ABSTRACT
Eosinophilic gastrointestinal disorders (EGID) are a group of disorders characterized by pathologic eosinophilic infiltration of the esophagus, stomach, small intestine, or colon leading to organ dysfunction and clinical symptoms (J Pediatr Gastroenterol Nutr; Spergel et al., 52: 300-306, 2011). These disorders include eosinophilic esophagitis (EoE), eosinophilic gastritis (EG), eosinophilic gastroenteritis (EGE), eosinophilic enteritis (EE), and eosinophilic colitis (EC). Symptoms are dependent not only on the location (organ) as well as extent (layer invasion of the bowel wall). Common symptoms of EoE include dysphagia and food impaction in adults and heartburn, abdominal pain, and vomiting in children. Common symptoms of the other EGIDs include abdominal pain, nausea, vomiting, early satiety, diarrhea, and weight loss. These disorders are considered immune-mediated chronic inflammatory disorders with strong links to food allergen triggers. Treatment strategies focus on either medical or dietary therapy. These options include not only controlling symptoms and bowel inflammation but also on identifying potential food triggers. This chapter will focus on the clinical presentation, pathophysiology, and treatment of these increasingly recognized disorders.
Subject(s)
Enteritis/epidemiology , Enteritis/therapy , Eosinophilia/epidemiology , Eosinophilia/therapy , Eosinophilic Esophagitis/epidemiology , Eosinophilic Esophagitis/therapy , Gastritis/epidemiology , Gastritis/therapy , Adolescent , Adrenal Cortex Hormones/therapeutic use , Adult , Aged , Aged, 80 and over , Biological Therapy , Child , Child, Preschool , Diet Therapy , Enteritis/diagnosis , Enteritis/physiopathology , Eosinophilia/diagnosis , Eosinophilia/physiopathology , Eosinophilic Esophagitis/diagnosis , Eosinophilic Esophagitis/physiopathology , Female , Gastritis/diagnosis , Gastritis/physiopathology , Genetic Predisposition to Disease , Humans , Immunologic Factors/therapeutic use , Infant , Male , Middle Aged , Proton Pump Inhibitors/therapeutic use , Sex Factors , Young AdultABSTRACT
OBJECTIVES: The incidence of eosinophilic esophagitis is unknown in our area. The aim of our study was to determine the incidence of eosinophilic esophagitis and its possible association with the most frequent absolute annual pollen counts. METHODS: A descriptive retrospective multicenter observational study was designed to calculate the incidence of eosinophilic esophagitis in children aged under 15 years in the southwest region of Madrid, Spain in 2002-2013 (data were provided by the Statistics Institute of Madrid). We collected data on age, sex, clinical presentation, and date of endoscopic diagnosis. Relative risk (RR) was estimated (Stata v.11) using negative binomial regression models to assess the association between incidence and pollen counts (provided by Subiza Clinic). RESULTS: The study population comprised 254 patients (192 male [75.6%], aged 0.5-14.99 years). The clinical presentation was esophageal impaction in 23.6%, dysphagia in 22%, gastroesophageal reflux-like symptoms in 44.9%, and other findings in 9.4%. The annual incidence from 2002 to 2013 per 100 000 children aged <15 years per year was, respectively, 0.81, 1.5, 0.37, 3.17, 3.07, 4.36, 6.87, 7.19, 8.38, 9.05, 9.14, and 9.68. The incidence of eosinophilic esophagitis increased by an average of 19% annually (RR, 1.19; 95%CI, 1.14-1.25; P<.001). In the overall analysis, the relationship between incidence and absolute annual and monthly counts during the pollen seasons of the respective pollen types was analyzed only for Platanus species, which had an RR >1 (1.17 and 1.06, respectively) (P<.05). CONCLUSION: The incidence of diagnosis of pediatric eosinophilic esophagitis increased by an average of 19% annually. No significant association was found between incidence and pollen counts, except for a weak association with Platanus species.
Subject(s)
Eosinophilic Esophagitis/diagnosis , Eosinophilic Esophagitis/epidemiology , Allergens , Child , Female , Humans , Incidence , Male , Pollen , Spain/epidemiologyABSTRACT
Eosinophilic esophagitis and asthma are frequently found as comorbid conditions in children and adults along with other manifestations of atopic diathesis. These two conditions have similar T helper 2 responses-driven pathophysiology and share common management strategies such as using systemic corticosteroids and targeted anti-cytokine biologic therapies. Review of the literature finds that asthma is often a comorbid condition in eosinophilic esophagitis in both children and adults; however, the EoE-asthma relationship remains poorly characterized mechanistically and clinically. EoE and asthma commonly share several comorbid conditions such as allergic rhinitis and gastroesophageal reflux disease; therefore, addressing these comorbid conditions has the potential to improve and/or maintain control in both diseases. Similar to asthma, patients with EoE frequently demonstrate elevations in serum markers of atopy, including serum IgE levels, peripheral eosinophil counts, and T helper 2-related cytokines. Gastroesophageal reflux disease is thought to affect asthma through microaspirations, airway hyperresponsiveness, and increased vagal tone. The understanding of the relationship between gastroesophageal reflux and EoE is still evolving but seems to be bidirectional and interactive. In terms of treatment, similar classes of medications have been used in both EoE and asthma. In both children and adults, EoE remission can be achieved by food trigger avoidance and use of corticosteroids and biologic therapies. Asthma control is mostly achieved through inhaled corticosteroids, and long but biologic therapies are increasingly used in severe subsets of the disease. Significant clinical and mechanistic work needs to be accomplished to better understand the relationship between asthma, EoE, and their interaction with other allergic diseases. Understanding whether shared mechanisms exist can lead to the development of new diagnostic and therapeutic strategies. The following review examines the existing literature regarding prevalence, common comorbidities, and potential therapeutic approach and identifies gaps in knowledge and future directions.
Subject(s)
Asthma/epidemiology , Eosinophilic Esophagitis/epidemiology , Gastroesophageal Reflux/epidemiology , Rhinitis, Allergic/epidemiology , Th2 Cells/immunology , Adrenal Cortex Hormones/therapeutic use , Adult , Antibodies, Monoclonal/therapeutic use , Asthma/immunology , Asthma/therapy , Biological Therapy , Child , Comorbidity , Cytokines/antagonists & inhibitors , Eosinophilic Esophagitis/immunology , Eosinophilic Esophagitis/therapy , HumansABSTRACT
BACKGROUND: Multiple lines of evidence point to the potential importance of early-life environmental factors in the rapid increase in the incidence of eosinophilic esophagitis (EoE), but potential exposures have not been extensively studied. OBJECTIVE: We sought to assess the association between prenatal, intrapartum, and postnatal factors and the development of pediatric EoE using a case-control study. METHODS: Patients with EoE were recruited from an existing registry at Cincinnati Children's Hospital Medical Center (CCHMC). Population-based community control subjects were identified from a separate CCHMC registry. Mothers of study subjects were contacted and completed a Web-based questionnaire. Crude and adjusted models were used to estimate associations. RESULTS: Mothers of 127 cases and 121 control subjects were included. We observed a positive association between several early-life factors and EoE, including prenatal (maternal fever: adjusted odds ratio [aOR], 3.18; 95% CI, 1.27-7.98; preterm labor: aOR, 2.18; 95% CI, 1.06-4.48), intrapartum (cesarean delivery: aOR, 1.77; 95% CI, 1.01, 3.09), and infancy (antibiotic use: aOR, 2.30; 95% CI, 1.21-4.38; use of an acid suppressant: aOR, 6.05; 95% CI, 2.55-14.40) factors. We observed an inverse association between having a furry pet in infancy and EoE (aOR, 0.58; 95% CI, 0.34-0.97). No associations were observed for breast-feeding or maternal multivitamin or folic acid supplement use. CONCLUSION: Early-life factors, including maternal fever, preterm labor, cesarean delivery, and antibiotic or acid suppressant use in infancy, were associated with risk of pediatric EoE; having a pet in the home was protective. These results add to growing evidence that implicate early-life exposures in EoE pathogenesis.
Subject(s)
Eosinophilic Esophagitis/epidemiology , Eosinophilic Esophagitis/etiology , Pregnancy Complications , Case-Control Studies , Child , Comorbidity , Female , Humans , Infant , Infant, Newborn , Male , Odds Ratio , Pregnancy , Public Health Surveillance , Registries , Risk Assessment , Risk FactorsSubject(s)
Eosinophilic Esophagitis , Esophageal Neoplasms , Gastroesophageal Reflux , Gastrointestinal Microbiome , Biomarkers/analysis , Diet Therapy , Electric Stimulation Therapy , Eosinophilic Esophagitis/diagnosis , Eosinophilic Esophagitis/epidemiology , Eosinophilic Esophagitis/etiology , Eosinophilic Esophagitis/therapy , Esophageal Neoplasms/diagnosis , Esophageal Neoplasms/epidemiology , Esophageal Neoplasms/etiology , Esophageal Neoplasms/therapy , Esophagectomy , Esophagoscopy , Gastroesophageal Reflux/diagnosis , Gastroesophageal Reflux/epidemiology , Gastroesophageal Reflux/etiology , Gastroesophageal Reflux/therapy , Humans , Incidence , Neoadjuvant Therapy , Proton Pump Inhibitors/therapeutic use , Psychotherapy , Sequence AnalysisABSTRACT
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by esophageal dysfunction and eosinophilic infiltrate (≥15/hpf) in the esophageal epithelium and the absence of other potential causes of eosinophilia. The prevalence is increasing and is the most common cause of solid food dysphagia in children and young adults. This article will review the diagnosis and management of EoE based on consensus conferences, systematic reviews, and meta-analysis and highlights seminal studies in our evolving treatment of this disease. However, all answers are not available and I will remark about the lessons learned in my clinical practice seeing EoE patients over the last 25 years. The complicated etiology of the complaint of dysphagia in EoE patients will be reviewed. The importance of utilizing endoscopy, biopsies, and barium esophagram to help define the 2 phenotypes (inflammatory, fibrostenosis) of EoE will be highlighted. The controversy about PPI-responsive esophageal eosinophilia will be discussed and contrasted with idiopathic EoE. Finally, the 3 treatment options for EoE (drugs, diet, dilation) will be reviewed in detail and a useful clinical management algorithm presented.