Comparison of esomeprazole to aerosolized, swallowed fluticasone for eosinophilic esophagitis.

BACKGROUND: Both gastroesophageal reflux disease and allergy/atopy have been implicated in the pathogenesis of eosinophilic esophagitis (EoE). There are no prospective studies comparing treatment of EoE with acid suppression versus topical corticosteroids. OBJECTIVE: To determine the outcome of adult eosinophilic esophagitis patients treated with esomeprazole versus topical fluticasone. DESIGN: Prospective randomized controlled trial. SETTING: Academic medical center. PARTICIPANTS: Adults (18-80) diagnosed with EoE by symptoms of dysphagia and esophageal biopsies with >or=15 eosinophils/hpf. INTERVENTIONS: Subjects were randomized to esomeprazole (40 mg by mouth every morning) or aerosolized, swallowed fluticasone (440 mcg by mouth twice a day) for 8 weeks. MAIN OUTCOME MEASUREMENTS: Improvement in dysphagia (8-point scale), esophageal eosinophil infiltration before and after treatment, prevalence of GERD measured by validated questionnaire and baseline pH study. RESULTS: About 56% (14/25) had acid reflux by pH study. There was no difference between treatment groups in improvement in dysphagia scores [3/12 (25%) of the esomeprazole group versus 6/12 (50%) in the fluticasone group, P = 0.40]. Eosinophil infiltration decreased with treatment in both groups, and there was no difference in the amount of decrease between groups (P = 0.70). LIMITATIONS: Small sample size, unexpectedly high drop-out rate. CONCLUSIONS: Gastroesophageal reflux disease is common in adult eosinophilic esophagitis patients. Dysphagia improves and esophageal eosinophilic infiltration decreases with either treatment. There was no difference in degree of improvement in dysphagia or eosinophil infiltration in patients treated with either topical fluticasone or oral esomeprazole. GERD may be important in the pathogenesis of adult EoE.

The role of gastroesophageal reflux in exercise-triggered asthma: a randomized controlled trial.

BACKGROUND: Exercise-triggered asthma (ETA) develops when physical activity triggers asthma symptoms during or directly after exercise. In patients prone to symptoms of supra-esophageal reflux, exercise may trigger gastroesophageal reflux (GER), resulting in such symptoms. AIMS: To determine the prevalence of abnormal pH in patients with ETA and to determine whether acid suppression improves symptoms in ETA patients. METHODS: We performed a randomized double-blind trial of rabeprazole versus placebo in the treatment of patients with ETA. Patients underwent treadmill protocol to determine their VO(2 max). Next, pH testing was initiated while undergoing a 30-min treadmill program exercising them at 65% of their VO(2 max). They were subsequently randomized to rabeprazole or placebo for 10 weeks. At the end of 10 weeks, exercise testing was repeated. RESULTS: A total of 31 patients completed the study (20 asthmatics, 11 non-asthmatics). Twenty-two out of 30 (73%) subjects had abnormal pH studies. For all subjects, rabeprazole improved symptoms more than placebo (P = 0.03). The association was stronger in the pH-positive group (P = 0.009). CONCLUSION: Acid reflux is common in ETA patients. Many patients with exercise-related respiratory symptoms are misdiagnosed as chronic asthmatics. Exercise-related symptoms improve with the use of acid suppression. This study suggests that ETA patients may benefit from acid suppression.

Success rate of direct percutaneous endoscopic jejunostomy in patients who are obese.

BACKGROUND: Direct percutaneous endoscopic jejunostomy (DPEJ) is increasingly used as a method for obtaining jejunal enteral access. The most cited reason of unsuccessful placement is poor transillumination, which may be related to obesity. Whether obesity affects failure and complication rates has not been previously described. OBJECTIVE: To compare the success rate and adverse events (AEs) associated with DPEJ placement in patients who were overweight and patients who were obese compared with patients who were normal or underweight defined by body mass index (BMI). DESIGN: Retrospective database review. SETTING: A tertiary-referral center. PATIENTS: Eighty DPEJ placements between February 2000 and September 2005. MAIN OUTCOME MEASUREMENTS: DPEJ placement success in patients who were overweight/obese (BMI >or= 25) versus patients who were normal or underweight (BMI <25). Secondary end points included procedure time and AEs. RESULTS: Eighty DPEJs were placed in 75 patients. Of these DPEJs, 65 (81%) succeeded and 15 (19%) failed. Success rates were 23 of 24 for patients who were underweight (96%), 25 of 31 for patients with normal BMI (81%), 8 of 11 for patients who were overweight (73%), and 6 of 10 for persons who were obese (60%) (odds ratio 3.43, 95% CI 1.03-11.44; P< .05 for BMI >or= 25 vs BMI<25). Overall, AEs were not significantly different for patients with BMI <25 versus BMI >or=25 (24/55 vs 9/21, respectively; P= .64). However, 4 of the 5 severe AEs occurred in patients with a BMI >or= 25 (P= .07). LIMITATIONS: Retrospective single center. CONCLUSIONS: DPEJ placement in patients who were overweight or obese was feasible, but procedural success was less frequent, and a trend toward more frequent major AEs was seen than in persons with normal or decreased BMI. BMI was an easily assessed preprocedural factor for DPEJ success and complication rates.

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.