Esophageal Remodeling Correlates With Eating Behaviors in Pediatric Eosinophilic Esophagitis.

INTRODUCTION: There are limited data characterizing eating habits among pediatric patients with eosinophilic esophagitis (EoE). We compared eating behaviors in pediatric patients with EoE with healthy controls and assessed the degree of correlation with symptomatology, endoscopic and histologic findings, and esophageal distensibility. METHODS: We conducted a prospective, observational study where subjects consumed 4 food textures (puree, soft solid, chewable, and hard solid) and were scored for eating behaviors including number of chews per bite, sips of fluid per food, and consumption time. Symptomatic, endoscopic, histologic, and esophageal distensibility data were collected for case subjects. RESULTS: Twenty-seven case subjects and 25 healthy controls were enrolled in our study (mean age 11.0 years, 63.5% male). Compared with healthy controls, pediatric patients with EoE demonstrated more chews per bite with soft solid (13.6 vs 9.1, P = 0.031), chewable (14.7 vs 10.7, P = 0.047), and hard solid foods (19.0 vs 12.8, P = 0.037). Patients with EoE also demonstrated increased consumption time with soft solid (94.7 vs 58.3 seconds, P = 0.002), chewable (90.0 vs 65.1 seconds, P = 0.005), and hard solid foods (114.1 vs 76.4 seconds, P = 0.034) when compared with healthy controls. Subgroup analysis based on disease status showed no statistically significant differences in eating behaviors between active and inactive EoE. Total endoscopic reference score positively correlated with consumption time ( r = 0.53, P = 0.008) and number of chews ( r = 0.45, P = 0.027) for chewable foods and with number of chews ( r = 0.44, P = 0.043) for hard solid foods. Increased consumption time correlated with increased eosinophil count ( r = 0.42, P = 0.050) and decreased esophageal distensibility ( r = -0.82, P < 0.0001). DISCUSSION: Altered eating behaviors including increased chewing and increased consumption time can be seen in pediatric patients with EoE, can persist despite histologic remission, and may be driven by changes in esophageal distensibility.

Esophageal remodeling in eosinophilic esophagitis.

PURPOSE OF REVIEW: Eosinophilic esophagitis (EoE) is a Th2 immune/antigen-mediated disorder characterized by esophageal dysfunction and eosinophilic inflammation. Worsening dysphagia and food impactions are significant complications associated with esophageal remodeling and fibrostenotic disease. This review highlights the most recent research findings pertaining to mechanisms of sub-epithelial fibrosis in EoE, current diagnostic tools, and therapeutic approaches. RECENT FINDINGS: Recent studies leveraging publicly available single cell sequencing databases and comparative proteomics have furthered our understanding of the mechanisms mediating fibrosis. Fibroblast crosstalk with the extracellular matrix and with epithelial, endothelial, and T cells have been implicated, with the likely existence of multiple fibroblast sub-types. Accurate diagnosis of remodeling with biopsies remains a challenge due to inadequate depth of sampling. Web-based tools incorporating epithelial findings show promise in predicting subepithelial fibrosis. Impedance planimetry with esophageal distensibility measurements are increasingly utilized tools to assess fibrostenotic severity. Immunostaining and luminal captured proteins associated with remodeling show promise as potential molecular markers of fibrosis. Anti-inflammatory therapy may improve esophageal fibrosis and distensibility, although specific fibrosis-targeted therapy is lacking. SUMMARY: Recent studies highlight novel mechanisms of fibrosis in EoE. Improved understanding of these mechanisms may lead to novel diagnostic strategies and therapies, and thereby inform treatment decisions.

Eosinophilic Gastrointestinal Disease.

This JAMA Insights Clinical Update discusses the symptoms, diagnosis, and management of eosinophilic gastrointestinal diseases.

Clinical and atopic features of patients with primary eosinophilic colitis: an Italian multicentre study.

Eosinophilic colitis (EC) is the rarest among primary eosinophilic gastrointestinal disorders (EGID). EC is underdiagnosed due to its blurred and proteiform clinical manifestations. To explore the clinical and atopic characteristic of EC adult patients, the diagnostic delay, and relapse-associated factors, by comparison with patients with eosinophilic esophagitis (EoE) and irritable bowel syndrome (IBS). EC patients followed-up at four clinics were included, and clinical, histopathological, and laboratory data were retrieved. As control groups, age-matched patients with EoE and IBS were recruited. Allergy tests included skin prick test and serum specific IgE. Diagnostic delay was assessed. Overall, data from 73 patients were retrieved, including 40 with EC (median age 39 years IQR 22.5-59, F:M 2.1:1), 12 with EoE (F:M ratio: 1:5), and 21 with IBS (F:M ratio: 1:0.9). The most common features in EC patients were female sex (67.5%), atopy (77.5%), abdominal pain/distention (70%), diarrhoea (77.5%), and faecal calprotectin elevation (22.5%). Blood eosinophils were elevated in EoE, but not in EC (p < 0.001), while ECP did not differ across the three groups (p = 0.4). The frequency of allergen sensitization reached 25% of patients. Several frequent pan-allergens for this region were present. The overall diagnostic delay was 10 months (IQR 4-15). Factors contributing to a greater diagnostic delay were atopy, weight loss, and a previous misdiagnosis. EC is mostly a diagnosis of exclusion, burdened by a substantial diagnostic delay. In female patients the presence of allergen sensitization, abdominal symptoms and faecal calprotectin elevation should raise the suspicion of EC.

Esofagitis eosinofílica: consideraciones fisiopatológicas y terapéuticas / Eosinophilic esophagitis: physiopathological and therapeutic aspects

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Esofagitis eosinofílica / Eosinophilic esophagitis

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Enfermedades esofágicas: enfermedad por reflujo gastroesofágico, Barrett, acalasia y esofagitis eosinofílica / Oesophageal diseases: gastroesophageal reflux disease, Barrett´s disease, achalasia and eosinophilic oesophagitis

Las novedades más importantes en patología esofágica en la Digestive Disease Week 2015 han sido: 1. Enfermedad por reflujo gastroesofágico: a) la hipervigilancia parece un factor patogénico clave en los síntomas de reflujo refractarios a inhibidores de la bomba de protones; b) las ondas peristálticas inducidas por la deglución posreflujo podrían ser un excelente criterio diagnóstico para la enfermedad por reflujo gastroesofágico; c) la pHmetría laríngea no es útil para el diagnóstico en los síntomas extraesofágicos; d) la recomendación de perder peso recogida en la historia clínica en pacientes con enfermedad por reflujo gastroesofágico y obesidad o sobrepeso es un marcador de calidad excelente y se asocia a mejores resultados. 2. Esófago de Barrett: a) la displasia de bajo grado persistente en más de una endoscopia y el diagnóstico de 'indeterminado para displasia' se asocian a un alto riesgo de progresión a neoplasia; b) el narrow band imaging (imagen de banda estrecha) permite identificar las áreas de displasia sobre esófago de Barrett con una elevada sensibilidad y especificidad; c) la endoscopia inicial pasa por alto un elevado porcentaje de neoplasias avanzadas sobre Barrett. Debe considerarse la reendoscopia precoz; d) los endoscopistas especializados en Barrett obtienen un rendimiento muy superior en el diagnóstico de lesiones avanzadas. Los pacientes de alto riesgo -varones, edad avanzada, fumadores y con Barrett largo- podrían beneficiarse del control en un centro de referencia. 3. Acalasia: la peroral endoscopic myotomy parece altamente eficaz y segura, independientemente de las características de los pacientes (edad, comorbilidad) y de las variaciones técnicas utilizadas. 4. Esofagitis eosinofílica: la budesonida tópica y las dietas de exclusión son razonablemente efectivas en pacientes que no responden a los inhibidores de la bomba de protones

The most important novel findings presented on oesophageal disease in DDW 2015 were the following: 1) GERD: a) hypervigilance seems to be a key pathogenic factor in reflux symptoms refractory to PPI; b) post-reflux swallowing-induced peristaltic waves could be an excellent diagnostic criterion for GERD; c) laryngeal pH-metry is not useful in the diagnosis of extra-oesophageal symptoms; d) the recommendation of weight loss adequately recorded in the clinical reports of patients with GERD and obesity or overweight is an excellent quality indicator and is associated with better outcomes. 2) Barrett´s oesophagus: a) persistent low-grade dysplasia in more than one endoscopy and a diagnosis of 'indefinite for dysplasia' are associated with a high risk of neoplastic progression; b) narrow-band imaging allows areas of dysplasia on Barrett´s oesophagus to be identified with high sensitivity and specificity; c) initial endoscopy fails to identify a high percentage of advanced neoplasms in Barrett’s oesophagus. Early re-endoscopy should be considered; d) endoscopists specialized in Barret’s oesophagus obtain a much higher yield in the diagnosis of advanced lesions. Patients at high risk–men, older patients, smokers and those with long-segment Barrett’s oesophagus-could benefit from follow-up in a referral center. 3) Achalasia: POEM seems safe and effective, independently from patient characteristics (age, comorbidity) and the technical variations used. 4) Eosinophilic esophagitis: topical budesonide and exclusion diets are reasonably effective in PPI non-responders

Efectividad de los marcadores serológicos de activación del eosinófilo en la monitorización de la actividad de la esofagitis eosinofílica / Effectiveness of serological markers of eosinophil activity in monitoring eosinophilic esophagitis

Introducción: resulta necesario encontrar marcadores serológicos de actividad en esofagitis eosinofílica (EoE) accesibles en la práctica clínica que eviten la realización de endoscopias repetidas a los pacientes. Objetivo: evaluar la eficacia de los marcadores de actividad del eosinófilo en la monitorización de la EoE. Material y métodos: se reclutaron de forma prospectiva, pacientes con EoE tratados con dietas (dieta de exclusión de 6 alimentos y dieta dirigida en base a los test de alergia). Se analizaron parámetros demográficos, valor sérico de proteína catiónica eosinofílica (PCE) (μg/ml), IgE sérica total (KU/l), eosinófilos en sangre periférica (ESP) (U/mm3), así como pico máximo de eosinófilos/ campo de gran aumento en las biopsias esofágicas. Se analizó la variación encontrada en estos valores de acuerdo con la respuesta a las dietas. Resultados: 30 pacientes (66,7 % varones; edad media 33,43 años) fueron incluidos, 22 respondedores y 8 no respondedores. El 90 % de los pacientes presentaba antecedentes personales de atopia. No se detectó descenso significativo de IgE sérica total ni PCE tras la dieta en respondedores y no respondedores. Sin embargo los ESP descendieron significativamente en los pacientes respondedores (ESP pre-dieta 397,27 vs. post-dieta 276,81; p = 0,024) pero no así en los no respondedores (ESP pre-dieta 460 vs. post-dieta 317,5; p = 0,23). Conclusión: la IgE sérica total y PCE no se comportan como marcadores de actividad de la EoE. Sin embargo los ESP podrían desempeñar una función en este sentido, aunque considerando que este parámetro puede verse influenciado por las enfermedades atópicas concomitantes (AU)

Background: it is necessary to find serological markers accessible in clinical practice to prevent the need to perform repeated endoscopies. Objective: to assess the efficacy of eosinophil activity markers in monitoring eosinophilic esophagitis (EoE). Material and methods: thirty patients were included prospectively, all under dietary treatment –diets excluding 6 foods, and allergy test based diet (skin prick test and specific IgE). The variables assessed were demographic parameters, eosinophil cationic protein (ECP) levels (μg/mL), total IgE (KU/L), peripheral blood eosinophils (PBE) (U/mm3), and the maximum peak of eosinophils/hpf in esophageal biopsies. The variation found between these figures was assessed in line with response to dietary treatment. Results: thirty patients (66.7 % males; mean age 33.43 years) were included in the study, 22 responders and 8 non-responders. Ninety percent presented a personal history of atopy. No significant decrease was detected in serum total IgE and ECP after diet in responder and nonresponders. However, the PBE decreased significantly in responders but not in nonresponders, PBE in responders (pre-diet. 397.27 vs. post-diet 276.81, p = 0.024) and non-responders PBE (pre-diet. 460 vs. post-diet 317.5, p = 0.23). Conclusion: serum total IgE and ECP do not act as markers for EoE activity. However PBE may play a role in this regard, bearing in mind that this parameter may be influenced by concomitant atopic conditions (AU)

Eosinophilic esophagitis: manometric and pHmetric findings / Esofagite eosinofílica: achados manométricos e pHmétricos

CONTEXT: Eosinophilic esophagitis is an entity characterized by an esophageal inflammatory infiltrate of eosinophils, manifested by dysphagia, intermittent food impactions and symptoms similar to gastroesophageal reflux disease (GERD), that predominantly affects young adults. There may be association of eosinophilic esophagitis with GERD, and motor abnormalities have been described. OBJECTIVE: The main objectives of this study are to describe the findings at esophageal manometry and pH monitoring in patients with eosinophilic esophagitis. METHODS: Cross-sectional study of 20 patients with a diagnosis of eosinophilic esophagitis, submitted to esophageal manometry and 24h pH monitoring. Were analysed the manometric changes and the presence of abnormal reflux on pH monitoring. RESULTS: Twenty patients (15 men, 5 women) had a mean age of 29 years. Motility disorders were found in 25% (5/20) patients with ineffective esophageal motility being the most common finding. pH monitoring revealed abnormal reflux on 25%, without any relationship with manometric findings. CONCLUSIONS: Manometric abnormalities were observed in 25% of patients and abnormal reflux on pH monitoring also in 25%. This study showed no relationship between abnormal reflux and the presence of manometric changes.

CONTEXTO: A esofagite eosinofílica é uma doença inflamatória crônica, caracterizada por infiltrado eosinofílico no esôfago e se manifesta por disfagia, impactações alimentares e sintomas similares aos da doença do refluxo gastroesofágico (DRGE), com maior incidência em adultos jovens. Pode haver associação da esofagite eosinofílica com a DRGE, e anormalidades motoras têm sido descritas. OBJETIVO: Os principais objetivos deste estudo são descrever as alterações manométricas e a presença de refluxo anormal à pHmetria esofágica em pacientes com esofagite eosinofílica. MÉTODOS: Estudo transversal de 20 pacientes com diagnóstico de esofagite eosinofílica, submetidos a esofagomanometria e pHmetria esofagiana de 24 h. Foram analisadas as alterações manométricas e a presença de refluxo anormal à pHmetria. RESULTADOS: Vinte pacientes (15 homens, 5 mulheres) com média de idade de 29 anos. Distúrbios da motilidade esofagiana foram encontrados em 25% dos pacientes, com predomínio da motilidade esofagiana ineficaz. A pHmetria revelou refluxo anormal também em 25%, sem relação entre os achados manométricos e pHmétricos. CONCLUSÕES: Anormalidades manométricas foram encontradas em 25% dos pacientes e refluxo anormal à pHmetria também em 25%. Neste estudo, não houve relação entre refluxo anormal e a presença de alterações à esofagomanometria.

Esofagite eosinofílica / Eosinophilic esophagitis

A esofagite eosinofílica (EoE), primeiramente descrita em 1978 como uma doença rara, vem, nos últimos anos, sendo cada vez mais diagnosticada em pacientes com disfagia, impactação alimentar e/ou pirose. Há controvérsia quanto ao aumento de incidência da EoE. Ele é atribuído, em algumas séries, ao maior conhecimento da doença por parte dos médicos (maior número de diagnósticos), embora alguns defendam que ocorre um aumento real do número de casos.

Eosinophilic esophagitis that was first described in 1978 as a rare disease, it has been increasingly diagnosed in patients with dysphagia, food impaction and/or heartburn. There is controversy regarding the increased incidence of eosinophilic esophagitis. In some cases, it is attributed to a greater knowledge about the disease by doctors (large number of diagnostics), however some people support that it occurs a real increase number of cases.

Esofagitis eosinofílica, una enfermedad en auge / Eosinophilic esophagitis, a pathology on the rise

La esofagitis eosinofílica es una enfermedad que consiste en una condición inflamatoria del esófago, que se caracteriza por tener un elevado porcentaje de eosinófilos. Es un problema de origen alérgico y su diagnóstico está aumentando en la población, sobre todo en niños y adultos jóvenes, a lo largo de la última década. La fisiopatología no está completamente establecida actualmente. El diagnóstico se confirma con endoscopia y toma de biopsias. El diagnóstico diferencial hay que hacerlo con la enfermedad por reflujo gastroesofágico, gastroenteritis eosinofílica, enfermedad de Crohn, enfermedad del tejido conjuntivo, síndrome hipereosinofílico, infecciones y respuesta de hipersensibilidad a fármacos. Actualmente no hay un tratamiento que sea definitivo. A continuación se presenta un caso clínico, que fue valorado inicialmente en la consulta de atención primaria (AU)

The eosinophilic esofagitis is a pathology that consists of an inflammatory condition of the esophagus, which is characterized for having a high percentage of eosinophils. It is a problem of allergic origin and his diagnosis is increasing in the population, especially in children and adult young persons, throughout last decade. The fisiopathology is not completely established nowadays. The diagnosis is confirmed with endoscopia and capture of biopsies. The differential diagnosis is necessary to be done with the disease for reflux gastroesofágico, gastroenteritis eosinofílica, by Crohn’s disease, pathology of connective fabric, syndrome hipereosinofílico, infections and response of hypersensitivity to medicaments. Nowadays there is no a treatment that is definitive. We present a clinical case, which was valued initially for the consultation of Primary care (AU)