Features Of Eosinophilic Esophagitis Research Articles

Etiology and management of esophageal impaction in children: A review of 11 years

INTRODUCTION:Esophageal impaction in children is a medical emergency that needs an immediate medical attention. In the last years multiple objects have been detected and were removed endoscopically. In the last decade, Eosinophilic Esophagitis (EoE) has been associated with esophageal stenosis, leading to esophageal impaction with various objects including toys, food, coins and other.AIM:To determine the various objects and symptoms associated with impactions and to develop algorithm that guides Emergency Department Physicians and Primary care Providers when facing such problem in pediatric patient.MATERIAL AND METHODS:A retrospective chart review of all children referred to the pediatric gastroenterology service at Marshall University for FB impaction between 2000 and 2010 was performed. Foreign bodies treated by other specialties were excluded from this review. Clinical and demographic data were retrieved.RESULTS:A total of 291 charts with the diagnosis of foreign body reviewed of which only 126 met the inclusion criteria and considered for final calculation. Male/Female ratio and mean age were 1.17:1.0, and 3.65 ± 0.75 years, respectively. Time of impaction before ER evaluation was: < 24hrs in 75 patients, >24hrs in 17 and in 34 the time of ingestion was not known. Radiology was performed in 118 patients, of whom 1 had pneumo-mediastinum and 1 had pneumothorax. Endoscopic localization of the objects showed: 81- proximal, 23- middle esophagus, and 22- in the distal esophagus. The esophageal mucosa showed non-specific changes in 37 patients, 5 with EoE features, 1 patient with hiatal hernia, 1 patient with candidiasis, and in 5 pts had no mucosal description.CONCLUSION:Children with foreign body in the esophagus are commonly seen in our Hospital ER. Those children may harbor undiagnosed medical conditions that will need future therapy. Careful endoscopic assessment with mucosal biopsies is needed to diagnose those conditions earlier. Referral to a GI specialist may be warranted.

Eosinophilic Esophagitis in a Developing Country: Is It Different from Developed Countries?

Background and Objective. Despite the extensive reporting of eosinophilic esophagitis (EoE) from industrialized developed countries, reports from developing countries are rare. The aim of our study was to determine the epidemiological, clinical, and endoscopic features of EoE and response to therapy in children and adults from a developing country, Saudi Arabia. Methods. We identified patients diagnosed with EoE in our center from 2004 to 2011. EoE was defined as esophageal mucosal infiltration with a peak eosinophil count ≥15 eosinophils/high-powered field. Results. Forty-five patients were diagnosed with EoE (37 children and 8 adults; 36 males; median age 10.5 years, range from 1–37 years). Feeding difficulty, vomiting/regurgitation, and failure to thrive predominated in young children, whereas dysphagia and food impactions predominated in older children and adults. Allergy testing revealed food sensitization in 12 of 15 patients (80%); 3 responded to elemental formula, while 8 failed to respond to dietary manipulation after the allergy testing. Thirty-nine patients achieved remission by swallowed inhaled fluticasone. The majority of patients experienced a recurrence of symptoms upon the discontinuation of fluticasone. Conclusion. Our data indicate that EoE is increasingly recognized in Saudi Arabia and show many similarities to data from North America and Europe.

The Accuracy of Endoscopic Features in Eosinophilic Esophagitis

We assessed the accuracy of esophageal endoscopic features in children with eosinophilic esophagitis (EoE) living in rural communities in West Virginia. Specific esophageal endoscopic features for EoE disease have been identified in children and adults. In the published reports, the sensitivity of these features ranged between 19% and 56%. The accuracy of these features in children with EoE living in rural communities has not been published. A total of 271 patients' charts were reviewed of whom 53 children had EoE, 103 had gastroesophageal reflux disease, and 115 had normal esophagus. The calculated sensitivity, specificity, positive and negative predictive values, and accuracy rate for the presence of any mucosal feature for EoE disease were 88% (95% CI, 76-95), 98% (95% CI, 92-99), 96% (95% CI, 84-99), 94% (95% CI, 87-97), and 94.8%, respectively. The odds ratios for endoscopic furrows and erythema in EoE and gastroesophageal reflux disease patients were 155.4 (95% CI: 33.5, 719.8) and 13.4 (95% CI: 5.9, 30.5), respectively. When EoE patients were compared with normal patients, the odds ratio for erythema was 95.8 (95% CI: 31.4, 292.6). Dysphagia and choking were significantly more common in EoE children compared with control groups (P<0.001). Esophageal features of EoE in children living in rural communities have a high accuracy rate for the diagnosis of EoE compared with the data reported from children living in urban/semiurban communities. We suggest that in a proper clinical scenario, therapeutic measurement could be started before histology results are available. Future investigation of the phenotypic presentation of EoE disease in children from rural communities is warranted.

Diagnostic Utility of Major Basic Protein, Eotaxin-3, and Leukotriene Enzyme Staining in Eosinophilic Esophagitis

Features of eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) overlap. We aimed to determine whether staining for tissue biomarkers would differentiate EoE from GERD, suggesting utility for diagnosis of EoE. In this case-control study, EoE patients defined by consensus guidelines were compared to GERD patients with eosinophils on esophageal biopsy. Immunohistochemistry was performed for major basic protein (MBP), eotaxin-3, leukotriene A4 hydrolase (LTA4H), and leukotriene C4 synthase (LTC4S). After masking, the maximum staining density (cells per mm(2)) was quantified for each marker and compared between groups. Receiver operator characteristic curves were constructed, and the area under the curve (AUC) calculated to assess the diagnostic utility of each of the biomarkers alone and in combination with eosinophil counts. There were 51 EoE cases (mean age 24; mean 143 eosinophils per high-power field (eos per h.p.f.)) and 54 GERD controls (mean age 34; mean 20 eos per h.p.f.). The MBP density was higher in EoE than in GERD (1479 vs. 59 cells per mm(2); P<0.001), as was the eotaxin-3 density (2219 vs. 479; P<0.001). There were no differences for LTA4H and LTC4S. MBP density and eosinophil count correlated (R=0.81; P<0.001); correlation with eotaxin-3 was weaker (R=0.25; P=0.01). The AUC for diagnosis of EoE was 0.96 for MBP, 0.87 for eotaxin-3, 0.58 for LTA4H, 0.66 for LTC4S, and 0.99 for the combination of MBP, eotaxin-3, and eosinophil count. Patients with EoE had substantially higher levels of MBP and eotaxin-3 staining than GERD patients. These markers may have utility as a diagnostic assay for EoE.

Su1146 The Utility of Obtaining Biopsies for Eosinophilic Esophagitis (EoE) in Patients With Dysphagia Based on Endoscopic Findings

Background: Current guidelines indicate obtaining tissue to evaluate for eosinophilic esophagitis (EoE) as an option in patients with dysphagia who receive upper endoscopy evaluation without obvious cause for their complaint. However, the utility of this practice is unclear. The primary aim of the study was to determine the diagnostic yield of pathologic evaluation for EoE in patients with normal and abnormal findings on upper gastrointestinal endoscopy at the University of Oklahoma Health Sciences Center (OUHSC). Methods: All cases with a primary indication of dysphagia from January 2006 to November 2011 were retrospectively identified using the OUHSC electronic endoscopy database. Patients who had endoscopic biopsies for pathologic evaluation of EoE during their procedure were included for analysis. The pathologic reports and endoscopic findings were independently reviewed by different physicians who were not aware of the other results, then correlated by a third investigator to determine diagnostic yield rates for patients with and without endoscopic findings suggestive of EoE. Results: A total of 3,448 upper gastrointestinal endoscopies were performed at OUHSC during the study period. 547 procedures from 527 patients, age 18 to 90, met entry criteria and were analyzed. Review of these exams revealed 284/547 (52%) with a normal upper gastrointestinal endoscopy, 85/547 (16%) with features suggestive of EoE (furrowing or longitudinal rings), 73/547 (13%) with esophagitis, 45/547 (8%) with lower esophageal strictures or Schatzki ring, and 60/547 (11%) with other findings. Pathologic review indicated 303/547 (55%) with esophagitis, 207/547 (38%) with normal mucosa, and 37/547 (7%) with EoE. Among the 37 patients diagnosed with EoE, endoscopy revealed 23 (62%) with features of EoE, 7 (19%) with normal exam, and 7 (19%) with esophageal stenosis or esophagitis. The overall pathologic yield of EoE to endoscopic findings was 23/ 85 (27%) with features suggestive of EoE, 7/284 (2%) with normal exam, and 7/178 (4%) with all other findings. Conclusions: Endoscopic biopsies for pathologic evaluation of EoE often yield positive results in patients with endoscopic features suggestive of EoE. However, the yield of biopsies in those without endoscopic features suggestive of EoE is very low and is unlikely to alter patient management with increased cost.

Su1147 Prevalence of Eosinophilic Esophagitis in African Americans and Hispanics Presenting With Dysphagia: A Single Center Retrospective Analysis

Background: Current guidelines indicate obtaining tissue to evaluate for eosinophilic esophagitis (EoE) as an option in patients with dysphagia who receive upper endoscopy evaluation without obvious cause for their complaint. However, the utility of this practice is unclear. The primary aim of the study was to determine the diagnostic yield of pathologic evaluation for EoE in patients with normal and abnormal findings on upper gastrointestinal endoscopy at the University of Oklahoma Health Sciences Center (OUHSC). Methods: All cases with a primary indication of dysphagia from January 2006 to November 2011 were retrospectively identified using the OUHSC electronic endoscopy database. Patients who had endoscopic biopsies for pathologic evaluation of EoE during their procedure were included for analysis. The pathologic reports and endoscopic findings were independently reviewed by different physicians who were not aware of the other results, then correlated by a third investigator to determine diagnostic yield rates for patients with and without endoscopic findings suggestive of EoE. Results: A total of 3,448 upper gastrointestinal endoscopies were performed at OUHSC during the study period. 547 procedures from 527 patients, age 18 to 90, met entry criteria and were analyzed. Review of these exams revealed 284/547 (52%) with a normal upper gastrointestinal endoscopy, 85/547 (16%) with features suggestive of EoE (furrowing or longitudinal rings), 73/547 (13%) with esophagitis, 45/547 (8%) with lower esophageal strictures or Schatzki ring, and 60/547 (11%) with other findings. Pathologic review indicated 303/547 (55%) with esophagitis, 207/547 (38%) with normal mucosa, and 37/547 (7%) with EoE. Among the 37 patients diagnosed with EoE, endoscopy revealed 23 (62%) with features of EoE, 7 (19%) with normal exam, and 7 (19%) with esophageal stenosis or esophagitis. The overall pathologic yield of EoE to endoscopic findings was 23/ 85 (27%) with features suggestive of EoE, 7/284 (2%) with normal exam, and 7/178 (4%) with all other findings. Conclusions: Endoscopic biopsies for pathologic evaluation of EoE often yield positive results in patients with endoscopic features suggestive of EoE. However, the yield of biopsies in those without endoscopic features suggestive of EoE is very low and is unlikely to alter patient management with increased cost.

Su1149 Lack of Seasonal Variation in the Incidence of Eosinophilic Esophagitis

Background: Current guidelines indicate obtaining tissue to evaluate for eosinophilic esophagitis (EoE) as an option in patients with dysphagia who receive upper endoscopy evaluation without obvious cause for their complaint. However, the utility of this practice is unclear. The primary aim of the study was to determine the diagnostic yield of pathologic evaluation for EoE in patients with normal and abnormal findings on upper gastrointestinal endoscopy at the University of Oklahoma Health Sciences Center (OUHSC). Methods: All cases with a primary indication of dysphagia from January 2006 to November 2011 were retrospectively identified using the OUHSC electronic endoscopy database. Patients who had endoscopic biopsies for pathologic evaluation of EoE during their procedure were included for analysis. The pathologic reports and endoscopic findings were independently reviewed by different physicians who were not aware of the other results, then correlated by a third investigator to determine diagnostic yield rates for patients with and without endoscopic findings suggestive of EoE. Results: A total of 3,448 upper gastrointestinal endoscopies were performed at OUHSC during the study period. 547 procedures from 527 patients, age 18 to 90, met entry criteria and were analyzed. Review of these exams revealed 284/547 (52%) with a normal upper gastrointestinal endoscopy, 85/547 (16%) with features suggestive of EoE (furrowing or longitudinal rings), 73/547 (13%) with esophagitis, 45/547 (8%) with lower esophageal strictures or Schatzki ring, and 60/547 (11%) with other findings. Pathologic review indicated 303/547 (55%) with esophagitis, 207/547 (38%) with normal mucosa, and 37/547 (7%) with EoE. Among the 37 patients diagnosed with EoE, endoscopy revealed 23 (62%) with features of EoE, 7 (19%) with normal exam, and 7 (19%) with esophageal stenosis or esophagitis. The overall pathologic yield of EoE to endoscopic findings was 23/ 85 (27%) with features suggestive of EoE, 7/284 (2%) with normal exam, and 7/178 (4%) with all other findings. Conclusions: Endoscopic biopsies for pathologic evaluation of EoE often yield positive results in patients with endoscopic features suggestive of EoE. However, the yield of biopsies in those without endoscopic features suggestive of EoE is very low and is unlikely to alter patient management with increased cost.

Su1133 A Meta-Analysis of the Diagnostic Utility of the Endoscopic Features of Eosinophilic Esophagitis

vasculature 41%; endoscopy was normal in 17% (see Table). Rings and strictures were more prevalent in adults (57% and 25%, respectively) than in children <18 years of age (11% and 8%; p<0.05), while white plaques and pallor/decreased vasculature were more prevalent in children (36% and 58%) than in adults (19% and 18%; p<0.05; see Table). Prospective studies reported a greater prevalence of at least one endoscopic finding than retrospective studies (93% vs 80%; p<0.05). No differences according to study size were observed. The initially observed heterogeneity (I2 from 87-98%) was decreased after the stratified analysis. Conclusions: This meta-analysis demonstrated substantial heterogeneity in the prevalence of endoscopic findings in EoE, and the pooled prevalence varied by patient age and study design. While the prevalence of any one individual feature might be low, 83% of individuals reported in the literature have at least one finding on endoscopy, increasing to 93% when considering just prospective studies. Pooled prevalence of endoscopic findings in patients with EoE

600 Esophageal Epithelial and Mesenchymal Cross-Talk Leads to Features of Epithelial to Mesenchymal Transition (EMT) In Vitro

Background and Aims: Subepithelial fibrosis has recently been recognized as a histologic feature of eosinophilic esophagitis (EoE), a chronic inflammatory disease which leads to esophageal stricture, dysphagia, and recurrent food impaction. It is widely believed that activation by pro-fibrogenic cytokines including TGF-β, TNF-α, and IL-1β, stimulates fibroblasts to acquire the activated phenotype of myofibroblasts, morphologic intermediates between fibroblasts and smooth muscle cells which synthesize extracellular matrix (ECM) components. In the context of EoE, it has been suggested that these pro-fibrotic cytokines are released by circulating innate immune effector cells including mast cells and eosinophils, leading to fibroblast differentiation to the myofibroblast phenotype. To date, the potential role of esophageal epithelial cells as effector cells in EoE-associated tissue remodeling has never been investigated. In the current study, we investigated the consequences of crosstalk between esophageal epithelial cells and esophageal fibroblasts, and explored the ability of esophageal epithelial cells to develop features characteristic of epithelial to mesenchymal transition (EMT) In Vitro. Methods and Results: To determine whether factors secreted by esophageal epithelial cells can influence fibroblast expression of pro-fibrotic genes, we stimulated primary human fetal esophageal fibroblasts (FEF3 cells) with conditioned epithelial media (CEM) harvested from confluent non-transformed immortalized esophageal epithelial cells (EPC2-hTERT). Using qRT-PCR, we quantified FEF3 expression of profibrotic cytokines TGF-β, TNF-α, and IL-1β at various time points after CEM stimulation. Surprisingly, we observed a robust induction in mRNA expression of IL-1β and TNF-α, with a modest induction of TGF-β after stimulation. Based upon this unexpected result, we hypothesized that fibroblast derived factors might induce epithelial to mesenchymal transition (EMT) In Vitro. To test this hypothesis, we cultured FEF3 cells in CEM for 2 days, and transferred this fibroblast-conditioned CEM onto EPC2-hTERT cells for 5 days. Surprisingly, this led to enhanced esophageal epithelial expression of α-smooth muscle actin (SMA) and decreased expression of epithelial-specific e-cadherin, features suggestive of EMT. Similar changes in α-SMA and e-cadherin expression were observed after EPC2-hTERT cells were cultured with recombinant TGF-β, TNF-α, and IL-1β. Conclusions: There is a complex interplay between the esophageal epithelium and its underlying matrix. Our results suggest for the first time that paracrine signals from epithelium prime adjacent fibroblasts to express profibrotic cytokines and that these cytokines may, in turn, play a role in epithelial to mesenchymal transition by human esophageal epithelial cells In Vitro.

Su1157 Antigenic Stimulation of an Intestinal Epithelial/Eosinophil Co-Culture Model With Ragweed Antigen Significantly Reduces Trans Epithelial Electrical Resistance (TEER)

Background: Eosinophilic esophagitis (EoE) has emerged as a leading cause of dysphagia in adults. Characteristic esophageal features on endoscopy include structural/fibrostenotic (rings, narrow caliber, strictures) and inflammatory manifestations (longitudinal furrows, exudates, edema). Aim: The purpose of this study was to correlate the clinical, endoscopic and histopathologic features in adult EoE patients. Methods: A total of 106 encounters of 81 patients with EoE were analyzed. Data included an EoE-directed symptom-severity patient questionnaire evaluating symptoms of dysphagia (frequency, intensity, duration), meal duration, chest pain, and overall symptom severity. Video recordings of endoscopies were reviewed in a blinded manner using a classification and grading scheme for the esophageal features of EoE. Histopathology was reviewed for peak eosinophil count/high power field by pathologists blinded to the patients' clinical status. Associations between endoscopic features, histology and symptoms were evaluated using the Spearman rank correlation analysis. Results: The endoscopic severity of both structural and inflammatory esophageal features of EoE, including rings, exudates, longitudinal furrows, and edema, correlated significantly with peak eosinophil counts (see Table 1). Presence of “crepe paper mucosa” did not demonstrate significant association with peak eosinophil counts. Both structural (rings, narrow-caliber esophagus and strictures) and inflammatory (furrows, exudates and edema) composite endoscopic scores demonstrated a strong correlation with peak eosinophil counts. The strongest association with the degree of esophageal eosinophilia was found with a combination of both structural and inflammatory findings (p < 0.0001). The esophageal diameter (in mm) was negatively correlated with overall symptom severity (Spearman's rho = -0.4883, P = 0.0339). None of the individual or combined patient reported symptoms correlated significantly with either endoscopic or histopathologic findings. Conclusion: The severity of both structural and inflammatory endoscopic features associated with EoE is significantly associated with the degree of esophageal eosinophilia. Patient reported symptom severity was not associated with the degree of esophageal eosinophilia. Esophageal stricture diameter was inversely correlated with EoE symptom severity. The prognostic and therapeutic implications of these observations need to be determined. Table 1: Endoscopic Severity Grade vs. Eosinophil Count/hpf

Diagnostic Utility of Major Basic Protein and Eotaxin-3 Staining in the Esophageal Epithelium for Differentiation of Eosinophilic Esophagitis from Gastroesophageal Reflux Disease: ACG Governors Award for Excellence in Clinical Research

Purpose: Features of eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) overlap. Markers of eosinophil activation and migration, such as major basic protein (MBP) and eotaxin-3, have been implicated in EoE pathogenesis, but their role in diagnosis of EoE has not been extensively characterized. The aim was to determine whether the MBP and eotaxin-3 staining in the esophageal epithelium differentiates EoE from GERD and has utility for diagnosis of EoE. Methods: In this case-control study, cases had a new diagnosis of EoE, defined by 2007 consensus guidelines (≥15 eosinophils in ≥1 high-power field; ≥1 symptom of esophageal dysfunction; other causes of eosinophilia excluded; no response to proton-pump inhibition). Controls had GERD (≥1 typical symptom; other causes excluded) and were selected to have inflammation including eosinophils on biopsy because this is the group where there is diagnostic difficulty. Immunohistochemistry was performed for MBP and eotaxin-3. After masking, maximum epithelial MBP and eotaxin-3 staining density was quantified (positive cells/mm2). Staining levels and eosinophil counts (eos/hpf; hpf = 0.24mm2) were compared, and receiver operator characteristic (ROC) curves were constructed. Results: For the 51 EoE patients (mean age: 24; 69% male; mean of 143 eos/hpf) and 55 GERD patients (mean age 34; 61% male; mean of 20 eos/hpf), the maximum MBP density was higher in EoE than in GERD (1479 ± 1290 cells/mm2 vs 59 ± 103; p<0.001) as was the max eotaxin-3 density (2219 ± 1782 vs 479 ± 777; p<0.001; see Figure). MBP density and eosinophil count strongly correlated (R = 0.81; p<0.001); correlation with eotaxin-3 was weaker (R = 0.25; p = 0.01). The area under the ROC curve for diagnosis of EoE was 0.96 for MBP staining alone, 0.87 for eotaxin-3 alone, 0.96 for MBP and eotaxin-3 together, and 0.99 for the combination of MBP, eotaxin-3, and eosinophil count.Figure: No Caption available.Conclusion: Patients with EoE have substantially higher levels of MBP and eotaxin-3 staining in the esophageal epithelium compared with GERD patients. Staining with MBP and eotaxin-3 provides added diagnostic value beyond eosinophil counts alone, and MBP staining in particular may have utility as a diagnostic assay for EoE.

Esophageal Subepithelial Fibrosis and Hyalinization Are Features of Eosinophilic Esophagitis

Esophageal Subepithelial Fibrosis and Hyalinization Are Features of Eosinophilic Esophagitis

Prevalence of Esophageal Eosinophils in Patients With Barrett's Esophagus

Recent studies have demonstrated high esophageal eosinophil counts in patients with GERD similar to eosinophilic esophagitis (EoE) yet the frequency of esophageal eosinophilia in GERD is unknown. Our aim was to determine the prevalence of dense esophageal eosinophilia in patients with Barrett's esophagus as a manifestation of GERD. The Mayo Clinic pathology database was reviewed for patients diagnosed with Barrett's esophagus from January to December 2008 with squamous mucosa obtained during endoscopic surveillance. Clinical, endoscopic, and histologic findings were reviewed. Patients with ≥15 eosinophils per high powered field were identified and compared to those without esophageal eosinophilia. Two hundred patients with Barrett's esophagus and squamous tissue obtained at the time of biopsy were identified. Fourteen of the 200 patients (7%) had ≥15 eosinophils per high powered field. Demographics, symptoms, and proton pump inhibitor therapies were similar between those with and without esophageal eosinophilia. Endoscopic features suggestive of EoE were found in the squamous mucosa of 2 patients with and 7 patients without esophageal eosinophilia. Use of photodynamic, radiofrequency ablation, or monopolar electrocoagulation therapy for ablation of Barrett's mucosa was not associated with a higher rate of esophageal eosinophilia. Basal cell hyperplasia, papillary elongation, and spongiosis occurred frequently in association with esophageal eosinophilic infiltration. High esophageal eosinophil counts were found in 7% of this cohort of 200 patients with Barrett's esophagus and likely underestimates prevalence. The finding of esophageal eosinophilia in this cohort was independent of proton pump inhibitor use, features of EoE, or endoscopic therapy for Barrett's esophagus. Further studies are needed to assess if these findings are applicable to all patients with GERD.

Esophageal Subepithelial Fibrosis and Hyalinization Are Features of Eosinophilic Esophagitis

Eosinophilic esophagitis (EE) is characterized by marked esophageal mucosal eosinophilia on histological examination. Although the clinical and histological features of EE are increasingly recognized, the overlap of clinical symptoms and histological findings with gastroesophageal reflux disease (GERD) can lead to diagnostic difficulty. In children with EE we sought to define the frequency of subepithelial fibrosis and define the clinical correlates of this feature. The specificity of this finding in EE was obtained by comparison with a matched group of children with GERD, to ascertain its usefulness as a histological aid in differentiating between the 2 diagnoses. Comparison was made between 27 patients with EE and 24 patients with GERD, whose endoscopic biopsy specimens included subepithelial tissue. Demographic data, symptoms, endoscopic findings, and other histological findings were also compared. In contrast to patients with GERD, those with EE more commonly reported longer periods of symptoms (especially dysphagia) and were more likely to have endoscopic abnormalities. Subepithelial fibrosis was present in 89% of patients with EE and 37.5% of patients with GERD (P < 0.0001). The features of fibrosis in EE included uniformity and hyalinization, whereas the fibrosis in GERD was predominantly associated with lymphoid tissue. Subepithelial fibrosis commonly occurs in children with EE and is associated with increased age and length of symptoms. We propose that along with mucosal eosinophilic infiltration the presence of subepithelial fibrosis is a feature of EE.

S1077 Are There Racial Differences in the Clinical, Endoscopic, and Histologic Features of Eosinophilic Esophagitis?

G A A b st ra ct s genes (COL6A1 and COL15A1) are upregulated (~3 folds), whereas COL14A1 is downregulated (~2 folds). IHC experiments using an antibody to CD44 showed more intense staining in EoE biopsies than in NL. A label-based cytokine and growth factors antibody array showed an increase in epidermal growth factor (EGF) and fibroblast growth factor (FGF7) in EoE biopsies. Conclusion: We have identified a number of novel genes whose expression is altered in EoE. Further investigating their role in inflammation and esophageal tissue damage could reveal the mechanisms of remodeling observed in the disease.

S1094 Limited Accuracy of Upper GI Studies in the Diagnosis of Eosinophilic Esophagitis in Adults

INTRODUCTION: Endoscopy (EGD) has high sensitivity and specificity in the diagnosis of eosinophilic esophagitis (EoE). Prior case series in EoE have detected abnormalities on upper GI studies (UGI) but the sensitivity of these findings is unknown. AIM: Evaluate the accuracy of UGI in the diagnosis of EoE and compare UGI findings with EGD features. METHODS: A single center adult EoE database identified patients (pts) with prior UGI. Initial UGI reports, EGD data and unblinded, re-evaluation of UGI images by a senior GI radiologist were compared. RESULTS: From 419 EoE pts, 59 (14%) pts with UGI were analyzed. EoE pts with UGI included 36 males with mean age of 40 years. UGI indications included: dysphagia (80%), known diagnosis of EoE (15%) and miscellaneous (abdominal pain and anemia;5%). Mean time between UGI and EGD was 56 days, excluding 13 pts with > 1.5 years between studies. Initial UGI results were classified into 5 categories: normal (15%), findings characteristic of EoE (rings/furrows/exudates; 0%), findings possibly consistent with EoE (stricture/barium tablet retention; 36%), features consistent with GERD (28%), and miscellaneous (hiatal hernia/Schatzki ring/tertiary contractions; 20%). EGD detected characteristic EoE abnormalities in 85% of pts. On re-evaluation of UGI studies by a radiologist, the detection rate of EoE features improved; however the sensitivity for rings and furrows was lower than EGD (Figure, *p<0.05). UGI re-evaluation demonstrated: normal (4%), characteristics of EoE (41%), possibly consistent with EoE (13%), GERD (26%), and miscellaneous (15%). Strictures were detected by UGI in 47% compared with 28% by EGD (NS). CONCLUSIONS: While commonly used as a diagnostic test for dysphagia, UGI studies have limited sensitivity for the diagnosis of EoE in adults. Characteristic features of rings and furrows are better detected on EGD than UGI. Radiologist's awareness of EoE increases the diagnostic yield of UGI detection of EoE features.

Can Eosinophilic Esophagitis be Differentiated From Gastroesophageal Reflux Disease? A Clinicopathologic Case-Control Study with Predictive Modeling

Purpose: Because features of eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) overlap, distinguishing them clinically can be challenging, and eosinophil counts alone do not suffice. The study aim was to characterize clinical, endoscopic, and histologic findings in patients with EoE and GERD, and determine factors which differentiated the two groups of patients. Methods: We performed a retrospective case-control study from 2000-2007. Cases were patients of any age with a new diagnosis of EoE, as defined by consensus guidelines (≥15 eosinophils in at least one high-powered field; at least one typical symptom of esophageal dysfunction (i.e. dysphagia, food impaction, chest pain, or heartburn); other causes of eosinophilia excluded; and lack of response to proton-pump inhibitor). Controls were patients of any age with GERD (at least one typical symptom; inflammation on esophageal biopsy; and a clinical evaluation excluding other causes). Clinical and endoscopic data were collected, and esophageal biopsy specimens were reassessed by GI pathologists. Cases and controls were compared, unconditional logistic regression was performed to develop a model to predict EoE, and receiver operator characteristic (ROC) curves were constructed. Results: Data from 151 patients with EoE and 226 GERD patients were analyzed. As compared to GERD patients, the key features that independently predicted EoE included: younger age; symptoms of dysphagia; documented food allergy; esophageal rings, linear furrows, and white plaques or exudates on upper endoscopy; the absence of a hiatal hernia on upper endoscopy; a higher maximum eosinophil count; and the presence of eosinophil degranulation on the biopsy specimen. The presence of heartburn and erosive esophagitis were not predictive. The area under the ROC curve for this model was 0.934 (see Figure). It was also reliable by regression diagnostic testing (i.e. Hosmer-Lemeshow goodness-of-fit; bootstrap stepwise regression).FigureConclusion: In our cohort, a set of readily available and routinely measured variables reliably differentiated EoE from GERD. Although validation is necessary, applying this model to cases of suspected EoE may lead to more accurate diagnosis.

Clinical, Endoscopic, and Histologic Findings Distinguish Eosinophilic Esophagitis From Gastroesophageal Reflux Disease

Features of eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) overlap; because they cannot be differentiated on the basis of eosinophil counts alone, it can be a challenge to distinguish these disorders. We aimed to characterize the clinical, endoscopic, and histologic features of EoE and GERD and to identify factors that might be used to differentiate them. We performed a retrospective case-control study on data collected from 2000 to 2007. Cases were patients of any age with EoE, as defined by recent consensus guidelines; controls were patients of any age with GERD. Clinical and endoscopic data were collected, and all esophageal biopsy specimens were reassessed by gastrointestinal pathologists. Cases and controls were compared, unconditional logistic regression was performed to develop a model to predict EoE, and receiver operator characteristic curves were constructed. Data from 151 patients with EoE and 226 with GERD were analyzed. Compared with GERD, features that independently predicted EoE included younger age; symptoms of dysphagia; documented food allergies; observations of esophageal rings, linear furrows, white plaques, or exudates by upper endoscopy; an absence of a hiatal hernia, observed by upper endoscopy; a higher maximum eosinophil count; and the presence of eosinophil degranulation observed in biopsy specimens. The area under the curve for this model was 0.934. We identified a set of readily available and routinely measured variables that differentiate EoE from GERD. Use of this type of analysis with patients suspected to have EoE might lead to more accurate diagnoses.

Esophageal trachealization: A feature of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is an inflammatory condition characterized by intense eosinophilic infiltration of the esophagus. EE is frequently misdiagnosed as gastroesophageal reflux disease. Here, we present a child with EE and a characteristic endoscopic finding, “ringed esophagus”. An 11-year-old Saudi boy presented with dysphagia for 1 year. He had experienced an intermittent sensation of solid food sticking in his chest, which was relieved by drinking liquids. A barium swallow excluded anatomical causes of dysphagia, but revealed multiple-ringed esophagus. Endoscopy showed a furrowing and trachealizing appearance of the entire esophagus. Hisologically, extensive eosinophilic infiltration was a feature in biopsies obtained from the esophagus. The child responded well to a 2-month course of inhaled fluticasone. Symptoms recurred 3 months after discontinuation of therapy, which necessitated resumption of inhaled fluticasone. The endoscopic appearance of multiple esophageal rings should raise suspicion of EE and be confirmed by esophageal biopsies.

Distinguishing Features of Eosinophilic Esophagitis in Children

Distinguishing Features of Eosinophilic Esophagitis in Children