Presentation Of Eosinophilic Esophagitis Research Articles

Eosinophilic Esophagitis Presenting as Hiccups

Purpose: A 24 year old woman was referred to our care in March 2011 with a 3 year history of persistent hiccups and mild, intermittent dyspepsia. Her symptoms began with occasional mild chest discomfort lasting one minute followed by bouts of hiccups but progressed to up to ten episodes per day. She had no prior medical history other than one admission for renal calculi and her only prescription was birth control pills. She had no history of allergy and no known family history of illness as she was adopted. Six months before our evaluation she was treated empirically with ranitidine with no relief in her symptoms. She underwent esophagogastroduodenoscopy (EGD), which demonstrated trachealization of the esophagus and biopsies from the distal esophagus showed significant eosinophilic infiltration. She was subsequently placed on a 6 week course of high-dose omeprazole (40 mg twice daily), with minimal relief of her symptoms. A follow-up EGD showed persistent esophageal eosinophilia (peak eosinophils count of 23 per high power field) consistent with a diagnosis of eosinophilic esophagitis (EoE) (Figure 1). The patient was started on topical fluticasone (440 mcg twice daily). Within 1 week of treatment her symptoms improved substantially, with hiccups occurring fewer than 2 times per week. After 6 weeks her chest discomfort and hiccups resolved entirely. A post-treatment EGD demonstrated resolution of trachealization and histological remission of EoE. In conclusion, hiccups may be associated with eosinophilic esophagitis. Thus, EoE should be considered in the differential diagnosis of patients with refractory hiccups.Figure: Hematoxylin and eosin from esophageal biopsy shows large numbers of intraepithelial eosinophils as well as multiple degranulated eosinophils.

Family Psychosocial Dysfunction is a Prominent Feature in Eosinophilic Esophagitis Presenting as Pediatric Feeding Disorder

Family Psychosocial Dysfunction is a Prominent Feature in Eosinophilic Esophagitis Presenting as Pediatric Feeding Disorder

Time Trends in Foreign Body Impactions in the Esophagus: What is the Impact of the Increasing Prevalence of Eosinophilic Esophagitis?

Background: Esophageal foreign body impaction (EFBI) is a major presentation of eosinophilic esophagitis (EoE), but the impact of the increasing prevalence of EoE on the epidemiology of EFBI is not known. Aim: To determine whether the number of EFBI cases has increased with the increasing prevalence of EoE, and to assess characteristics of patients presenting with EFBI. Methods: Cases of EFBI from 2002 to 2009 were identified by querying the University of North Carolina Hospital's billing database (2005-2009), clinical database (2006-2009), and endoscopy database (2002-2009) for all records with ICD-9 code “935.1foreign body in the esophagus.” Charts were reviewed to confirm EFBI and to extract all pertinent data. Cases of EoE were defined per 2007 consensus guidelines and cross-referenced with our EoE database. Results: Of the 479 cases of EFBI identified (59% male, 67% Caucasian, mean age 35 ± 30 yrs), 289 (60%) were food impactions, 107 (22%) were coin impactions, and 83 (17%) were other objects (ex: golf tee, tooth, staple) or not specified. Overall, 45 EFBI patients (9%) had EoE, 39 of whom were diagnosed after the EFBI episode. The number of EGDs performed for food impaction nearly quadrupled between 2002 and 2009, however increasing diagnosis of EoE did not fully account for this trend (see figure). Only 97 (32%) of the 303 patients undergoing EGD had esophageal biopsies, and 31 (32%) of those patients biopsied had EoE (19 children, 12 adults). The type of impacted item (food vs. other) was associated with obtaining esophageal biopsies during the EGD (35% vs. 20%, p=0.012), but the proportion of cases with biopsies did not change over time. More subjects with food impaction had EoE compared to those with other types of EFBI (12% vs. 4%; p=0.003); only one patient with a coin impaction had EoE. On multivariate logistic regression analysis, the presence of EoE was themost significant predictor of recurrent EFBI (OR 3.6, 95%CI: 1.7-7.6). Conclusions: The number of EGDs performed for EFBI has increased dramatically at our center, and the increasing prevalence of EoE in this patient population only partially explains this trend. However, because only a minority of patients had biopsies at the time of EFBI, the incidence of EoE in this population is likely substantially underestimated. Physician education regarding the high prevalence of EoE in subjects with food impaction may increase the proportion of subjects biopsied and the number of EoE diagnoses made in this patient population.

Pilot Study of Radiological Assessment of Short-Term Corticosteroid Therapy on Esophageal Distensibility in Eosinophilic Esophagitis (EoE)

Background: Esophageal foreign body impaction (EFBI) is a major presentation of eosinophilic esophagitis (EoE), but the impact of the increasing prevalence of EoE on the epidemiology of EFBI is not known. Aim: To determine whether the number of EFBI cases has increased with the increasing prevalence of EoE, and to assess characteristics of patients presenting with EFBI. Methods: Cases of EFBI from 2002 to 2009 were identified by querying the University of North Carolina Hospital's billing database (2005-2009), clinical database (2006-2009), and endoscopy database (2002-2009) for all records with ICD-9 code “935.1foreign body in the esophagus.” Charts were reviewed to confirm EFBI and to extract all pertinent data. Cases of EoE were defined per 2007 consensus guidelines and cross-referenced with our EoE database. Results: Of the 479 cases of EFBI identified (59% male, 67% Caucasian, mean age 35 ± 30 yrs), 289 (60%) were food impactions, 107 (22%) were coin impactions, and 83 (17%) were other objects (ex: golf tee, tooth, staple) or not specified. Overall, 45 EFBI patients (9%) had EoE, 39 of whom were diagnosed after the EFBI episode. The number of EGDs performed for food impaction nearly quadrupled between 2002 and 2009, however increasing diagnosis of EoE did not fully account for this trend (see figure). Only 97 (32%) of the 303 patients undergoing EGD had esophageal biopsies, and 31 (32%) of those patients biopsied had EoE (19 children, 12 adults). The type of impacted item (food vs. other) was associated with obtaining esophageal biopsies during the EGD (35% vs. 20%, p=0.012), but the proportion of cases with biopsies did not change over time. More subjects with food impaction had EoE compared to those with other types of EFBI (12% vs. 4%; p=0.003); only one patient with a coin impaction had EoE. On multivariate logistic regression analysis, the presence of EoE was themost significant predictor of recurrent EFBI (OR 3.6, 95%CI: 1.7-7.6). Conclusions: The number of EGDs performed for EFBI has increased dramatically at our center, and the increasing prevalence of EoE in this patient population only partially explains this trend. However, because only a minority of patients had biopsies at the time of EFBI, the incidence of EoE in this population is likely substantially underestimated. Physician education regarding the high prevalence of EoE in subjects with food impaction may increase the proportion of subjects biopsied and the number of EoE diagnoses made in this patient population.

Presentation of Eosinophilic Esophagitis as Failure to Thrive in Young Children

RATIONALE: Eosinophilic esophagitis (EE) is an emerging disorder in children characterized by eosinophilic infiltration of the esophagus. In children it presents most commonly with dysphagia or gastroesophageal reflux symptoms while the knowledge regarding the presenting symptoms in young children (< 8years of age) is scarce.

Vitamin D deficiency, eosinophilic esophagitis, and health literacy

To review the recent literature on three topics that are important in pediatric office practice: vitamin D deficiency, eosinophilic esophagitis, and health literacy. Review of current literature will help pediatricians understand the prevalence of vitamin D deficiency, its potential negative health effects, and vitamin D supplementation guidelines. This article also provides practitioners with current knowledge of the evaluation and treatment of eosinophilic esophagitis. The article concludes with a summary of recent literature on health literacy and available techniques to improve patient education. Vitamin D deficiency in pediatric and adolescent patients is extremely common and has potential negative skeletal and extra-skeletal effects. Eosinophilic esophagitis is an increasingly recognized problem. Pediatric patients benefit from early recognition and treatment of the disease. There are effective techniques that improve patient health literacy. Vitamin D deficiency, eosinophilic esophagitis, and poor health literacy are three important problems that potentially negatively impact the lives of children and adolescents. Pediatricians should regularly counsel their patients regarding appropriate vitamin D intake. Practitioners should be aware of the clinical presentation of eosinophilic esophagitis. Pediatricians should utilize strategies to improve patient education with the goal of improving health outcomes.

An unusual presentation of eosinophilic esophagitis

An unusual presentation of eosinophilic esophagitis

S1888 Atypical Presentation of Eosinophilic Esophagitis: A Retrospective Review

S1888 Atypical Presentation of Eosinophilic Esophagitis: A Retrospective Review

Eosinophilic Esophagitis Presenting with Dyspepsia and Anorexia

Purpose: Eosinophilic esophagitis (EoE) is characterized by an eosinophilic infiltration of the esophagus and is increasingly recognized as a cause of dysphagia and heartburn unresponsive to antireflux therapy. We report a case of eosinophilic esophagitis that presented without dysphagia, heartburn or endoscopic abnormalities to alert clinicians to the importance doing of esophageal biopsies in atypical presentations of EoE. Methods: A 19 yo college student presented with a 3 year history of anorexia and dyspepsia. Multiple foods and milk seemed to cause dyspepsia. However, his symptoms persisted despite avoiding milk and milk products. He had several episodes of minor hematemesis that led to an endoscopy at age 16 (by a different physician) showing only a small Mallory-Weiss tear and normal duodenal biopsies. Because of worsening symptoms and weight loss of ten pounds, he was referred for further evaluation. Family history was notable for mother with celiac sprue. A gastric emptying test was normal, LFTs and CBC were normal except for borderline eosinophilia; WBC = 7000/uL and 7.3% eosinophils (normal 0–7.0%). A full panel of celiac antibodies were negative except for an antigiadin IgG of 100.0 U/ml (normal <10.0 U/ml). A repeat endoscopy to assess for celiac sprue was normal except for slight gastric retention. Multiple biopsies were negative for celiac sprue and H. pylori. There was no eosinophilia in the duodenal or gastric biopsies. The esophagus was endoscopically normal without evidence of esophagitis, rings, or any other abnormalities. Biopsies from a normal appearing GE junction revealed a focal dense eosinophilic infiltration in the squamous epithelium (≥28 eosinophils per high powered field) consistent with EoE. The patient was started on fluticasone swallowed twice a day with resolution of all symptoms within a few weeks. Results: EoE is becoming more frequently diagnosed as a cause of dysphagia and heartburn and is predominantly considered in younger patients presenting with symptoms that are unresponsive to antireflux therapy or with endoscopic signs of EoE such as ringed esophagus. Diagnosis is by clinical features supported by esophageal biopsy with ≥15 eosinophils per HPF. Five biopsies (including proximal esophagus) have a sensitivity of 100%. Other bloodwork and endoscopic findings are neither sensitive nor specific. Conclusion: This case highlights the importance of esophageal biopsies in the diagnosis of EoE in atypical presentations. We suggest that clinicians consider the possibility of EoE in patients with prolonged, non-specific upper GI complaints and biopsy the esophagus even if the mucosa appears normal on endoscopy.

The Grape Obstruction

Purpose: Eosinophilic esophagitis (EE) is an esophageal disorder characterized by upper GI symptoms and associated with dense eosinophilic infiltration of the esophagus. The exact pathophysiology is unknown, but there is an association with food allergies suggesting an aberrant immune response is responsible. EE is increasing in prevalence, most likely due to increased recognition. Clinically, EE usually presents with dysphagia and food-bolus impaction is common. Endoscopically, linear furrows or mucosal rings are often observed in the esophagus. Histologically, greater than 15 eosinophils are present per high power field. We present a case of eosinophilic esophagitis presenting with a grape obstructing the esophagus and innovative management with removal of the grape using the barrell apparatus from a banding device. Methods: A 26 year old male prisoner with no past medical history was brought to our emergency department with the complaint of dysphagia and inability to swallow his secretions after eating grapes. Malingering was initially suspected, but GI was eventually consulted. EGD revealed a fully intact grape obstructing the distal esophagus. A transient appearance of a ringed esophagus and persistent longitudinal furrows were observed as well. Results: An attempt was made with a Roth net to retrieve the grape but was unsuccessful. Rat tooth forceps were then used to excise multiple pieces of the grape, however the grape maintained its integrity and we were unable to push the grape through the GE junction. The bands were then removed from the plastic barrell of a variceal ligation device. This cap was utilized to provide a larger area of forceful suction enabling us to remove the grape from its impacted location. Multiple biopsies were then taken along the length of the esophagus which revealed degranulated eosinophils and greater than 15 eosinophils per high power field confirming the diagnosis of eosinophilic esophagitis. Conclusion: Eosinophilic esophagitis is chronic inflammatory disease of the esophagus and while there are many effective treatments, the optimal therapy has yet to be fully defined. As it is being recognized more frequently, different presentations and findings are being documented. This case is the first, to our knowledge, of eosinophilic esophagitis presenting with a grape as a food-bolus impaction. Another case of a grape causing esophageal obstruction has been described, but the primary pathology was a stricture. This case also demonstrates an alternative use for the barrell on banding devices, which may prove useful with foreign bodies such as in this case.

Demographic Data and Symptoms of Eosinophilic Esophagitis in Adults

The clinical presentation of eosinophilic esophagitis in adults is varied but most often starts with some form of dysphagia. These patients often may be diagnosed incorrectly as having gastroesophageal reflux disease or functional disease, given the paucity of objective endoscopy and radiographic findings in some patients, even though symptoms often are severe and persistent. A careful history with attention to detail and a compilation of compatible characteristics is key to the clinician's diagnosing eosinophilic esophagitis in an adult.

Association of eosinophilic inflammation with esophageal food impaction in adults

Esophageal food impaction is a common presentation of eosinophilic esophagitis. The prevalence of eosinophilic esophagitis among patients with food impaction is unknown. To address this, we evaluated clinicopathologic features of adults with food impaction. For a 3-year period, patients from a single, adult, community-based gastroenterology practice with esophageal food impaction were evaluated. Histories were assessed and esophageal biopsy specimens were evaluated by routine and immunohistochemical techniques. Thirty-one patients with food impaction were evaluated. Seventeen of 31 patients had >20 eosinophils/high power field (HPF) without gender predilection. Thirteen of these 17 patients had been treated with proton pump inhibitors at the time biopsy specimens were obtained. Patients with >20 eosinophils/HPF were significantly younger (mean age 42 +/- 4 years) than patients with <20 eosinophils/HPF (mean age 70 + 3 years). Superficial white exudates and eosinophilic microabscesses in the squamous epithelium were features observed only in patients with >20 eosinophils/HPF. Immunopathologic analysis demonstrated increased CD8 lymphocytes and major basic protein deposition in their squamous epithelium. More than half of patients with esophageal food impaction in a primary gastroenterology practice have >20 eosinophils/HPF. Based on clinicopathologic features, a significant number likely have eosinophilic esophagitis.