Recognition Of Eosinophilic Esophagitis Research Articles

Eosinophilic Esophagitis in Esophageal Atresia.

Recent studies have reported a higher prevalence of eosinophilic esophagitis in children with esophageal atresia. Under recognition of eosinophilic esophagitis in these patients may lead to excessive use of antireflux therapy and an escalation of interventions, including fundoplication, as symptoms may be attributed to gastroesophageal reflux disease. In addition, long-term untreated eosinophilic esophagitis may lead to recurrent strictures due to transmural esophageal inflammation, necessitating repeated dilatations. Eosinophilic esophagitis should be considered when children with esophageal atresia show persistent symptoms on standard antireflux treatment, increasing dysphagia, and recurrent strictures. Treatment has been found to not only significantly reduce intraepithelial eosinophil count, but also to improve symptoms, and to lower the occurrence of strictures and the need for dilatations. Future prospective studies are warranted in this area.

The Global Face of Eosinophilic Esophagitis: Advocacy and Research Groups

Although eosinophilic esophagitis (EoE) has been described in the literature for a substantial period, its recognition as a disease entity on the global stage is still relatively new. It has become a major diagnosis of consideration by medical providers when both adult and pediatric patients present with dysphagia, food impaction, and gastroesophageal reflux-like symptoms. In addition to the clinical work of specialists such as allergy-immunologists and gastroenterologists, the evolution of research organizations and advocacy groups focused on EoE have greatly assisted in bringing attention to, and raising awareness about, this disease. As a result of their efforts, diagnosis and treatment guidelines have been developed, and medical providers now have a specific ICD code for EoE. This represents a new model for the interaction of patients and medical provider, where patients not only advocate for their disorder, but also drive physician education and a patient-centered research agenda and its funding. It should be noted, though, that these organizations and advocacy groups are mainly located in North America and Europe, and as a result, EoE has largely been associated with the Caucasian demographic. However, it has been described in Asia, the Middle East, Latin America, and Africa. Physicians from these areas have increased awareness and understanding in the medical and research communities in their countries through case reports and the establishment and analysis of potential patient cohorts. At this time, the prevalence of EoE in these regions is comparably lower, but this may be due to less recognition and understanding of EoE, as well as medical efforts being directed towards more ubiquitous disease processes, such as infectious diseases. With the support and ongoing work of researchers, patients, and their family members, understanding and recognition of EoE as a clinically significant disease entity will continue to grow.

Eosinophilic Esophagitis in Children with Esophageal Atresia.

Recent studies have reported a higher prevalence of eosinophilic esophagitis in children with esophageal atresia. Under recognition of eosinophilic esophagitis in these patients may lead to excessive use of antireflux therapy and an escalation of interventions, including fundoplication, as symptoms may be attributed to gastroesophageal reflux disease. In addition, long-term untreated eosinophilic esophagitis may lead to recurrent strictures due to transmural esophageal inflammation, necessitating repeated dilatations. Eosinophilic esophagitis should be considered when children with esophageal atresia show persistent symptoms on standard antireflux treatment, increasing dysphagia, and recurrent strictures. Treatment has been found to not only significantly reduce intraepithelial eosinophil count, but also to improve symptoms, and to lower the occurrence of strictures and the need for dilatations. Future prospective studies are warranted in this area.

Recent advances in the recognition and management of eosinophilic esophagitis.

The incidence and recognition of eosinophilic esophagitis is increasing. Pathophysiological understanding of eosinophilic esophagitis is improving and an immunological reaction to ingested food is likely to play a significant role. Patients present with dysphagia and food bolus obstruction. Both histological and endoscopic criteria have been developed and validated. Dietary therapy, topical steroid therapy, proton pump inhibitors and endoscopic dilation are the main approaches to therapy; however, novel targeted therapies are being developed. Among the food items commonly implicated are wheat, dairy, nuts, soy, shellfish and eggs. A multidisciplinary approach to management in dedicated clinics may yield the best results.

Prevalence of Eosinophilic Esophagitis in the United States

Eosinophilic esophagitis (EoE) has become a major cause of upper gastrointestinal morbidity in children and adults. However, there are few data on the nationwide prevalence of EoE. We aimed to estimate the prevalence of EoE in the United States. We collected health insurance claims from a large database that represented the U.S. commercially insured population. We analyzed data from 2008 to 2011, identifying cases of EoE by using a previously validated definition, and calculated a period prevalence by using data from 2009 to 2011. EoE was defined as any instance of the International Classification of Diseases, 9th revision code 530.13. We calculated the prevalence of the code in the database and standardized the estimate to the U.S. population. Of 35,575,388 individuals in this database, 16,405 had at least 1 code for EoE. The mean age was 33.5 years, 65% were male, 55.8% had dysphagia, and 52.8% had a diagnostic code for at least 1 allergic condition. Among 11,569,217 individuals with continuous insurance coverage between mid-2009 and mid-2011, 6513 had at least 1 code for EoE. When standardized to the U.S. population, the estimated period prevalence of EoE was 56.7/100,000 persons, translating to approximately 152,152 cases in the U.S. Prevalence peaked in men 35-39 years old, with a rate of 114.6/100,000 persons. Despite its relatively recent description, EoE is frequently diagnosed in the United States, with an estimated prevalence of 56.7/100,000 persons. This estimate depends on the accuracy of the International Classification of Diseases, 9th revision code, but it could be an underestimate, because knowledge of the code and recognition of EoE are increasing.

Su1843 The Prevalence of Eosinophilic Esophagitis in the United States: Estimates From a Large Administrative Database

Background: Eosinophilic esophagitis (EoE) is a major cause of upper GI morbidity in both children and adults. However, most assessments of the prevalence of EoE are from single centers, and there are few data on the nationwide prevalence of EoE. Aim: To estimate the prevalence of EoE in the United States. Methods: We performed a retrospective analysis of the LifeLinkTM Health Plan Claims Database. This database is representative of a U.S. national commercially insured population and contains medical and pharmaceutical claims for .90 million individuals. We analyzed data from 2008-2011 in subjects age 0-64 who had ≥6 months of continuous enrollment. EoE was defined as a single instance of the ICD9 code 530.13. This code was approved in 2008 and we have previously validated its extremely high specificity (.99%) for diagnosis of EoE using administrative records among commercially insured patients. For this analysis, we compiled the number of patients with this code over the study timeframe, calculated the prevalence of the code in the database, and then standardized the estimate to the U.S. population by age and sex using 2010 census data. Sensitivity analysis was performed based on the operating parameters of the 530.13 diagnostic code (sensitivity of 37%) that we previously demonstrated. Results: Of the 25,368,850 individuals in this database from 2008-2011, 16,405 (0.06%) were found to have at least one diagnostic code for EoE. The mean age for these EoE patients was 33.5 ± 17 yrs, and 65% were male. Of those with a diagnostic code for EoE, 52.8% also had a diagnostic code for at least one allergic condition. Specifically, 45.9% had a code for allergic rhinitis/sinusitis, 23.4% for asthma, 4.7% for food allergy, 8.6% for atopic dermatitis, and 1.8% for urticaria. Frequency of diagnosis tended to vary by U.S. census region, with 19% in the east (54/100,000), 34% in the midwest (76/100,000), 32% in the south (70/100,000), and 15% in the west ((52/100,000; p=0.08). The cumulative prevalence of EoE increased over time from 7/100,000 in 2008, to 31/100,000 in 2009, 50/100,000 in 2010, and 65/ 100,000 in 2011, likely reflecting increasing use of the code. When standardized to the U.S. population, the estimated prevalence of EoE was 67/100,000, or approximately 178,789 cases. Applying the known sensitivity of the code to the U.S. population, and assuming only 37% of patients with EoE are identified by the code, the prevalence in the U.S. could be as high as 181/100,000 or about 480,000 cases. Conclusions: EoE is becoming more common in the U.S., with an estimated prevalence between 67 and 181/100,000. These values may underestimate the true prevalence given that both knowledge of the new ICD9 code and recognition of EoE are increasing. The estimated prevalence of EoE is beginning to approach that of Crohn's disease.

Eosinophilic Esophagitis: An Update

As recognition of eosinophilic esophagitis (EoE) continues to grow, so does the number of questions about the biology of the disease and treatment for

The Potential Impact of Contemporary Developments in the Management of Patients with Gastroesophageal Reflux Disease Undergoing an Initial Gastroscopy

Recent developments may alter the approach to patients presenting with gastroesophageal reflux disease (GERD)-like symptoms. A newly proposed Montreal consensus definition of Barrett's esophagus includes all types of esophageal columnar metaplasia, with or without intestinal-type metaplasia. There is also increasing recognition of eosinophilic esophagitis (EE) in patients with GERD-like symptoms. To quantify the impact of these developments on a multiphysician general gastroenterology practice in a tertiary care medical centre. Medical charts of all patients having an initial gastroscopy for GERD-like symptoms over a one-year period were reviewed retrospectively, and audits of their endoscopic images and esophageal biopsies were performed. Of the 353 study participants, typical symptoms of heartburn and acid reflux were present in 87.7% and 23.2%, respectively. Less commonly, patients presented with atypical symptoms (eg, dysphagia in 9.4%). At endoscopy, 26% were found to have erosive esophagitis and 12% had endoscopically suspected esophageal metaplasia. Histological evaluation was available for 65 patients. Ten of the 65 biopsied patients (15%) met traditional criteria for Barrett's esophagus (ie, exhibiting intestinal-type metaplasia), whereas 49 (75%) fulfilled the newly proposed consensus definition of Barrett's esophagus. Five patients (7.7%) met the study criteria for EE (more than 20 eosinophils per high-power field), four of whom had not been previously recognized. Among patients presenting with GERD-like symptoms, the prevalence of Barrett's esophagus may increase markedly if the Montreal definition is adopted. In addition, growing awareness of EE may lead to an increase in the prevalence of this diagnosis. Prospective studies of the management implications of these findings are warranted.

Noninvasive Markers of Eosinophilic Esophagitis

There has been an increasing awareness and recognition of eosinophilic esophagitis (EE), a chronic condition with periods of exacerbation and remission, over the last decade. The complex pathophysiology of EE and eosinophil physiology provide several candidate biomarkers that could be studied on various noninvasively obtained body specimens. This article reviews several potential noninvasive biomarkers of EE.

Retrospective Analysis of Esophageal Food Impaction: Differences in Etiology by Age and Gender

Eosinophilic Esophagitis (EE) is an emerging cause of esophageal food impaction (EFI) not accounted for in previous studies. We sought to determine the causes of EFI in a recent cohort with recognition of EE. A retrospective chart review of all patients with EFI during the past 5 years was performed. Etiology was determined by endoscopy report, pathology results, and follow-up studies. A total of 85 EFIs occurred, in 79 patients (55 men, 30 women, age 18-100). The most common etiologies of EFI were Schatzki's ring (n = 18), peptic stricture (n = 18), EE (n = 9), esophagitis (n = 9), and no underlying diagnosis (n = 20). EE was significantly more frequent in men (P < .025) and those <50 years old (P < .025). There was a significant difference in the age at which men (median age = 44) and women (median age = 71) present with EFI (P < .001). The etiology of EFI differs significantly by age and gender. This information may be useful in evaluation and management of EFI.

Demographic, Clinical, and Pathologic Characteristics of Eosinophilic Esophagitis Utilizing a National Pathology Database

Purpose: Reports on Eosinophilic Esophagitis (EE) are limited to small series of patients from single institutions. The goal of this study was to characterize demographic, clinical and pathologic features of EE over a diverse patient population. Methods: Patients diagnosed with EE without other organ involvement were identified utilizing a national pathology database (Pathology Partners Inc., Irving, TX) from January 2002 to May 2006. EE was defined by: 1) a mean of ≥20 eosinophils in 5 HPF, or 2) when 5 HPF were not available, a mean of ≥30 eosinophils in 2–4 HPF. Eosinophils were not counted beyond 100 per HPF. Demographic and clinical information was provided by the endoscopist. Results: 363 cases met the inclusion criteria (308 by criteria #1, 55 by #2). Patients were identified from 26 states, from a database receiving pathology specimens from 34 states. Male gender predominated 3:1, 270 males (74.4%) to 93 females (25.6%). Ages ranged from 14 months to 98 years, with 42 children (0–17 years), and 321 adults: 78 (21.5%) age 18–29, 84 (23.1%) age 30–39, 88 (24.2%) age 40–49, 32 (8.8%) age 50–59, 25 (6.9%) age 60–69, and 14 (3.9%) age 70 or greater. Dysphagia was present in 65.0% of patients, followed by GERD/heartburn (28.4%), and abdominal pain/dyspepsia (15.2%). In adults, the most commonly reported indications were dysphagia (70.1%), GERD/heartburn (27.1%), and abdominal pain/dyspepsia (13.1%) whereas children reported GERD/heartburn (38.1%), abdominal pain/dyspepsia (31.0%) followed by dysphagia (26.2%). Across adult age groups, the prevalence of dysphagia and GERD/heartburn symptoms ranged from 44–79%, and 16–43%, respectively. The mean eosinophil count per HPF was 57.5 in children and 65.3 in adults. The count ranged from 53.6 in the 70 year plus bracket to 71.2 in the 18–29 year olds. Over the study time period, EE was diagnosed in 0.1% (1/726) of all patients with dysphagia who had upper endoscopy with esophageal biopsy in 2002, 0.9% (20/2226) in 2003, 1.2% (43/3621) in 2004, and 1.9% (110/5892) in 2005. Conclusions: 1. EE is a national disease. 2. EE can be found in any age group but more commonly in men. 3. Dysphagia is the predominant symptom in most adults followed by GERD symptoms. 4. The degree of eosinophilic infiltration remains high throughout all age ranges. 5. The prevalence and/or recognition of EE is increasing markedly in this country.

Eosinophilic esophagitis

Eosinophilic esophagitis is a new disease commonly confused with gastroesophageal reflux disease. Because of different treatments, recognition of eosinophilic esophagitis is important. Recent work further characterizes the allergic response, demonstrating a population of eosinophils different from gut and blood that specifically homes to the esophagus in eosinophilic esophagitis. Further data suggest a multi-step allergy process starting with an atopic skin response that later primes the esophagus on further allergen exposure. Diagnosis of eosinophilic esophagitis is suggested by food impaction in a young adult with a personal and family history of allergy. Barium radiography may be useful for obvious signs of eosinophilic esophagitis including rings and strictures. Treatment is based on systemic or topical steroids or identification and elimination of food allergens sometimes with elemental diets. Recent data show the latter to be superior both for the short and long term but with the caveat of compliance being difficult. Eosinophilic esophagitis is an allergy-based disorder. It presents commonly in adults as long standing dysphagia, sometimes with food impaction. Radiography is useful but will miss subtle signs of eosinophilic esophagitis. Treatment options are limited to steroid formulations or avoidance of food allergens though compliance, particularly with elemental formulas, remains problematic.

Eosinophilic Esophagitis (EE) in Adults: Emerging Entity or Misdiagnosed Malady

EE has been increasingly recognized as an important cause of dysphagia and food impaction in adults. Endoscopic therapy of food impactions and strictures in EE has been associated with esophageal tears and perforation. Our goal was to review demographic and endoscopic findings of our cohort of 74 adult patients (pts) to better understand the clinical course of this illness. Methods: We conducted a chart review of pts seen between 1999 and 2004 with a diagnosis of EE based on at least 15 eosinophils per high powered field. Demographic, endoscopic and histologic data were collected. Results: 74 pts were included in this analysis, the largest adult series studied to date. The mean pt age was 38 yrs (14-76) with a mean duration of symptoms of 6.9 yrs (.5-20). 57 pts (76%) were male. The most common presenting symptoms were dysphagia (90%), food impaction (55%) and heartburn (31%). 53% of pts had been to the emergency room with food impactions requiring endoscopic removal. 43% of pts had previous endoscopies an average of 5 yrs (.5-23) prior to their diagnosis of EE. The most common initial diagnosis in this group were Schatzki's rings (SR) (37%), esophageal strictures/webs (26%), reflux (22%), peptic strictures (11%) and congenital esophageal stenosis (4%). 88% of cases were diagnosed with EE after 2003. 20% of pts had bx initially read as GERD and subsequently changed to EE on repeat histologic review. 70% of pts had an allergic history; 77% having seasonal allergies, 17% having combined seasonal and food and 7% with allergic skin conditions. Of pts with a complete blood count, only 9% had a peripheral eosinophilia. The most common endoscopic findings were mucosal rings (81%) and linear furrows (74%) followed by strictures (31%), exudates (15%), small caliber (10%) and edema (8%). Incidental findings of hiatal hernia, SR and esophagitis were seen in 45%, 16% and 16% respectively. 50% of pts were treated with dilation using CRE balloon (70%), Savory (16%) and a combination of methods (8%). Conclusions: (1) 43% of pts had endoscopies for dysphagia with diagnoses other than EE an average of 5 years prior, likely representing misdiagnoses. (2) The majority of pts were diagnosed after 2003 suggesting increased recognition by gastroenterologists and pathologists. (3) Better recognition of EE should allow earlier medical treatment that may reduce the need, and thereby prevent complications associated with endoscopic procedures for EE. EE has been increasingly recognized as an important cause of dysphagia and food impaction in adults. Endoscopic therapy of food impactions and strictures in EE has been associated with esophageal tears and perforation. Our goal was to review demographic and endoscopic findings of our cohort of 74 adult patients (pts) to better understand the clinical course of this illness. Methods: We conducted a chart review of pts seen between 1999 and 2004 with a diagnosis of EE based on at least 15 eosinophils per high powered field. Demographic, endoscopic and histologic data were collected. Results: 74 pts were included in this analysis, the largest adult series studied to date. The mean pt age was 38 yrs (14-76) with a mean duration of symptoms of 6.9 yrs (.5-20). 57 pts (76%) were male. The most common presenting symptoms were dysphagia (90%), food impaction (55%) and heartburn (31%). 53% of pts had been to the emergency room with food impactions requiring endoscopic removal. 43% of pts had previous endoscopies an average of 5 yrs (.5-23) prior to their diagnosis of EE. The most common initial diagnosis in this group were Schatzki's rings (SR) (37%), esophageal strictures/webs (26%), reflux (22%), peptic strictures (11%) and congenital esophageal stenosis (4%). 88% of cases were diagnosed with EE after 2003. 20% of pts had bx initially read as GERD and subsequently changed to EE on repeat histologic review. 70% of pts had an allergic history; 77% having seasonal allergies, 17% having combined seasonal and food and 7% with allergic skin conditions. Of pts with a complete blood count, only 9% had a peripheral eosinophilia. The most common endoscopic findings were mucosal rings (81%) and linear furrows (74%) followed by strictures (31%), exudates (15%), small caliber (10%) and edema (8%). Incidental findings of hiatal hernia, SR and esophagitis were seen in 45%, 16% and 16% respectively. 50% of pts were treated with dilation using CRE balloon (70%), Savory (16%) and a combination of methods (8%). Conclusions: (1) 43% of pts had endoscopies for dysphagia with diagnoses other than EE an average of 5 years prior, likely representing misdiagnoses. (2) The majority of pts were diagnosed after 2003 suggesting increased recognition by gastroenterologists and pathologists. (3) Better recognition of EE should allow earlier medical treatment that may reduce the need, and thereby prevent complications associated with endoscopic procedures for EE.