and dietitians is essential in the success of this approach.

Immunotherapeutic approaches for the treatment of eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a clinical pathologic disease characterized by symptoms of esophageal dysfunction and eosinophilia of the esophagus. When the diagnosis is confirmed, it is important to treat the eosinophilic inflammation not only to control the presenting symptoms, but also to prevent acute and chronic complications. The pathogenesis of EoE is most likely a mixed IgE and non-IgE food-mediated reaction, where Th2 cytokines drive esophageal eosinophilia as in other atopic diseases. Hence, it is not surprising that therapy is based on inflammation control, with steroids (oral or topical) and/or food antigen avoidance. However, these treatment options are not specific, reduce the quality of life of patients and have significant side effects, therefore, there is an ongoing effort to design more specific immunotherapies. In this review, we review standard and immunotherapeutic options for EoE treatment, such as anti-IL-5, anti-TNFα, anti-IgE, anti-CRTH, oral allergy desensitization and environmental immunotherapy.

PD21 ‐ Diagnosis and treatment of eosinophilic esophagitis guided by micro‐arrays technology

Background Eosinophilic esophagitis (EoE) is an immune-mediated disease of the esophagus characterized by symptoms related to esophageal disfunction and histollogically by an eosinophil-predominat inflammation. Multiple therapies have been suggested to be helpful in EoE including endoscopic dilation, medical therapy and withdrawal dietary but, the election of what food should be excluded is very difficult. Component-resolved diagnosis and microarray technology have been recently introduced into clinical allergy practice, and may be particularly useful in food-sensitized allergic patients.

PP-026 Oral viscous budesonide suspension for the treatment of eosinophilic esophagitis

BackgroundBudesonide is a frequently used glucocorticoid in the treatment of eosinophilic esophagitis and other inflammatory gastrointestinal diseases.In the Czech Republic the treatment of oesophageal inflammation by topical corticosteroids has only...

Is the consistency more important than the ingredients for steroid treatment in eosinophilic esophagitis?

Is the consistency more important than the ingredients for steroid treatment in eosinophilic esophagitis?

Invariant natural killer T-cell neutralization is a possible novel therapy for human eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a recently recognized inflammatory disorder that needs a potential therapeutic strategy. We earlier showed that iNKT cell-deficient mice are protected from allergen-induced EoE. Therefore, we now tested the hypothesis that iNKT cells are induced in the human EoE and is a novel possible target for the treatment of human EoE. Accordingly, we examine number of iNKT cells and eosinophils and expression of iNKT-associated cell surface receptors and chemokines by performing immunofluorescence, qPCR and ELISA in the esophageal biopsies and blood samples of normal subjects (comparison control) and EoE patients. Herein, we show that iNKT cell number, their receptor subcomponents Vα24 and Vβ11 expression, and associated chemokine CXCL16 levels (or expression) are induced significantly in EoE patients compared with normal individuals. In addition, we show that CXCL16 levels (or expression) correlate with the mRNA levels of Vα24 receptor but not well with esophageal eosinophilia in human EoE. Of note, we show that in vivo activation of iNKT cells is sufficient to induce EoE in mice. Furthermore, we show that anti-mCD1d- and anti-hVα24Jα18-neutralizing antibody treatment protects allergen-induced experimental EoE. Taken together, we have shown first time that iNKT cells have a critical pathogenic role in human and experimental EoE. iNKT cell neutralization by humanized anti-CD1d and anti-Vα24Jα18 antibodies might be a novel and potential therapy for human EoE.

Eosinophilic Esophagitis Might Progress from Inflammatory to Fibrostenotic Disease

The optimal type and duration of treatment for eosinophilic esophagitis (EoE) remain unknown. In particular, the need for and effect of chronic or

Predictors of Non-Response to Topical Steroids Treatment in Eosinophilic Esophagitis

Predictors of Non-Response to Topical Steroids Treatment in Eosinophilic Esophagitis

“Hard to Swallow”: Dysphagia due to Eosinophilic Esophagitis in Adult Patient with Celiac Disease

Purpose: Background: Celiac Disease (CD) and eosinophilic esophagitis (EoE) have been reported concurrently in children and more recently in adults. Common etiological factor underlying both diseases are ingested and/or aero allergens. Management is based on dietary changes and/or topical steroids. Neuropsychiatric CD manifestations present barriers to diagnosis and management. Case: A 27-year-old man diagnosed to have CD, and anxiety disorder was evaluated for worsening dysphagia. Previous duodenal biopsies were consistent with Marsh III CD. He had a 7-year history of dyspepsia and dysphagia to both solids and liquids. He had three food impactions over past 3 years. Upper endoscopies (EGD) for disimpaction were suggestive of EoE and despite recommendations, he was nonadherent to gluten free diet (GFD) and had discontinued PPI therapy as it failed to improve dyspepsia and dysphagia symptoms. Well-chewed foods were easier to swallow, but for past 2 months, he reported choking even with swallowing saliva. He did not report food allergies. Examination was notable for a BMI of 30.4, anxiety, and absence of skin rash. Laboratory data: hemoglobin- 16g/dL, antiendomysial IgA positive, gliadin IGG 11 (<4.9EU/ml), gliadin IGA 1.4 (>6.1 EU/ml), heterozygous DQ8 genotype. Barium swallow was normal except for demonstration of gastro esophageal reflux on valsalva. EGD showed longitudinal furrows and plaques in mid esophagus and edematous duodenal mucosa. Biopsy of esophageal and duodenal mucosa confirmed EoE and CD diagnoses (marked increased esophageal intraepithelial eosinophils, >50 per high power field with degranulation and increased duodenal intraepithelial lymphocytosis, villous atrophy, and crypt hyperplasia with increased mitosis- Marsh III CD). In addition to nutritional counseling for GFD, patient was prescribed oral fluticasone and elimination diet for EoE treatment. He was also compliant with his psychiatric medications. At one-month follow up, dyspepsia was improved, dysphagia completely resolved- no choking spells. DISCUSSION Co-existent CD and EoE has been reported in pediatric literature but there are only few reports in adults. A nine times increased incidence of CD has been reported in children with EoE as compared to the general population. Our case report is unique in that our adult patient had co-existing CD and EoE and in whom the psychiatric co-morbidity initially posed a barrier to GFD adherence.

282: TSLP-elicited basophil responses mediate the pathogenesis of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a food allergy-associated disease characterized by esophageal eosinophilia and associated inflammation. EoE has become increasingly common in industrialized countries. However, current management strategies, such as treatment with swallowed steroids and dietary restrictions, are nonspecific or negatively impact the quality of life of EoE patients. In addition, use of more specific therapies that target immunoglobulin E (IgE) and interleukin (IL)-5 have been largely unsuccessful in ameliorating EoE. Thus, there is an urgent need to identify novel, specific immunological pathways that underlie the pathogenesis of EoE that could be targeted to treat this disease. Recently, a genome-wide association study identified that EoE is associated with a gain-of-function polymorphism in the gene that encodes thymic stromal lymphopoietin (TSLP). TSLP is an IL-7 family member cytokine that promotes allergic inflammation by eliciting T helper type 2 cytokine responses, IgE production, and the expansion of a distinct population of basophils. However, whether TSLP directly promotes allergic inflammation in the esophagus and the mechanisms by which TSLP might contribute to the pathogenesis of EoE remain unknown. Here, we describe a new murine model of experimental EoE-like disease that was used to investigate the role of TSLP in allergic inflammation of the esophagus. Murine experimental EoE-like disease developed independently of IgE but was dependent on TSLP-elicited basophils. Critically, therapeutic antibody-mediated neutralization of TSLP or depletion of basophil populations ameliorated established EoE-like disease in mice. Finally, elevated TSLP levels and exaggerated basophil responses were observed in esophageal biopsies from EoE patients, and a gain-of-function polymorphism in TSLP correlated with increased basophil responses in patients with EoE. Together, these data indicate that TSLP-elicited basophil responses may play a key role in mediating the pathogenesis of EoE, suggesting that targeting the TSLP-basophil axis could represent a new and promising therapeutic target in the treatment of EoE.