Management Of Eosinophilic Esophagitis Research Articles

Examining unmet needs in the management of eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease driven by a type 2 immune response and characterized by the accumulation of immune cells (eosinophils, basophils, and mast cells) in the esophagus. Patients may present with EoE at any age, and its prevalence is similar across age groups in the United States. If EoE is suspected, an endoscopy with biopsy is required to confirm the diagnosis; endoscopy allows clinicians to evaluate for the presence of rings, furrows, exudates, edemas, and/or strictures and biopsy helps to identify the associated histological changes, including eosinophilic infiltration of the esophageal mucosa. Symptoms of EoE vary by age and include dysphagia, impaction, regurgitation, chest and/or abdominal pain, and vomiting. Allergic comorbidities (eg, allergic rhinitis, asthma, or atopic dermatitis) are common among patients with EoE, which suggests that there may be a shared pathophysiology underlying these conditions. The symptoms of EoE vary widely from patient to patient, and delays in diagnosis are common. Disease progression may lead to lasting damage, including scarring and fibrosis of the esophagus, underscoring the need for early diagnosis and treatment to reduce the clinical, economic, and humanistic burden associated with EoE. Current standard of care treatment options include diet therapy, esophageal dilation, proton pump inhibitors, and topical swallowed corticosteroids; however, these treatments may not provide optimal disease management over the long term. The symptoms of EoE, its complications, and disease management considerations (eg, dietary limitations) are associated with diminished quality of life. There remains an unmet need for long-term management options. It is important for stakeholders to understand the current treatment landscape and unmet needs when considering the assessment of future therapies.

Butyrate and propionate restore interleukin 13-compromised esophageal epithelial barrier function.

BackgroundEosinophilic esophagitis (EoE) is a food allergen driven disease that is accompanied by interleukin (IL) 13 overexpression and esophageal barrier dysfunction allowing transepithelial food allergen permeation. Nutraceuticals, such as short‐chain fatty acids (SCFAs) that restore barrier function and increase immune fitness may be a promising tool in the management of EoE. Here, we investigated the effects of the SCFAs acetate, propionate, and butyrate on an IL‐13‐compromised human esophageal epithelial barrier, including the mechanisms involved.MethodsAn air‐liquid interface culture model of differentiated human EPC2‐hTERT (EPC2) was used to study whether SCFAs could restore barrier function after IL‐13‐induced impairment. Esophageal epithelial barrier function was monitored by transepithelial electrical resistance (TEER) and FITC‐dextran paracellular flux, and was further examined by qPCR and immunohistochemical analysis. G protein‐coupled receptor (GPR) GPR41, GPR43, GPR109a, or histone deacetylase (HDAC) (ant)agonists were used to assess mechanisms of action of SCFAs.ResultsIL‐13 stimulation decreased TEER and increased FITC flux, which was counteracted by butyrate and propionate, but not acetate treatment. Barrier proteins FLG and DSG1 mRNA expression was upregulated following butyrate and propionate treatment, whereas expression of eosinophil chemoattractant CCL26 and protease CAPN14 was downregulated. Similarly, butyrate and propionate restored FLG and DSG1 protein expression. Similar effects were observed with an HDAC antagonist but not with GPR agonists.ConclusionNutraceuticals butyrate and propionate restore the barrier function of esophageal epithelial cells after an inflammatory insult and may be of therapeutic benefit in the management of EoE.

Treatment of Eosinophilic Esophagitis: Diet or Medication?

Eosinophilic esophagitis (EoE) is an antigen-triggered chronic disease of increasing prevalence in children and adults. Untreated or therapy-resistant EoE leads to complications of esophageal food impactions and luminal narrowing. The past decade has seen a number of new clinical trials for EoE therapies including elimination diets, proton pump inhibitors, swallowed topical corticosteroids, and biologics. In this review, we comment on the current state of the art for dietary and pharmacologic management of EoE and the need for future clinical trials to help tailor therapies to individual patients with this chronic disease.

Budesonide (Jorveza)


 CADTH recommends that Jorveza should be reimbursed by public drug plans for the maintenance of remission in adults with eosinophilic esophagitis (EoE) if certain conditions are met.
 Jorveza should only be reimbursed if prescribed by a specialist with experience in the diagnosis and management of EoE, and the cost of Jorveza is reduced.
 Jorveza should only be covered for adult patients who have a confirmed diagnosis of EoE, in whom treatment with a proton pump inhibitor (PPI) did not work, and whose symptoms (dysphagia and pain during swallowing) have resolved after receiving induction treatment with Jorveza.

Eosinophilic Esophagitis for the General Pediatrician.

This article reviews pediatric eosinophilic esophagitis (EoE), a clinicopathologic disorder with symptoms related to esophageal dysfunction and characterized by eosinophil-predominant inflammation present on esophageal biopsy. As part of this review, we outline the pathophysiology, clinical features, diagnostic criteria, approved treatment options, and emerging therapies of EoE. Although previously considered a rare condition, EoE has emerged primarily in Western countries, with an estimated incidence of 4 per 100,000 persons. Understanding disease manifestation, diagnosis, and treatment options are critical for primary care physicians and specialists alike as EoE presentation varies by patient age. Several treatment options are approved for first-line management and can be used interchangeably based on symptoms and patient preference. Additionally, the collaboration of gastroenterologists, allergist-immunologists, and nutritionists is recommended for a multidisciplinary approach to long-term EoE management. [Pediatr Ann. 2021;50(8):e325-e329.].

Management of Eosinophilic Esophagitis During Oral Immunotherapy

Food allergies are antigen-driven diseases that can lead to IgE-mediated reactions of immediate hypersensitivity (eg,anaphylaxis triggered by a single food) or non-IgE reactions of delayed hypersensitivity such as eosinophilic esophagitis (eg,inability to eat multiple foods manifesting as abdominal pain, choking, dysphagia, vomiting, reflux, food impaction). Although both types of disease have their own unique set of challenges in diagnosis and management, it is a particularly vexing problem when a patient is afflicted by both conditions. This situation can happen when individuals with IgE-mediated food allergy undergo desensitization using currently available forms of oral immunotherapy. In this Grand Rounds Review, we review diagnostic approaches to oral immunotherapy-associated eosinophilic esophagitis, potential relationships between primary and secondary eosinophilic esophagitis, potential management approaches, areas of uncertainty, and upcoming research. Optimally supporting patients in their journey with food allergy requires shared decision making regarding alternative management strategiesand the stimulation of robust research.

The role of the allergist in the management of eosinophilic esophagitis.

The purpose of this review is to provide the current understanding of the role of allergens/antigens, the use of allergy testing, and to elucidate the role of the allergist in the management of eosinophilic esophagitis (EoE). EoE is a T2 immune disorder that is part of the atopic march. EoE patients commonly have multiple concurrent allergic disorders. Recent studies demonstrate that, like other allergic diseases, epithelial barrier dysfunction plays a key role in EoE pathogenesis. Aero- and food allergens have been identified as EoE triggers. EoE management includes the assessment and avoidance of its instigating antigens. Due to the integrated T2 immune response in an allergic individual, proper EoE care should include the control of underlying atopic disorders. EoE is a complex disease that is optimally managed by a multidisciplinary approach. This review provides an update on the role of the allergist in the clinical management of EoE.

Drivers of Variation in Diagnosis and Management of Eosinophilic Esophagitis: A Survey of Pediatric Gastroenterologists.

Widespread variation in the diagnosis and treatment of eosinophilic esophagitis (EoE) has previously been reported among adult gastroenterologists; however, variation in EoE practice in among pediatric populations is poorly characterized. The study objectives were to describe guideline adherence and understand reasons for variation in EoE practice among pediatric gastroenterologists following publication of the updated 2018 international EoE guidelines. We developed and administered a 28-item survey to pediatric gastroenterologists via an email listserv using the PEDGI Bulletin Board from 03/2019 to 04/2019. The survey was developed using evidence-based review, expert validation, and cognitive interviews. Survey domains included respondent knowledge of and adherence to published guidelines, diagnostic and management approach and rationale, and participant demographics. Analysis included descriptive statistics and tests for association. A total of 288 pediatric gastroenterologists completed the survey, most of whom practiced in an academic center (73%). More than half (63%) reported knowledge of the 2018 updated guidelines; however, only 52% agreed with them and 50% reported adherence. Respondents who reported not agreeing with updated guidelines cited concerns regarding increasing number of endoscopies (72%), misdiagnosing eosinophilia from reflux (56%), and insufficient data (23%). The most common drivers of decision making with respect to therapy choice were patient/family preference, evidence/guidelines, and symptom burden. Many physicians are not adherent to current guidelines for reasons which include lack of knowledge of updated guidelines and concern regarding the strength of the supporting evidence. This study elucidates several areas to enhance education regarding these guidelines to promote widespread adherence.

The role of advanced endoscopy in the management of inflammatory digestive diseases (upper gastrointestinal tract).

The Japan Gastroenterological Endoscopy Society held four serial symposia between 2019 and 2020 on the state-of-the-art of issues related to upper GI inflammatory diseases. This review discusses some of the topics addressed in these symposia. The papers regarding nonerosive reflux disease, recent improvements in intraesophageal pH-impedance monitoring and endoscopic diagnosis using image-enhanced endoscopy have been published. Many publications have addressed its usefulness in endoscopic treatment of gastroesophageal reflux disease such as anti-reflux mucosectomy. In the management of eosinophilic esophagitis, since the symptoms are subjective, objective indicators have been sought, and ultrasonography and high-resolution manometry may be useful tools for evaluation. The natural course of this condition, especially of asymptomatic cases, is not well clarified. Some newly developed anti-acid or anti-inflammatory medicines are now under investigation. With regard to autoimmune gastritis, because of widespread medical examinations, diagnosis of asymptomatic cases has been increasing. Recently, its endoscopic characteristics have become clear and the natural history of these conditions is being elucidated. The Kyoto Classification of Gastritis has been reported to be useful not only for Helicobacter pylori diagnosis but also for identification of risks of gastric cancer. Its usefulness is now recognized in Asia and Europe.

Treatment with compounded fluticasone suspension improves the clinical, endoscopic, and histologic features of eosinophilic esophagitis.

No approved medication exists for the treatment of eosinophilic esophagitis (EoE) in the United States, which forces patients to utilize off-label drugs and/or create their own formulations. We assessed the efficacy of a standardized compounded fluticasone suspension. To do this, we performed a retrospective cohort study identifying all EoE patients treated with compounded fluticasone. Compounded fluticasone was prescribed during routine clinical care and dispensed by a specialty compounding pharmacy. Clinical data were extracted from medical records. Outcomes (symptomatic, endoscopic, and histologic) were assessed after the initial and last compounded fluticasone treatment in our system. There were 27 included patients (mean age 34.2; 67% male; 96% white) treated for a mean length of 5.4 ± 4.4months. The majority (89%) previously utilized dietary elimination or topical corticosteroids, and many (75%) had primary non-response or secondary loss of response to these treatments. After starting compounded fluticasone, symptoms and endoscopic findings improved [dysphagia (89 vs. 56%, P = 0.005), food impaction (59 vs. 4%, P = 0.003), heartburn (26 vs. 4%, P = 0.01), chest pain (26 vs. 8%, P = 0.05), white plaques (63 vs. 32%; P = 0.005), furrows (81 vs. 60%; P = 0.06), and edema (15 vs. 4%; P = 0.16)]. The median of the peak eosinophil counts decreased from 52 to 37 eos/hpf (P = 0.10) and 35% of patients achieved <15 eos/hpf. In conclusion, compounded fluticasone provided a significant improvement in symptoms and endoscopic findings, with more than a third achieving histologic response in a treatment refractory EoE population. Compounded fluticasone should be considered as an EoE management option.

The role of endoscopy in eosinophilic esophagitis: from diagnosis to therapy

Endoscopy plays an important role in the management of eosinophilic esophagitis (EoE), since it is involved in the diagnosis, follow-up and treatment of this condition. In patients presenting with food impaction, dysphagia and other symptoms of suspected EoE, esophago-gastric-duodenoscopy (EGD) with multiple esophageal biopsies should be performed to confirm or rule out the diagnosis of EoE. The EREFS system, a validated instrument for assessment of the endoscopically-identified esophageal features in EoE (edema, rings, exudates, longitudinal furrows and strictures), is currently used in the clinical practice for the evaluation of the macroscopic aspects of esophageal mucosa during EGD. Multiple esophageal biopsies are mandatory to further confirm EoE diagnosis and subsequent response to treatment, since symptoms reported by patients do not always correlate with histological activity, and considering the low sensitivity of endoscopic assessment; a cut-off of ≥15 eosinophils in at least one high power field is the density threshold considered the standard for diagnosis (sensitivity 100%, specificity 96%). Other histological features, included in the EoE histologic scoring system (EoEHSS), are supportive for the diagnosis and for the assessment of inflammatory activity during follow-up. Esophageal dilation, performed either with Savary dilators/bougie or hydrostatic balloon, is an effective and safe treatment in both adult and pediatric EoE patients with fibrostenotic features, mainly in association with other therapeutic strategies which can control eosinophilic inflammation.

The role of endoscopy in eosinophilic esophagitis: from diagnosis to therapy

Endoscopy plays an important role in the management of eosinophilic esophagitis (EoE), since it is involved in the diagnosis, follow up and treatment of this condition. In patients presenting with food impaction, dysphagia and other symptoms of suspected EoE, esophago-gastric-duodenoscopy (EGD) with multiple esophageal biopsies should be performed to confirm or rule out the diagnosis of EoE. The EREFS system, a validated instrument for assessment of the endoscopically-identified esophageal features in EoE (edema, rings, exudates, longitudinal furrows and strictures), is currently used in the clinical practice for the evaluation of the macroscopic aspects of esophageal mucosa during EGD. Multiple esophageal biopsies are mandatory to further confirm EoE diagnosis and subsequent response to treatement, since symptoms reported by patients do not always correlate with histological activity, and considering the low sensitivity of endoscopic assessment; a cut-off of ≥ 15 eosinophils in at least one high power field is the density threshold considered the standard for diagnosis (sensitivity 100%, specificity 96%). Other histological features, included in the EoE histologic scoring system (EoEHSS), are supportive for the diagnosis and for the assessment of inflammatory activity during follow-up. Esophageal dilation, performed either with Savary dilators/bougie or hydrostatic baloon, is an effective and safe treatment in both adult and pediatric EoE patients with fibrostenotic features, mainly in association with other therapeutic strategies which can control eosinophilic inflammation.

S1892 An Interesting Case of Eosinophilic Esophagitis

INTRODUCTION: Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease with eosinophilic predominant inflammation. Symptoms include dysphagia, food impaction, and chest pain. Diagnosis is made via biopsy, requiring more than 15 eosinophils per high-power field. First line therapy is proton pump inhibitors (PPIs) along with dietary modifications and topical glucocorticoid to reduce inflammation. Untreated EoE can lead to fibrosis and strictures, requiring endoscopic dilatation. Given the consequences, it is important to recognize EoE, identify uncommon cofactors, and manage inflammation. We present a case of rumination syndrome found on manometry in a patient with unresolved EoE. CASE DESCRIPTION/METHODS: A 20-year-old male with Autism spectrum disorder, seasonal allergies, food allergies, asthma, and EoE presented for a second opinion for continued symptoms of dysphagia and post-prandial regurgitation to both solids and liquids along with a 10-pound weight loss while on a PPI 40 mg daily. He had been diagnosed with EoE with EGD and biopsies 2 years prior unresponsive to PPI. His PPI was advanced to 40 mg twice daily and he was started on a topical budesonide slurry. Because he continued to have significant symptoms an EGD was performed with high-resolution manometry catheter placement. EGD revealed mucosal changes consistent with EoE, confirmed via biopsy. Esophageal motility testing showed rumination pattern on multiple occasions during the post-prandial period. The patient was given a referral to behavioral health for rumination syndrome and his PPI and topical budesonide were continued. DISCUSSION: This case illustrates rumination syndrome as a possible cofactor in the management of EoE. Rumination syndrome is a functional gastrointestinal disorder consisting of cyclic regurgitation and ingestion of food matter. High-resolution manometry is the preferred test to diagnose rumination syndrome. Historically, rumination syndrome is considered a rare disorder, with scant systemic research, thus it is often missed or misdiagnosed due to lack of awareness. To the best of our knowledge, only two case reports have described the presentation of rumination syndrome in the setting of EoE. In both cases, as well as in our case, EoE was found to be histologically refractory to standard management in the setting of ongoing rumination. We find this an important case that highlights rumination syndrome may be present in refractory EoE and manometry with rumination protocol should be considered in these patients.

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

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

Plasminogen Activator Inhibitor-1 as a Marker of Esophageal Functional Changes in Pediatric Eosinophilic Esophagitis

Esophageal remodeling in eosinophilic esophagitis (EoE) can lead to esophageal rigidity with eventual luminal compromise and stenoses. Gauging esophageal functional alterations in EoE is challenging. An epithelial marker of functional remodeling would impact EoE management. Esophageal biopsy specimens from children with and without EoE and primary human esophageal epithelial cells were used for PAI-1 immunohistochemistry, and cell proliferation experiments. PAI-1 immunostaining and basal cell hyperplasia were assessed in the context of concurrently obtained esophageal compliance measures on endoscopic functional lumen imaging probe (EndoFLIP). EndoFLIPs were performed in 45 children (32 with and 13 without EoE). Epithelial PAI-1 was increased in patients with active EoE versus inactive or control patients (P < .01). Esophageal compliance was lower in EoE patients versus controls, particularly in the proximal esophagus (P < .001). Proximal compliance was the strongest predictor of EoE (AUROC 0.88, 95% CI 0.77, 0.98) with esophageal compliance of less than 2.6%mL/mmHg demonstrating 82% sensitivity and 84% specificity for EoE. PAI-1 inhibition significantly diminished esophageal epithelial cell proliferation, suggesting PAI-1 could trigger basal cell hyperplasia. A composite mid-esophageal BZH+ PAI-1 score was the strongest predictor of altered compliance (P = .02, AUROC 0.89 (95% CI 0.80, 0.99). PAI-1 is significantly elevated in pediatric EoE and distinguishes altered compliance in children. PAI-1 may be a novel disease marker and therapeutic target.

290 COMPARATIVE EFFICACY OF CORTICOSTEROIDS FORMULATIONS FOR THE MANAGEMENT OF EOSINOPHILIC OESOPHAGITIS: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS.

Abstract Topical corticosteroids are the foundation of pharmacologic treatment for eosinophilic oesophagitis (EoE) and administered mainly as nebulized swallowed fluticasone or budesonide viscous solution (BVS). Recently, a budesonide orodispersible tablet (BOT) has been approved for the treatment of EoE. The ideal formulation of topical corticosteroid delivery is unclear. Therefore, we aimed to compare the efficacy of BOT with other topical corticosteroid formulations for achieving histological remission in adult patients with EoE in a network meta-analysis (NMA). Methods A systematic literature review was performed using Medline and EMBASE from 1990 to July 2019. Eligible studies evaluated adult patients with a diagnosis of EoE treated with a topical corticosteroid in a randomized controlled trial. The outcome of interest was the proportion of patients achieving induction of histological remission (peak esophageal eosinophil count &amp;lt;5 eosinophils/high-power field). Direct comparisons were performed using the Mantel–Haenszel method and an NMA was performed using a fixed effect Bayesian framework with Markov Chain Monte Carlo simulations. Heterogeneity between studies was analyzed using the Cochrane Q test and consistency was verified. Results The search yielded 321 references and 6 (447 patients) were included in the quantitative summary. In the NMA, all formulations of topical corticosteroids were associated with greater histological remission rates than placebo. BOT was associated with a significantly higher rate of histological remission compared to BVS (odds ratio [OR] = 4.9; 95% credible interval [CrI] = 1.4,19.1), fluticasone (OR = 7.4; 95%CrI = 1.7,34.5), nebulized swallowed budesonide (NSB) (OR = 25.0; 95%CrI = 2.9,247.2) and placebo (OR = 387.6; 95%CrI = 97.5,2275.6). Similar trends were shown in direct comparisons. Analysis of the ranking of treatment options based on probability of effectiveness found BOT to be most probable followed by BVS, fluticasone, NSB, and placebo, consecutively. Conclusion This NMA of randomized controlled trials suggests that BOT is significantly more likely to achieve histological remission in adult patients with EoE compared to BVS, fluticasone, and NSB. We hypothesize that the superiority of BOT is related to increased contact time and targeting all inflammatory sites in the oesophagus, in contrast to other formulations. This NMA suggest that BOT is the first choice therapy amongst topical corticosteroids for the management of EoE.

Management of Eosinophilic Esophagitis: Dietary and Nondietary Approaches

Eosinophilic esophagitis (EoE) is an allergen-driven chronic inflammatory condition, characterized by symptoms related to esophageal dysfunction and confirmed histologically by esophageal mucosal eosinophilia. Since its first description in the 1990s, the incidence and prevalence of EoE have been on the rise. It is known to affect all ages of various ethnic backgrounds and both sexes; however, it is most seen in White males. Children with EoE often present with abdominal pain, nausea, vomiting, and failure to thrive, whereas adults with EoE typically present with dysphagia and food impaction. Diagnosis of EoE requires histologic confirmation of elevated esophageal eosinophils in a symptomatic patient, and only after secondary causes have been excluded. Because EoE is a chronic and progressively fibrostenotic disease, treatment goals include resolution of symptoms, induction and maintenance of disease remission, and prevention and possibly reversal of fibrostenotic complications, while minimizing treatment-related adverse effects and improving quality of life. Treatment strategies include the "3 D's"-drugs, diet, and dilation. Standard drug therapies include proton-pump inhibitors and topical corticosteroids. Dietary therapies include elemental diet, allergy testing-directed elimination diet, and empiric elimination diets. Endoscopic esophageal dilation for EoE strictures can alleviate esophageal symptoms but has no effect on mucosal inflammation. Recent progress in EoE research has made possible evidence-based clinical guidelines. Ongoing pharmacologic trials show promise for novel biologic agents in the treatment of refractory EoE.

Differences in Management of Eosinophilic Esophagitis in Europe: An Assessment of Current Practice.

The aim of the study was to assess differences in the diagnosis and management of eosinophilic esophagitis (EoE) by European pediatric (PG) and adult gastroenterologists (AG), and their self-reported adherence to guidelines. A multiple-choice questionnaire gauged the diagnostic and management strategies of gastroenterologists treating children or adults in 14 European countries and the United Arab Emirates (UAE). Questionnaires were completed by 465 PG and 743 AG. PG were significantly more likely to take biopsies in patients with symptoms of esophageal dysfunction (86.2% PG vs 75.4% AG, P < 0.001) and to perform endoscopic follow-up (86.3% PG vs 80.6% AG, P < 0.001). After failure of proton-pump inhibitors (PPIs), topical steroids were the preferred second-line therapy; however, PG opted more frequently for elimination diets (47.5% PG vs 13.7% AG, P < 0.001). More PG than AG indicated having read recent guidelines (89.4% PG vs 58.2% AG, P < 0.001). Geographic differences in practice were reported, with respondents from the United Kingdom, Portugal, and Spain more often adhering to recommended biopsy protocols. Physicians in the UAE, France, Lithuania, and Poland tended to opt for steroid therapy or elimination diets as first-line therapy, in contrast to most other countries. Significant differences in general practice between PG and AG were demonstrated with notable divergence from consensus guidelines. International practice variations are also apparent. Among other strategies, educational activities to highlight current recommendations may help harmonize and optimize clinical practice.

Eosinophilic Esophagitis: Existing and Upcoming Therapies in an Age of Emerging Molecular and Personalized Medicine.

Recent research efforts have spurred great progress in the diagnosis and management of eosinophilic esophagitis (EoE). Nonetheless, challenges remain in addressing disease burden and impairment in the growing EoE population. We highlight work from the Cincinnati Center for Eosinophilic Disorders, the Consortium of Eosinophilic Gastrointestinal Disease Researchers, and others that address these ongoing challenges. New tools for characterizing EoE disease activity include the EoE Histology Scoring System (EoEHSS), endoscopic alternatives, validated patient-reported outcome (PRO) questionnaires, and investigational biomarkers. These diagnostic and monitoring strategies have been complemented by advances in EoE therapy. Treatment modalities have refined the traditional approaches of dietary elimination, swallowed steroids, and proton pump inhibitors (PPI), and biologics offer promise for future treatment. This review summarizes EoE advances in disease management and newly defined EoE endotypes that may serve as the foundation for EoE-personalized medicine.

Practice patterns and adherence to clinical guidelines for diagnosis and management of eosinophilic esophagitis among gastroenterologists.

Real-world practice patterns of eosinophilic esophagitis (EoE) among gastroenterologists are not well-described. The aim is to describe practice patterns of EoE diagnosis and management and assess concordance with consensus guidelines. We conducted a cross-sectional online survey of gastroenterologists in the USA using Qualtrics, which was dispersed through the North Carolina Society of Gastroenterology (NCSG) and the American College of Gastroenterology member listservs. A similar survey was sent to NCSG members in 2010 and responses were compared in a subanalysis. Of 240 respondents, 37% (n = 80) worked in an academic setting versus 63% (n = 138) community practice setting. Providers saw a median of 18 (interquartile range 2-100) EoE patients annually and 24% (n = 52) were 'very familiar' with EoE guidelines. A proton-pump inhibitor (PPI) trial was required by 37% of providers prior to EoE diagnosis. In total, 60% used a ≥15 eosinophils per high-power field cut point for diagnosis and 62% biopsied from the proximal and distal esophagus on initial exam. Only 12% (n = 28) followed EoE diagnosis guidelines. For first-line treatment, 7% used dietary therapy, 32% topical steroids, and 61% used PPIs; 67% used fluticasone as first-line steroid; 41% used maintenance steroid treatment in responders. In the NCSG cohort, a higher proportion in 2017 followed guideline diagnosis recommendations compared with 2010 (14% vs. 3%; P = 0.03) and a higher proportion used dietary therapy as first-line treatment (13% vs. 3%; P = 0.046). There is variability in EoE practice patterns for EoE management, with management differing markedly from consensus guidelines. Further education and guideline dissemination are needed to standardize practice.