Presentation Of Eosinophilic Esophagitis Research Articles

S2705 Spontaneous Hematemesis as a Rare Initial Presentation of Eosinophilic Esophagitis: A Case Report

S2705 Spontaneous Hematemesis as a Rare Initial Presentation of Eosinophilic Esophagitis: A Case Report

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.

Differences in Clinical Presentation of Eosinophilic Esophagitis in Pediatric Patients With Ulcerative Colitis and Crohn Disease

Significance: Eosinophilic esophagitis (EoE) is an inflammatory condition characterized by T helper-2 (TH2) cytokines. Ulcerative colitis (UC) and Crohn disease (CD) are inflammatory conditions with different clinical presentations and immune profiles. UC is associated with TH2 cytokines and CD with TH1 cytokines. We investigated potential differences in the association of EoE with UC and CD because of these different immune profiles. Methods: We utilized ICD-9 and ICD-10 codes to find patients with inflammatory bowel disease (IBD) and EoE. We defined EoE as any esophageal biopsy with &gt;15 eosinophils. We collected demographic, clinical, laboratory, endoscopic, and histological data. Results: Thirty patients had both EoE and IBD. 14.9% of UC patients had EoE and 5.7% of CD patients had EoE. 64.7% of UC patients presented with UC and EoE at the same time, whereas 76.9% of CD patients presented with EoE at follow up. Ten of 13 CD patients were on anti-tumor necrosis factor (TNF) at EoE diagnosis. No UC patients were on anti-TNF at EoE diagnosis. Eighty-three percent of CD patients had mild disease or were in remission, whereas 50% of UC patients had moderate to severe disease at the time of EoE diagnosis. Conclusion: A higher percentage of UC than CD patients had EoE. EoE was more likely to be present at the initial diagnosis of UC than CD. EoE was more likely after diagnosis and treatment of CD with anti-TNF, when CD activity was mild or in remission. The difference in presentation suggests that anti-TNF or it’s impact on inflammation may differentially impact the association of EoE with CD and UC.

158. Case Series: Eosinophilic Esophagitis Presenting as an Eating or Feeding Disorder

Eosinophilic esophagitis (EoE) is a multifactorial allergic disease associated with chronic inflammation of the upper gastrointestinal tract. A variety of genetic, epigenetic, dietary, and environmental factors have been implicated in the pathophysiology of EoE, though the etiology is still not fully understood. Symptoms of EoE typically reflect esophageal dysmotility, and can be relatively nonspecific in children of all ages. While younger children may present with abdominal pain, vomiting, coughing, regurgitation, poor weight gain or food refusal, older children and adolescents more commonly complain of dysphagia, dyspepsia, choking on foods (food impaction), slow eating, and weight loss.

Clinical profile and characteristics of eosinophilic esophagitis patients presenting with refractory gastroesophageal reflux disease in Makassar, Indonesia.

Refractory Gastroesophageal Reflux Disease (GERD) is a typical GERD that does not respond to Proton Pump Inhibitor (PPI) treatment for 8-12 weeks. One of the differential diagnoses for refractory GERD is eosinophilic esophagitis which is characterized by eosinophilic infiltration into the esophagus endothelium. However, to date, eosinophilic esophagitis is still poorly understood and data is still limited. The aim was to describe the profile and characteristics of patients with eosinophilic esophagitis presenting with refractory GERD in Makassar, Indonesia. This descriptive study involved patients with refractory GERD from two hospitals. In addition to basic demographic data, history, and body mass index, all subjects underwent peripheral blood tests to measure eosinophil level and flexible esophagoscopy, from which esophageal biopsy was done to assess the tissue eosinophil level. Eosinophilic esophagitis was established based on the examination of >15 eosinophils/high power field. Out of 32 subjects, two subjects were diagnosed with eosinophilic esophagitis (6.3%). Both subjects were male with normal BMI in the age range of 36-55 years and none had peripheral blood eosinophilia. Symptoms of eosinophilic esophagitis were similar to refractory GERD. Peripheral blood eosinophilia was not associated with incidence of eosinophilic esophagitis.

Clinical presentation of eosinophilic esophagitis in the pediatric age

Clinical presentation of eosinophilic esophagitis in the pediatric age

S0381 Incidence and Seasonal Variation of Food Bolus Impaction in Patients With Underlying Eosinophilic Esophagitis

INTRODUCTION: Eosinophilic Esophagitis (EoE) is a chronic disorder of the esophagus characterized as a condition with esophageal symptoms such as dysphagia and an identifiable eosinophilic infiltrate on biopsies in the absence of other etiology. Studies into the reason for the recent rise in incidence and prevalence have discussed the environmental factors that may be associated with the disorder with the pathogenesis thought to be a combination of inflammatory and allergy mediated. In this setting, reports have found that cases can be provoked by aeroallergens and the observation of seasonal variation and geographic variation in presentation. The primary aim of this study was to search for a potential seasonal variation in the presentation of esophageal food bolus impaction in patients with EoE. METHODS: A retrospective analysis of endoscopies completed from May 2017 through April 2019 for foreign body removal or with food found in the esophagus was performed. The study identified a total of 177 cases with 19 cases of esophageal food bolus impaction in patients with established or newly identified EoE. Cases were analyzed regarding seasonal variation in incidence of food bolus impaction and demographic data and variables such as eosinophil count on biopsy and level of impaction were also analyzed using Fisher’s exact test. RESULTS: The overall incidence of esophageal food impaction in cases of EoE was higher in the winter with 10/19 (52.6%) of overall cases occurring in winter compared to 3/19 (15.8%) in other seasons although this did not reach statistical significance (P = 0.0561). 63.2% of the patients were male and 89.5% were white. The difference in eosinophil count and level of impaction did not significantly vary by season (P = 0.5885 and 0.4250). There were four observable strictures found in the group. CONCLUSION: In our study there was a higher incidence of food impaction in the winter season but this did not reach statistical significance. No difference was found in the magnitude of the eosinophilic infiltrate in biopsy specimens by season or by level of impaction. Previous studies have had differing findings on the role of aeroallergens in the pathophysiology and presentation of EoE as well as the presence of seasonal variation and the specific season. Due to these varied findings and small numbers in our study, ongoing evaluation is warranted to shed further light on the presence of possible seasonal variation and the impact environment has on EoE.Figure 1.: Esophageal Food Impaction by Season (P = 0.0561).Figure 2.: Eosinophil Count by Season.Figure 3.: Level of Impaction by Season (P = 0.4250).

S0352 Endoscopic Biopsies During Presentation for Esophageal Food Impaction: An Important Opportunity for Timely Diagnosis of Eosinophilic Esophagitis

INTRODUCTION: Esophageal food impaction (EFI) is a common initial presentation of eosinophilic esophagitis (EoE). Patients presenting with EFI requiring endoscopic intervention present an opportunity to obtain esophageal biopsies to evaluate for EoE and optimize diagnostic yield before initiation of empiric treatment. We aimed to evaluate practices of esophageal biopsy at time of EFI at our institution and identify missed opportunities to diagnose EoE. METHODS: We performed a single center retrospective chart review on a subset of adult patients from 10/2015 -1/2020 who presented to NYU Langone Health with EFI. Patients who underwent upper endoscopy (EGD) and were found to have a retained esophageal food bolus were included. Those with prior diagnosis of EoE were excluded. Proportions were compared using Chi-square or Fisher’s exact test, and rank sum tests were used to compare continuous variables. Logistic regression was used to assess factors associated with subsequent need for diagnostic EGD. RESULTS: 123 patients with EFI were reviewed, 50 (40.7%) were biopsied at the time of EGD (Table 1). Among those biopsied, a new diagnosis of EoE was found in 52%. Of the patients who did not undergo biopsy at index EGD, 23% underwent repeat EGD at our institution and were found to have a new EoE diagnosis. Biopsies performed during EGD for EFI did appear to decrease the need for repeat procedure (OR 0.63, 95% CI 0.25-1.63), although not statistically significant. Patients with furrows were more likely to be biopsied however the report of other classic endoscopic features of EoE (such as exudates, ring, stricture, edema), was not significantly associated with the rate of biopsy (Table 2). Time of procedure and history of prior EFI also did not appear to influence rate of biopsy. CONCLUSION: Biopsy at the time of EFI is important to obtain a timely diagnosis of EoE. At our center, less than half of patients were biopsied at time of initial EGD for EFI, and over half of those biopsied were diagnosed with EoE. The diagnosis of EoE was missed in 23% patients who were not biopsied at time of EFI, and on subsequent EGD with biopsy were found to have EoE. This delay in biopsy likely leads to unnecessary EGDs and more patients who are unaware of their diagnosis. Future educational initiatives aimed at GI providers are needed to improve rates of biopsies during initial EGD for EFI to reduce the need for additional diagnostic procedures.Table 1Table 2

A Pediatric Patient with Eosinophilic Esophagitis Presenting with Candida Esophagitis: Case Report

A Pediatric Patient with Eosinophilic Esophagitis Presenting with Candida Esophagitis: Case Report

Endoscopic management of eosinophilic esophagitis presenting as a double lumen esophagus.

Endoscopic management of eosinophilic esophagitis presenting as a double lumen esophagus.

Clinical outcomes of adults with eosinophilic esophagitis with severe stricture

Eosinophilic esophagitis (EoE) is an inflammatory disease of the esophagus. Its prevalence has been increasing steadily over the past 3 decades. The prognosis of patients with EoE presenting with severe esophageal strictures is poorly understood. The aim of this study was to describe the clinical outcomes of patients with EoE with severe strictures and identify factors associated with a greater likelihood of improvement in esophageal diameter. This study is a retrospective chart review of patients with EoE with severe stricture, defined as anesophageal diameter of 10mm or less at one point in their disease course. Each patient's clinical course was followed during standard-of-care follow-up with medical or dietary therapy in conjunction with repeated esophageal dilation. Multivariate regression analysis was performed to determine which variables are associated with endoscopic response, defined by an improvement in esophageal diameter to 13mm and to 15mm. From a cohort of 1091 adults with EoE, severe strictures were identified in 66 patients (7%). Of the 66 patients, 59 (89%) achieved an esophageal diameter of≥13mm and 43 (65%) achieved≥15mm. Initial diameter (odds ratio, 1.58; 95% confidence interval, 1.06-2.35; P= .025) and histologic remission (odds ratio, 34.97; 95% confidence interval, 6.45-189.49; P< .0001) were significantly associated with achieving a diameter≥15mm. Age at diagnosis, gender, and number of months to maximum esophageal diameter were not associated with achieving either diameter. Most patients with EoE with severe stricture experienced improvement in esophageal diameter to≥15mm with treatment, suggesting that the currently available treatment options are effective for patients with severe strictures. The most significant factors associated with disease reversibility are initial esophageal diameter and histologic remission.

Eosinophilic esophagitis presenting with spontaneous esophageal rupture: a case report

BackgroundEosinophilic esophagitis, once considered a rare disorder, has been increasingly recognized as a leading cause of dysphagia and food impaction in children and adults over the last few decades. It predominantly occurs in young men with a history of atopy. Dysphagia and food impaction are the most common presentations. However, rarely, spontaneous perforation (Boerhaave’s syndrome) may occur in association with eosinophilic esophagitis.Case presentationA 40-year-old white woman with known history of eosinophilic esophagitis, who was non-compliant with treatment, presented with chest pain and developed acute spontaneous transmural esophageal perforation while eating a snack. Surgical repair was required.ConclusionIn a relatively young patient who presents with spontaneous esophageal perforation, eosinophilic esophagitis should always be ruled out as subsequent treatment may prevent recurrent perforation.

Mediastinal abscess, an unusual way of presentation of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is one of the most prevalent esophageal diseases and the leading cause of dysphagia and food impaction in children and young adults. EoE represents a chronic, local immune-mediated esophageal disease, characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Mediastinal abscess is an uncommon condition that typically appears after esophageal perforations or thoracic surgeries, usually requiring treatment for surgical intervention due to its high morbidity–mortality. Mediastinal abscess, outside these two contexts, is extremely rare. We present the case of a mediastinal abscess secondary to EoE. It is important to think about this entity when there is a mediastinal abscess without trauma or previous surgery.

Esophageal Dilation Demonstrates That the Majority of Esophageal Strictures Are Located in the Distal Esophagus in Adults With Eosinophilic Esophagitis

Introduction: Dysphagia caused by esophageal stricture is the most common clinical presentation of eosinophilic esophagitis (EoE) in adults. Esophageal dilation is an accepted therapeutic modality to manage strictures that persist in spite of medical therapy. Mucosal disruption following dilation not only provides evidence of an effective dilation but also identifies the site of dominant stricture formation Methods: We conducted a retrospective chart review for EoE adults receiving care from a single provider at an urban university based medical center. Patients from 2000 to 2017 who had undergone esophageal dilation for their EoE symptoms were identified. Demographic and clinical information and endoscopic features and results of dilation were collected. Location of mucosal disruption after dilation was recorded in all cases. Disruptions located between 15-27.5 cm from the incisors were defined as proximal strictures, and those above 27.5 cm from the incisors as distal strictures. A disruption was considered proximal and distal if there were multiple mucosal lacerations identified with one localized proximally and another distally, or from a disruption in the mid-esophagus spanning above and below 27.5 cm. Major complications of esophageal perforation or GI bleeding requiring hospitalization or blood transfusion were assessed. Results: Of 640 EoE patients identified, 250 patients had undergone 718 dilations. The average number of dilations per patient was 2.87 ± 2.62 dilations. Among the 718 dilations, 152 (23%) had proximal disruptions, 118 (18%) had both proximal and distal, 317 (47%) had distal only, 110 (16%) had no disruptions. Among 250 patients receiving dilation, 150 (52%) had only disruptions in the distal esophagus. 58 (23%) had disruptions in both the proximal and distal esophagus, and 25 (10%) had only proximal disruptions. Overall, distal esophageal strictures were present in 75% whereas proximal strictures were present in 33% of patients. A single complication of a contained esophageal perforation occurred (0.14%) that was managed conservatively with antibiotics. No major bleeding complications were identified. Conclusion: (1) The results of the largest single center experience of esophageal dilation in EoE affirm that dilation is a safe procedure with low risk of major complications. (2) The majority of strictures in EoE occur in the distal rather than proximal esophagus. (3) We speculate that factors including gastroesophageal reflux may influence stricture formation in EoE.324_A Figure 1 No Caption available.324_B Figure 2 No Caption available.

Emergency Department Visits among Patients with Eosinophilic Esophagitis and Acute Exposures to Particulate Pollution (PM2.5)

Research suggests that environment plays a significant role in the presentation of eosinophilic esophagitis (EoE), an allergic disease affecting the esophagus, resulting in inflammation and esophag...

Proposed criteria to differentiate heterogeneous eosinophilic gastrointestinal disorders of the esophagus, including eosinophilic esophageal myositis.

AIMTo define clinical criteria to differentiate eosinophilic gastrointestinal disorder (EoGD) in the esophagus.METHODSOur criteria were defined based on the analyses of the clinical presentation of eosinophilic esophagitis (EoE), subepithelial eosinophilic esophagitis (sEoE) and eosinophilic esophageal myositis (EoEM), identified by endoscopy, manometry and serum immunoglobulin E levels (s-IgE), in combination with histological and polymerase chain reaction analyses on esophageal tissue samples.RESULTSIn five patients with EoE, endoscopy revealed longitudinal furrows and white plaques in all, and fixed rings in two. In one patient with sEoE and four with EoEM, endoscopy showed luminal compression only. Using manometry, failed peristalsis was observed in patients with EoE and sEoE with some variation, while EoEM was associated with hypercontractile or hypertensive peristalsis, with elevated s-IgE. Histology revealed the following eosinophils per high-power field values. EoE = 41.4 ± 7.9 in the epithelium and 2.3 ± 1.5 in the subepithelium; sEoE = 3 in the epithelium and 35 in the subepithelium (conventional biopsy); EoEM = none in the epithelium, 10.7 ± 11.7 in the subepithelium (conventional biopsy or endoscopic mucosal resection) and 46.8 ± 16.5 in the muscularis propria (peroral esophageal muscle biopsy). Presence of dilated epithelial intercellular space and downward papillae elongation were specific to EoE. Eotaxin-3, IL-5 and IL-13 were overexpressed in EoE.CONCLUSIONBased on clinical and histological data, we identified criteria, which differentiated between EoE, sEoE and EoEM, and reflected a different pathogenesis between these esophageal EoGDs.

38 Pediatric Patients With Eosinophilic Esophagitis Presenting With Food Impaction: A Possible Disease Subpopulation?

38 Pediatric Patients With Eosinophilic Esophagitis Presenting With Food Impaction: A Possible Disease Subpopulation?

Gender is a determinative factor in the initial clinical presentation of eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease resulting in symptoms of esophageal dysmotility. Abnormalities include dysphagia, food impaction and reflux. Although men appear to comprise a majority of the EoE population, few studies have directly assessed gender-associated clinical differences. The aim of this study is to identify the effect of gender on the initial clinical presentation of adult-onset EoE patients. We reviewed our electronic medical record database from January 2008 to December 2011 for adults diagnosed with EoE per the 2011 updated consensus guidelines. Patient demographics, presenting symptoms, endoscopy findings and complications were recorded. Proportions were compared using chi-squared analysis, and means were compared using the Student's t-test. A total of 162 patients met the inclusion criteria and 71 (44%) were women. Women were more likely to report chest pain (P = 0.03) and heartburn (P = 0.06), whereas men more commonly reported dysphagia (P = 0.04) and a history of food impaction (P = 0.05). Endoscopic findings were similar between groups. No patients suffered esophageal perforations. These data suggest that men report more fibrostenotic symptoms and women report more inflammatory symptoms at the time of diagnosis. There was no difference in endoscopic findings between genders. This is one of the only reviews comparing differences in clinical presentation, endoscopic findings and complications between gender for EoE. The current recommended guidelines state that any patient with symptoms of esophageal dysfunction should be biopsied for EoE. Our findings support biopsying patients with typical and atypical symptoms of dysmotility including heartburn and chest pain.

Seasonal recurrence of food bolus obstruction in eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is a newly recognised condition that is apparently increasing in prevalence, and the aetiology is poorly understood. The role of aeroallergens in EoE is controversial, given the success of dietary therapy. Massive aeroallergen exposure leading to food bolus obstruction events (FBOE) has been described, and the diagnosis of EoE by esophageal biopsy noted to be more common in the pollen season according to previous case series. To determine if a seasonal variation and a geographical variation occurred in EoE presenting as FBOE in adults, and to track the prevalence of FBOE and EoE over time. A retrospective case-control study analysis was performed from January 2002 to January 2012 to identify all FBOE in adults presenting to five tertiary hospitals in Melbourne, Australia. Endoscopy, histopathological reports, case notes and blood tests were examined, and postcodes recorded. Records of pollen counts were obtained. Cases were defined according to esophageal biopsy and grouped based on month of diagnosis. All other causes of FBOE served as controls. One thousand, one hundred and thirty-two FBOE were identified. Biopsies were only performed in 278 of these cases, and 85 patients were found to have EoE after biopsy. Patients with EoE were younger (mean age 38 years, range 18-72) compared with those with alternative diagnosis (mean age 64.4 range 22-92), more likely to be male (M : F = 4:1 compared with 1.68:1 ) and had a higher eosinophil count in venous blood. Overall no seasonality was demonstrated in FBOE secondary to any diagnosis, although the six cases of recurrent FBOE secondary to EoE mainly occurred in the grass pollen season in subsequent years. FBOE cases were evenly distributed throughout metropolitan Melbourne irrespective of population density. EoE as a percentage of FBOE increased over time. Seasonal aeroallergens may be important for a subgroup of patients with EoE presenting as recurrent FBOE. Esophageal biopsies are performed in a minority of patients, representing a significant departure from ideal management and contributing to recurrent unnecessary FBOE. EoE is an increasingly important cause of FBOE.

Esophageal Food Impaction and Eosinophilic Esophagitis: A Retrospective Study, Systematic Review, and Meta-Analysis.

Esophageal food impaction (EFI) can be the initial presentation of eosinophilic esophagitis (EoE). EoE is characterized by persistent esophageal eosinophilia (EE). Both EFI and EE are related to a variety of conditions. To date, the relationship between EFI, EE, and EoE remains unclear. To review our institutional experience with EFIs and combine our knowledge with the existing literature to conduct a systematic review and meta-analysis for delineating the relationship between EFI, EE, and EoE. We reviewed medical records of 72 children with EFI presenting to our emergency center between 2007 and 2013. PubMed, EMBASE, and Scopus databases were screened from inception until July 2014 to identify studies linking EFI and EoE. Included studies were methodically assessed for the quality and strength of association between EFI and EoE. Our institutional experience highlighted the possibility of proton-pump inhibitor therapy-responsive EE (PPI-REE) as an underrecognized risk factor for EFI. A systematic review of 14 studies, including ours, revealed that most studies did not eliminate other causes of EFI or EE. The meta-analysis revealed that esophageal biopsies were obtained from 54% (40-68) of individuals presenting with EFI, and the overall EoE-attributable EFI among those who were biopsied was 54% (43-65). Substantial heterogeneity was noted among the studies. PPI-REE is an underestimated risk factor for EFI. The quality of existing evidence linking EFI and EoE is limited by several important factors. Future studies with robust design are warranted to delineate the relationship between EFI, EE, and EoE.