Eosinophilic Esophagitis Patients Research Articles

Increase in distal esophageal wall thickness with time in adult patients with eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a chronic disease which may progress to a fibro-stenotic phenotype due to esophageal sub-epithelial fibrosis. Esophageal wall thickening in patients with EoE has been demonstrated in a few studies using endoscopic ultrasound (EUS). The aim of this study was to longitudinally assess the endoscopic appearance, wall thickness, histology, and dysphagia score of EoE patients. Patients with EoE were recruited and studied between February 2012 and April 2021. Patients were evaluated on two separate occasions at least 12 months apart with endoscopy, EUS, and esophageal mucosal biopsies. The dysphagia score and epidemiology data were also assessed. A total of 16 EoE patients were included with a mean follow-up duration of 2.2 ± 1.2 years. In 14/16 (88%) patients, the total wall thickness of the distal esophagus significantly increased (P=0.0012) as a result of thickening of the muscularis propria (P=0.0218). However, only 1/14 (7%) patient had an increase in the dysphagia score, while 8/14 (57%) and 5/14 (36%) had a stable and reduced dysphagia score, respectively. No differences were found in the total thickness of other esophageal regions, dysphagia score, endoscopic appearance, and eosinophil count over time. Distal esophageal wall thickness increases with time in EoE patients, independent of the dysphagia score and eosinophil count.

Aeroallergen sensitization and associated esophageal eosinophilia in a group of Appalachian pediatric eosinophilic esophagitis (EoE) patients.

Eosinophilic Esophagitis (EoE) presents with multiple clinical comorbidities. The literature has documented food allergy as the most common comorbidity, although aeroallergen sensitization has been identified. We sought to determine the importance of aeroallergen sensitization in our pediatric EoE population.

NEW ONSET OF INFLAMMATORY BOWEL DISEASE IN A PATIENT WITH EOSINOPHILIC ESOPHAGITIS: 10-YEAR CONSTELLATION OF AUTOIMMUNE GASTROINTESTINAL DISORDERS

Abstract INTRODUCTION Inflammatory bowel disease (IBD) is well known for concurrent immune-mediated disorders such as eosinophilic esophagitis, psoriasis, and rheumatoid arthritis.(1) For the past two decades, we are seeing an increased occurrence of eosinophilic esophagitis (EoE) in long standing IBD patients (2) (3) (4), but the question has arisen as to new onset IBD in chronic EoE patients. One study that involved 4814 patients demonstrated that the prevalence of eosinophilic esophagitis in IBD was 5 times higher compared to general population and EoE in IBD is 2 times higher than expected.(5) Multiple factors have been identified that may trigger the exact inflammatory response in IBD and EoE patients. Both diseases are associated with an exaggerated response to interleukins, especially IL-13 sharing cytokines and helper T cell mediated pathophysiology that is linked to disruption of the gastrointestinal tract barrier. (6) (7) CASE DESCRIPTION A 25-year-old healthy male presented back in 2012 with a history of three months of worsening dysphagia that resulted in 15-lb weight loss. Upper endoscopy showed esophagus with small caliber lumen, linear furrows, and thin concentric rings with microscopic evidence of eosinophilic esophagitis. Over the years he developed multiple episodes of persistent dysphagia, several endoscopies demonstrated pangastritis and duodenitis with a new pyloric and duodenal bulb stricture. Due to his remitting-relapsing course despite long-term medical treatment, patient underwent additional workup including an abdominal CT and upper endoscopy that showed worsening of the pyloric stricture that improved after balloon dilation. In 2020, the patient developed diarrhea, rectal bleeding, generalized abdominal pain and 21 lb weight loss despite medical treatment. Colonoscopy showed multiple erosions in the ileum and rectum not seen on previous studies. The biopsy indicated ulcerated mucosa with necrosis in the ileum and rectal area with mixed inflammatory infiltration with the presence of a non-caseating granuloma consistent with Chron’s disease. DISCUSSION It is unclear which disease manifest first or if it is a clustering and co-occurrence of diseases. The fact that both diseases share the same pathogenetic mechanism with overexpression of mucosal interleukin-13 (IL-13) causing loss of functionality of the gastrointestinal barrier could explain symptoms observed on both. Many studies demonstrated that IBD was diagnosed before EoE in almost 2/3 of the cases. The association of EoE-IBD is found significantly more in males and occurs at a younger age compared to IBD alone. Further studies will be needed in order to confirm the co-occurrence of diseases because of the increased risk of IBD-related complications and higher chance of requiring systemic corticosteroids and anti-TNF therapy in patients who have coexisting EoE-IBD.

Diagnostic Performance of Endocytoscopy for Esophageal Eosinophilia

Introduction: Eosinophils in the esophageal epithelium are unevenly distributed in eosinophilic esophagitis (EoE). Esophageal eosinophilia (EE) may be observable by endocytoscopy (EC). This study aimed to evaluate the diagnostic performance of EC for the diagnosis of EE. Methods: A total of 33 EoE patients underwent EC with methylene blue staining from March 2020 to April 2021. A total of 194 EC images with corresponding biopsies were obtained. Three findings of EC, increased squamous cells (item I), increased inflammatory cells (item II), and cells with bilobed nuclei (item III), were established. These findings were reviewed by two endoscopists to diagnose EE. Another four endoscopists reviewed the images for interobserver agreement. Results: When all three items were met by EC, the sensitivity and the accuracy for the diagnosis of EE were 88% and 76%, respectively. The integrated diagnostic odds ratios (ORs) for the diagnosis of EE of the four endoscopists were significant (OR: 3.98, 95% CI: 2.94–5.40, p < 0.001). The results were similar when only item III was met. Interobserver agreement was good for item III to diagnose EE (kappa value = 0.653). Discussion/Conclusion: The diagnostic performance of EC for EE is acceptable and has good interobserver agreement. It may be useful for targeted biopsy in EoE patients.

Measuring esophageal compliance using functional lumen imaging probe to assess remodeling in eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is associated with fibrostenotic remodeling that can be objectively assessed using the functional lumen imaging probe (FLIP). This is typically done using a metric called distensibility plateau (DP). We aimed to describe a novel measure of compliance of the esophageal body and evaluate the associated clinical characteristics in EoE. One hundred seventy-one adult patients with EoE (mean (SD) age 38 (12) years), 31% female and 35 healthy, asymptomatic controls who completed 16-cm functional luminal imaging probe (FLIP) during endoscopy, were evaluated in a cross-sectional study. The esophageal body DP and compliance were measured using a customized analysis program, with compliance calculated as (Δ esophageal body volume)/(Δ pressure) between two FLIP-filled volumes. In controls, the median (5-95th percentile) DP was 19.8 mm (17.9-21) and esophageal body compliance was 0.37 ml/mmHg (0.18-1.1), which was greater than in EoE (DP 19 (11-21)), compliance 0.19 (0.02-0.71), p-values <0.001. Among EoE patients, 70 (41%) had normal compliance (>0.2ml/mmHg) and normal DP (>17 mm); 11 (6%) had normal compliance and reduced DP; 34 (20%) had reduced compliance and normal DP; and 56 (33%) had reduced compliance and reduce DP. Patients with both reduced compliance and DP had the greatest proportion of severe rings (61% with EREFS score 2-3) and stricture (100%). FLIP provides an objective evaluation of biomechanical properties of the esophageal wall that appears enhanced by complementary application of metrics of DP and esophageal body compliance.

Beige Mucosa Reflecting Active Sites of Eosinophilic Esophagitis.

We evaluated a 30-year-old woman with a 7-year history of eosinophilic esophagitis (EoE) with an initial complaint of moderate dysphagia. She gradually recovered after receiving proton pump inhibitors and oral budesonide. Only proton pump inhibitors were continued as a maintenance therapy until she developed very mild dysphasia 2 months earlier. Although endoscopy using white light imaging revealed characteristic findings of EoE, such as furrows and rings, with unclear images (Figure A), narrow-band imaging (NBI) revealed beige mucosa regions more clearly (Figure B). Magnified endoscopy using NBI revealed dot-shaped intrapapillary capillary loops and the absence of subepithelial vessels in the beige mucosa (Figure C). Target biopsied beige mucosa specimens revealed numerous intraepithelial eosinophils with basal layer hyperplasia and dilated intercellular spaces, reflecting active sites of EoE, whereas in nonbeige mucosa, normal squamous epithelium with few eosinophils was observed (Figure D). A recent study revealed that the loss or thinning of the superficial differentiated cell layer due to EoE activity allows 415-nm light to contact the hemoglobin component, resulting in a beige color change under NBI (Ayaki M, et al. J Gastroenterol Hepatol. 2022). The presence of beige mucosa under NBI in EoE patients, especially in cases without prominent EoE characteristic findings in white light imaging, indicates a suitable biopsied site for correct EoE diagnosis along with its histological activity.

IgG4+ cells are increased in the gastrointestinal tissue of pediatric patients with active eosinophilic gastritis and duodenitis and decrease in remission.

Recent studies have shown that IgG4 is increased in the esophageal tissue of eosinophilic esophagitis patients, including the presence of IgG4+ plasma cells. Our aim was to determine whether IgG4 is elevated in the gastric or duodenal tissue of pediatric patients with eosinophilic gastritis or duodenitis (EoG or EoD). This was a retrospective single center study. Pediatric patients were characterized as having active EoG, EoD, or as controls based on clinical symptoms and histologic features. Immunohistochemistry for IgG4 was performed in gastric and duodenal tissue, and peak IgG4+ cells were compared between groups and after treatment. The frequency of IgG4+ cells was significantly higher in patients with EoG and EoD compared to controls in the stomach [EoG 6.5 cells/hpf (3.6-10.9), control 0 cells/hpf (0-0.7), p<0.0001] and duodenum [EoD 7.5 cells/hpf (2.8-37), control 0.5 cells/hpf (0.3-1.3), p<0.001)] respectively, and positively correlated with eosinophil counts (stomach: r 0.74, p<0.0001; duodenum: r 0.57, p<0.0001). The amount of tissue IgG4 was significantly decreased in patients in remission but not in persistently active disease. These data suggest local tissue production of IgG4 may be a universal feature of eosinophilic gastrointestinal disease that tracks with disease activity.

Assessment of the clinical and allergy profiles of PPI responsive and non-responsive eosinophilic esophagitis.

A subset of patients with eosinophilic esophagitis (EoE) respond to proton-pump inhibitor (PPI) therapy, however they cannot be distinguished prior to PPI trial and the mechanism of PPI response remains unclear. Improved understanding of the distinct patient phenotypes in PPI-responsive EoE (PPI-r-EoE), PPI-non-responsive EoE (PPI-nr-EoE) and erosive esophagitis (EE) may help guide management. The aim of this paper is to compare the clinical and allergy profiles of PPI-r-EoE versus PPI-nr-EoE and EE. This was a retrospective case-control study of EoE patients (>15 eos/hpf on esophageal biopsies) at a tertiary center. EE controls were identified from the pathology database. EoE patients were classified as PPI-r-EoE or PPI-nr-EoE based on histologic response to twice-daily PPI for ≥8weeks. Patient demographics, comorbidities, symptoms, allergy history and endoscopic findings were recorded. Univariate analyses were performed using the Fisher-exact test or t-test. Multivariable analyses were performed using logistic regression. In all, 104 EoE (57 PPI-r-EoE/47 PPI-nr-EoE) and 80 EE subjects were included. On multivariable analyses, allergic conditions (aOR 20.1, P < 0.0001) and rings (aOR 108.3, P = 0.001) were independent predictors for PPI-r-EoE versus EE, whereas allergic conditions (aOR 4.8, P = 0.03), rings (aOR 27.5, P = 0.002) and furrows (aOR 17.1, P = 0.04) were independent predictors for PPI-nr-EoE versus EE. Esophageal rings was the only significant predictor found in PPI-nr-EoE versus PPI-r-EoE (OR 2.5, P = 0.03). Allergic conditions and esophageal rings are significantly more prevalent in PPI-r-EoE and PPI-nr-EoE compared with EE. PPI-r-EoE appears clinically similar to PPI-nr-EoE and significantly different from EE. Further studies are needed to delineate the underlying pathophysiology of PPI-r-EoE versus PPI-nr-EoE.

Monitoring Patients With Eosinophilic Esophagitis in Routine Clinical Practice - International Expert Recommendations

There are no studies or recommendations on optimal monitoring strategies for patients with eosinophilic esophagitis (EoE). Our objective was to develop guidance on how to monitor patients with EoE in routine clinical practice, on the basis of available clinical evidence and expert opinion. A multidisciplinary, international group of EoE experts identified the following important 3 questions during several consensus meetings: why, by what means, and when to monitor patients with EoE. A steering committee was named, and 3 teams were formed to review literature and to formulate statements for each topic. In a Delphi survey, a level of agreement of ≥75% was defined as threshold value for acceptance. In a final conference, results were presented, critical points and comments on the statements were discussed, and statements were rephrased/rewritten if necessary. Eighteen EoE experts (14 adult and pediatric gastroenterologists, 2 pathologists and 2 allergists) with a median of 21.7 years in clinical practice, mostly academic or university-based, completed the Delphi survey, which included 11 statements and a proposed algorithm for monitoring patients with EoE. Each statement attained ≥75% agreement. Participants discussed and debated mostly about the statement concerning surveillance intervals for EoE patients with stable disease. It was concluded that effective maintenance treatment probably reduces the development of EoE complications, and regular, structured, and, under certain conditions, individualized clinical follow-up is recommended to assess disease activity while opening a window to monitoring side effects, adjusting therapy, and encouraging adherence to treatment. Follow-up should comprise symptom assessment and periodic or repeated endoscopy with histological assessment in specific EoE settings.

A role for age-associated alterations in esophageal epithelium in eosinophilic esophagitis-associated fibrosis.

Subepithelial fibrosis occurs in a subset of eosinophilic esophagitis (EoE) patients and is associated with esophageal stricture. While mechanisms driving EoE fibrosis remain incompletely understood, findings from experimental systems support roles for epithelial-fibroblast crosstalk in this type of tissue remodeling. The current paradigm presents EoE as a progressive fibrostenotic disease in which aged patients develop fibrosis as a function of disease chronicity. In the current study we provide evidence that altered epithelial biology in the aging esophagus may also contribute to EoE-associated fibrosis. We find that induction of EoE inflammation in young and aged mice using the MC903/Ovalbumin protocol for the same time period results in increased lamina propria thickness uniquely in aged animals. Additionally, epithelial cells from aged mice less efficiently limit fibroblast contractility in collagen plug contraction assays compared to those from their young counterparts. Finally, to identify potential mechanisms through which aged esophageal epithelial cells may stimulate fibrotic remodeling, we perform cytokine array experiments in young and aged mice. These studies are significant as identification of age-associated factors that contribute to fibrotic remodeling may aid in the design of strategies toward early detection, prevention, and therapy of fibrostenotic EoE.

Eosinophilic esophagitis: Comparison of clinical, endoscopic and histological scoring systems.

Eosinophilic Esophagitis (EoE) has received increasing attention as a disease entity, and it is now recognized as an important disorder of the Upper Gastrointestinal Tract. Topical corticosteroids (tCS) are effective in clinical-pathological remission induction (RI) and remission maintenance (RM) of active EoE. With scoring systems, such as clinical (SDI), endoscopic (EREFS), and histological (EoEHSS) systems, EoE can be graded, and its disease activity can be assessed. To discover how closely results within each of the three scoring systems SDI, EREFS, and EoEHSS are correlated between initial diagnosis (ID), RI, and RM, and to determine how well scores from the three systems are intercorrelated at each time point. Retrospective cohort analysis of patients with active EoE was performed between 2006 and 2020, with follow-up for up to 6 years. SDI, EREFS and EoEHSS scores were recorded at ID, at RI, and in RM. Evaluation employed descriptive statistics, the Friedman test, and Bonferroni-corrected post hoc pairwise comparisons. At RI 29 and at RM 19 EoE patients provided data. Significant correlations were found between EREFS and EoEHSS at RI and in RM. Pairwise comparisons showed significant differences between ID and RI for SDI, for EREFS, and for EoEHSS. The scoring systems tested did not show intercorrelation at ID. Comparison revealed significant differences for SDI, EREFS, and EoEHSS between the systems at ID und RI, but not in RM, during tCS treatment. These results underline the efficacy of tCS (at RI and RM) in the treatment of active EoE.

Higher Body Mass Index Is Associated With Decreased Treatment Response to Topical Steroids in Eosinophilic Esophagitis

Understanding which eosinophilic esophagitis (EoE) patients will respond to treatment with topical corticosteroids (tCS) remains challenging, and it is unknown whether obesity impacts treatment response. This study aimed to determine whether treatment outcomes to tCS in EoE patients vary by body mass index (BMI). This retrospective cohort study of the University of North Carolina EoE Clinicopathologic database assessed subjects age 14 years or older with a new diagnosis of EoE. Their BMI was calculated and histologic, symptom, and endoscopic responses were recorded after tCS treatment. The treatment response of obese (BMI, ≥30 kg/m2) and nonobese EoE status was compared using bivariate and multivariate analyses. We identified 296 EoE patients treated with tCS. Baseline characteristics were similar, although obese EoE patients had more heartburn and hiatal hernias. Histologic response was higher forthose who were nonobese compared with obese at fewer than 15 (61% vs 47%; P= .049) and 6 or fewer (54% vs 38%; P= .02) eosinophils per high-power field, respectively. In addition, nonobese patients had significantly greater endoscopic and symptomatic responses. On multivariate analysis, increasing BMI was associated independently with decreased histologic response after accounting for age, heartburn, dilation, and hiatal hernia whether BMI was assessed as a continuous variable (adjusted odds ratio [aOR], 0.93; 95% CI, 0.89-0.98), as nonobese vs obese (aOR, 0.38; 95% CI, 0.21-0.68), or in 4 categories (overweight vs normal [aOR, 0.46; 95% CI, 0.26-0.84] or obese vs normal [aOR, 0.26; 95% CI, 0.13-0.51]). As BMI increases in EoE patients, the odds of histologic, symptomatic, and endoscopic responses to tCS decreases, with obese patients having an approximately 40% decrease in odds of response.

A CASE SERIES OF EOSINOPHILIC ESOPHAGITIS MANAGEMENT IN PEDIATRIC PATIENTS UNDERGOING FOOD ALLERGEN ORAL IMMUNOTHERAPY

<h3>Introduction</h3> Oral immunotherapy (OIT) is a promising treatment for food allergy and can significantly improve patients' quality of life. Eosinophilic esophagitis (EoE) is a known complication of OIT and is presently a contraindication for initiating OIT. We present the management and outcomes of a series of patients with EoE and concurrent treatment with OIT. <h3>Methods</h3> An IRB-approved retrospective chart review was conducted of pediatric patients within the multidisciplinary EoE clinic at our institution (from January 2004 to May 2022). Patients with a diagnosis biopsy-proven EoE and food allergy undergoing OIT were included in the analysis to create the largest case series of its type. <h3>Results</h3> Eleven patients aged 7-17 who were treated with OIT and underwent at least 2 esophagogastroduodenoscopies (EGD) were reviewed. Three patients were diagnosed with EoE prior to initiation of OIT, and the other 8 developed EoE after initiation of OIT. OIT was discontinued in 7 of 11 patients for management of EoE, in addition to treatment with proton pump inhibitors, topical corticosteroid, and/or food elimination diets. Four patients were able to continue OIT with improvement of symptoms and resolution noted on EGD. <h3>Conclusion</h3> The treatment of EoE in patients undergoing OIT requires shared decision-making with the patient/family, active OIT management, and close monitoring of treatment response involving allergists and gastroenterologists. The development of EoE does not always necessitate OIT discontinuation. This case series shows that with close monitoring and follow-up, a subset of patients with EoE can continue OIT safely and successfully.

LIKELIHOOD OF DIAGNOSIS OF EOSINOPHILIC ESOPHAGITIS VIA ENDOSCOPY IN DYSPHAGIA DURING THE COVID-19 PANDEMIC

<h3>Introduction</h3> The COVID-19 pandemic posed restrictions to many standard practices. Dysphagia is a common presentation of eosinophilic esophagitis (EoE) in adults. The gold standard method for diagnosis of EoE remains biopsy via esophagogastroduodenoscopy (EGD). We hypothesized that diagnosis of EoE decreased during the pandemic. In this study, we sought to investigate whether the COVID-19 pandemic influenced the likelihood of EGD for diagnosis of EoE in patients with dysphagia. <h3>Methods</h3> In this retrospective cohort study, we used the TriNetX Research Network to identify adult patients presenting with dysphagia to emergency department (ED) during the year of and the year preceding the pandemic. Patients with prior EoE diagnosis were excluded. Using 1:1 propensity score matching, the two cohorts were balanced for demographics, GERD diagnosis, body mass index, H2 blockers and proton pump inhibitors use, anemia, smoking, and alcohol use. The 30-day likelihood of EGD, EoE and GERD diagnosis were contrasted. <h3>Results</h3> We identified 23,759 adult patients presenting to the ED with dysphagia in 2020 during the pandemic, and 20,398 patients in 2019 (the preceding year). After propensity score matching, 19,196 patients remained in each cohort. During the 30-day follow-up period, more patients received EGD during the pandemic versus the pre-pandemic period (11% versus 10.2%; P=0.020). The 30-day likelihood of <i>de novo</i> EoE diagnosis was not different (0.8% versus 0.8%; P=0.95), but more patients received GERD diagnosis during the pandemic as compared to pre-pandemic (33% versus 31%; P<0.001). <h3>Conclusion</h3> Our results revealed that the COVID-19 pandemic did not significantly impact the likelihood of EoE diagnosis.

SUCCESSFUL TREATMENT OF REFRACTORY PEDIATRIC EOSINOPHILIC ESOPHAGITIS WITH DUPILUMAB

<h3>Introduction</h3> Eosinophilic esophagitis (EoE) is a chronic T-helper 2 (Th2) antigen driven disease characterized by eosinophilic infiltrates in the esophageal mucosa. Currently, there are no therapies approved by the United States Food and Drug Administration (FDA) for EoE in patients under twelve years of age. Expert guidance recommends the use of proton pump inhibitors (PPI), swallowed corticosteroids, elimination diets, and esophageal dilation<i>.</i> However, these interventions do not ameliorate symptoms and eosinophilic inflammation in all cases. Herein, we describe the successful treatment of a ten-year-old patient with EoE refractory to guideline-directed therapy with dupilumab. <h3>Case Description</h3> Our patient is a ten-year-old male with failure to thrive and EoE refractory to dietary change, swallowed corticosteroids, and PPI therapy. Due to the severity of his disease, the patient was initiated on monthly dupilumab injections. Following 6 months of dupilumab therapy (300mg subcutaneously Q4 weeks) he experienced endoscopic and histologic remission (0 eos/hpf). He remained in clinical and histologic remission more than 3 months after milk was reintroduced into the diet. <h3>Discussion</h3> We report the histologic, endoscopic, and symptomatic improvement in refractory pediatric EoE following treatment with monthly dupilumab in a ten-year-old male. Our findings suggest that the use of dupilumab can be extended to the pediatric population. Additionally, our case suggests that monthly injections, rather than the weekly injections utilized for adult EoE treatment, may be sufficient. Lastly, dupilumab also allowed for the liberalization of our patient's diet with sustained histologic and endoscopic resolution. In summary, dupilumab successfully treated refractory EoE and sustained disease remission despite allergen reintroduction.

AUTOIMMUNE DISEASE BURDEN IN CHILDREN WITH EOSINOPHILIC ESOPHAGITIS: A NATIONWIDE LONGITUDINAL STUDY.

<h3>Introduction</h3> Eosinophilic Esophagitis (EoE) is a chronic immune mediated disorder involving eosinophils leading to esophageal dysfunction. In this retrospective multi-center study, we investigated the incidence and risk factors for comorbid autoimmune diseases (AiD) in children using Cerner Health Facts, a national longitudinal database representing approximately 69 million patients. <h3>Methods</h3> All patients under 18 years of age with EoE were included in our analysis. Patient characteristics were evaluated as potential risk factors for comorbid AiD using multivariable regression built using all variables with p<0.05 on univariable analysis. <h3>Results</h3> We identified 6,285 patients with EoE. Mean age was 9.41±5.04 years, 32.04% (2,014) were female. In terms of race, 75.27% (4,731) were white and 11.81% (742) were African American. Overall, 7.0% (440/6,285) of children with EoE had at least one comorbid AiD. The most common AiD in those with EoE was ulcerative-colitis (143) followed by celiac (116) and autoimmune-thyroid disease (89). On multivariable regression, the factors associated with a higher risk of AiD included type-2 diabetes (odds-ratio (OR) 4.46), steroid use (OR 3.51), long-term medication use (OR 2.42), and digestive disorders (OR 1.85). African American race decreased the risk of AiD (OR 0.64). <h3>Conclusion</h3> We utilized a national database of patients with diag nosed EoE to identify the incidence and risk factors for AiD. Ulcerative colitis, celiac, and autoimmune thyroid disease were the most common AiD comorbid with EoE. The greatest risk factor for AiD was type-2 diabetes. Given that nearly 7% of identified EoE patients had comorbid AiD, careful evaluation for AiD in EoE setting may be warranted. We compared patient characteristics and variables of interest between the cohorts of patients with and without comorbid AiD using the chi-squared test for categorical variables, the t-test for normally distributed continuous variables, and the Mann-Whitney U test for non-normally distributed continuous variables. Factors with p<0.05 on univariable analysis were included in multivariable regression model. Statistical significance was defined as p<0.05. Independent risk factors for comorbid AiD were presented as adjusted Odds Ratios with 95% Confidence Intervals. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, North Carolina).

PREVALENCE AND CHARACTERISTICS OF EOSINOPHILIC ESOPHAGITIS IN 2019

<h3>Introduction</h3> Eosinophilic esophagitis (EoE) is a disorder characterized by eosinophilic infiltration of the esophagus causing esophageal dysfunction. Increased awareness about EoE is expected to result in increasing EoE prevalence. This study provides the current estimate of EoE prevalence in the United States and characterizes differences between pediatric and adult populations. <h3>Methods</h3> TriNetX Diamond Network, a claims-based database, was utilized to estimate the period prevalence of EoE between 1/1/2019 and 12/31/2019. EoE prevalence across different age and sex groups were contrasted. Descriptive statistics were used characterizing demographics, symptoms, and associated diseases. <h3>Results</h3> In 2019, 93,498,500 patients were identified in the database with any ICD-10 code, and 36,216 had an EoE diagnostic code for an overall period prevalence of 38.7 per 100,000. The majority of EoE patients were males (70.5%). Overall, the male-to-female prevalence OR was 1.76 (95% CI, 1.73-1.80). EoE peak prevalence among females was between ages 40-44 (44.5 per 100,000) whereas among males was between ages 35-39 (95.9 per 100,000). Pediatric males had greater odds than pediatric females of having EoE (OR, 2.36; 95% CI 1.77-3.17); this persists to a lesser degree into adulthood (OR 1.77; 95% CI, 1.43-2.19). As compared to male patients, we observed that females had higher prevalence of asthma (27.8% versus 21.8%), GERD (62.6% versus 54.8%), and rhinitis (33.0% versus 27.8%). Adult females were more likely than pediatric females to have GERD (64.0% versus 44.3%), a trend also seen in males (56% versus 43.8%). <h3>Conclusion</h3> Despite increased awareness of EoE, the estimated period prevalence of EoE remains relatively unchanged since 2009.

DEMOGRAPHICS AND CLINICAL CHARACTERISTICS OF PATIENTS WITH EOSINOPHILIC ESOPHAGITIS: A US-BASED INSURANCE CLAIMS DATA ANALYSIS

<h3>Introduction</h3> Real-world data on demographics and clinical characteristics of patients with eosinophilic esophagitis (EoE) are limited. We described patient characteristics, clinical symptoms, and comorbidities in US patients with newly-diagnosed EoE. <h3>Methods</h3> Retrospective analysis of 2017–2021 US MarketScan Commercial and Medicare administrative claims data including EoE patients with ≥12 months' continuous health plan enrollment pre- and post-first observed EoE diagnosis (index date). Demographic characteristics, clinical symptoms, and comorbidities pre-index in patients with incident (newly diagnosed) EoE were reported overall and stratified by age at EoE index date: <12 years (children), ≥12–17 years (adolescents) and ≥18 years (adults). Statistics were descriptive. <h3>Results</h3> 12,694 patients with incident EoE were identified and included (63.5% male; mean [SD] age 38.2 [16.5] years). The most common symptoms observed pre-index were dysphagia (38.0%), acid reflux (36.5%), and abdominal pain (25.9%). Mean (SD) days from first recorded chest pain and abdominal pain diagnosis to EoE diagnosis were 150.1 (114.6) and 146.3 (114.9), respectively, longer than EoE-specific symptoms such as dysphagia (82 [90.2]). Time from onset of dysphagia to EoE diagnosis was shorter in adults than in children and adolescents. Common comorbidities at index are presented in the <b>Figure</b>. Children and adolescents have a higher frequency of concomitant allergic diseases compared with adults. <h3>Discussion</h3> The presence of concomitant diseases and symptoms such as dysphagia and abdominal pain suggests a high disease burden. Comorbidities, presence of non-specific symptoms, duration of symptoms and patient age should be considered for a timely diagnosis of EoE.

Turkish Translation, Validation, and Reliability Analysis of Pediatric Eosinophilic Esophagitis Symptom Severity Module Version 2.0.

The PEESv2.0 was translated into Turkish by standardized procedural steps completed in cooperation with the Mapi Research Trust. The final version of the questionnaire was submitted to eosinophilic oesophagitis patients or their parents at 2 times point separated by 1 week. An age-matched control group was used to test the discriminant validity. Construct validity was tested using the Wilcoxon test, and internal consistency was tested using Cronbach's alpha. Test-retest reliability was measured with Cohen's kappa and intraclass correlation coefficient. One hundred twenty-eight participants (70 patients, 58 parents) were enrolled. Fifty-eight (39.1%) of them completed T-PEESv2.0-parent by proxy and 70 (54.7%) were T-PEESv2.0. The Cronbach's alpha coefficient and intraclass correlation coefficient for test-retest reliability were >0.70 for both questionnaires and for all domain (frequency and severity) and total scores. For discriminant validity analysis, subscale (frequency and domain) and total scores of the patient group were compared with those of the control group. The subscale and total scores were significantly different between the groups (P < 0.05). T-PEESv2.0 appeared to be valid and reliable, ready to be introduced as a clinical and research tool for the assessment of patients with eosinophilic oesophagitis.

Harnessing artificial intelligence to infer novel spatial biomarkers for the diagnosis of eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory condition of the esophagus associated with elevated esophageal eosinophils. Second only to gastroesophageal reflux disease, EoE is one of the leading causes of chronic refractory dysphagia in adults and children. EoE is a clinicopathologic disorder and the histological portion of the diagnosis requires enumerating the density of esophageal eosinophils in esophageal biopsies, and evaluating additional features such as basal zone hyperplasia is helpful. However, this task requires time-consuming, somewhat subjective manual analysis, thus reducing the ability to process the complex tissue structure and infer its relationship with the patient's clinical status. Previous artificial intelligence (AI) approaches that aimed to improve histology-based diagnosis focused on recapitulating identification and quantification of the area of maximal eosinophil density, the gold standard manual metric for determining EoE disease activity. However, this metric does not account for the distribution of eosinophils or other histological features, over the whole slide image. Here, we developed an artificial intelligence platform that infers local and spatial biomarkers based on semantic segmentation of intact eosinophils and basal zone distributions. Besides the maximal density of eosinophils [referred to as Peak Eosinophil Count (PEC)] and a maximal basal zone fraction, we identify the value of two additional metrics that reflect the distribution of eosinophils and basal zone fractions. This approach enables a decision support system that predicts EoE activity and potentially classifies the histological severity of EoE patients. We utilized a cohort that includes 1,066 biopsy slides from 400 subjects to validate the system's performance and achieved a histological severity classification accuracy of 86.70%, sensitivity of 84.50%, and specificity of 90.09%. Our approach highlights the importance of systematically analyzing the distribution of biopsy features over the entire slide and paves the way toward a personalized decision support system that will assist not only in counting cells but can also potentially improve diagnosis and provide treatment prediction.