Overview of Eosinophilic Esophagitis

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Overview of Eosinophilic Esophagitis

  1. 1. Overview of Eosinophilic Esophagitis Gabriel Rendon, M.D. Texas Digestive Disease Consultants
  2. 2. Case Vignette <ul><li>CC: Dysphagia </li></ul><ul><li>HPI: 28 year old white man referred to the GI clinic with three years of dysphagia. Intermittent, non-progressive, worse with solids; He also noted occasional sub-sternal chest pain. Denied heartburn, abdominal pain, weight loss, or change in bowel habits. Trial of Nexium was not helpful. </li></ul>
  3. 3. HPI (cont) <ul><li>PMH: Allergic rhinitis </li></ul><ul><li>Meds: Allegra, Nexium </li></ul><ul><li>NKDA </li></ul><ul><li>SH: Nonsmoker, rare EtoH use, no drug use. </li></ul><ul><li>FH: No significant GI diseases. </li></ul>
  4. 4. Physical Exam <ul><li>Vital signs: T 98.8 HR 86 BP 126/76 RR 16 </li></ul><ul><li>GEN: WNWD, NAD; </li></ul><ul><li>HEENT: normal; </li></ul><ul><li>CHEST: CTA; </li></ul><ul><li>CV: RRR no M/R/G; </li></ul><ul><li>ABD: S, NABS, NT, ND; </li></ul><ul><li>EXT: normal; </li></ul>
  5. 5. LABS <ul><li>CBC: WBC 8.0 Hgb 14.6 PLT 288 </li></ul><ul><ul><li>68 PMN 18 L 10 E 3 Mo </li></ul></ul><ul><li>Chem: WNL </li></ul><ul><li>LFT’s: </li></ul><ul><ul><li>AST 26 ALT 22 AlkPho 80 TB 0.6 DB 0.2 </li></ul></ul>
  6. 6. Endoscopy Distal esophagus Mid esophagus
  7. 7. Pathology <ul><li>Report: “Squamous mucosa with erosion, basal hyperplasia, increased papillae height, intercellular edema, and over 60 eosinophils per HPF. This is consistent with eosinophilic esophagitis.” </li></ul>
  8. 8. Eosinophilic Esophagitis <ul><li>Inflammatory disorder of the esophagus characterized by accumulation of eosinophils in the epithelium and a range of symptoms </li></ul><ul><li>First reported in the 1978 </li></ul><ul><li>Prior to 1995, there were only 12 manuscripts about EoE </li></ul><ul><li>More than 250 articles written in the past 10 years </li></ul>
  9. 9. Definition 1 <ul><ul><li>A clinicopathologic disorder of the esophagus characterized by a dense esophageal eosinophilia (>=15 eos/HPF) with severe squamous hyperplasia and upper GI symptoms </li></ul></ul><ul><ul><li>Gastric and duodenal biopsies are normal </li></ul></ul><ul><ul><li>No response to PPI therapy or normal pH monitoring </li></ul></ul>1. Furuta, et al. Eosinophilic Esophagitis in Children and Adults: A systematic review and Consensus recommendations for Diagnosis and Treatment. Gastroenterology 2007; 133: 1342-1363.
  10. 10. Pathogenesis <ul><li>Still poorly understood </li></ul><ul><li>The cellular and cytokine milieu similar to bronchial asthma [8] </li></ul><ul><li>Food allergens and/or aeroallergens </li></ul><ul><ul><li>Recent study of 19 pts observed documented food and aero-allergies in 18/19 (94.8%) [30] </li></ul></ul><ul><ul><li>seasonality and association with pollen count has been demonstrated [3] </li></ul></ul><ul><ul><li>Evidence of disease remission in children fed an elemental diet [31] </li></ul></ul>
  11. 11. Pathogenesis (cont) <ul><li>Association/Overlap with GERD </li></ul><ul><ul><li>Eosinophil derived inflammatory proteins (Il-6, PAF’s, vasoactive peptides) induce LES relaxations and decreased esophageal contractions [32] </li></ul></ul><ul><ul><li>Acid/pepsin can damage tight junctions-> increased permeability->antigen exposure to deeper layers [33] </li></ul></ul><ul><ul><li>Some cases of “classic” EoE have responded to dramatically to PPI’s [34] </li></ul></ul>
  12. 12. Epidemiology <ul><li>Males affected more commonly than females 1 </li></ul><ul><ul><li>Adults: 76% male, mean age 38 </li></ul></ul><ul><li>Can affect all races and ethnicities </li></ul><ul><li>In Olmsted county, prevalence 55/100,000 ( 0.05%) [35] </li></ul><ul><li>Recent systematic review of 9 papers [36]: </li></ul><ul><ul><ul><li>Population based prevalence of .03% </li></ul></ul></ul><ul><ul><ul><li>Symptom based prevalence of 2.8% </li></ul></ul></ul>
  13. 13. Prevalence in Selected Populations <ul><li>Solid Food dysphagia </li></ul><ul><ul><li>Prasad 27 prospectively studied 222 patients undergoing endoscopy with biopsy for solid food dysphagia; Overall 33/222 (15%) had EE </li></ul></ul><ul><ul><li>Mackenzie et al 29 prospectively studied 94 pts presenting with dysphagia: 11/94 (11.7%) met histologic criteria for EE </li></ul></ul><ul><li>Food impaction </li></ul><ul><ul><li>Desai et al 5 reported 31 patients presenting with food impaction over a 3 year period 17/31 (54%) had histology consistent with EE </li></ul></ul>
  14. 14. Clinical Features <ul><li>Children </li></ul><ul><ul><li>Feeding intolerance </li></ul></ul><ul><ul><li>Failure to Thrive </li></ul></ul><ul><ul><li>Heartburn </li></ul></ul><ul><ul><li>Emesis </li></ul></ul><ul><ul><li>Dysphagia/Food impaction </li></ul></ul><ul><ul><li>Refractory GERD </li></ul></ul><ul><li>Adults </li></ul><ul><ul><li>Intermittent dysphagia </li></ul></ul><ul><ul><li>Food impaction </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Refractory GERD </li></ul></ul>
  15. 15. Symptoms <ul><li>Straumann 8 prospectively re-examined 30 patients with known EoE </li></ul><ul><ul><li>30/30 (100%) intermittent dysphagia with food impactions </li></ul></ul><ul><ul><li>2/30 (6.7%) Heartburn </li></ul></ul><ul><li>Croese 6 reviewed 31 patients with EoE in Australia </li></ul><ul><ul><li>27/29 (93%) Dysphagia </li></ul></ul><ul><ul><li>19/27 (70%) Food Impactions </li></ul></ul><ul><ul><li>13/27 (48%) Heartburn </li></ul></ul><ul><ul><li>13/27 (48%) Chest Pain </li></ul></ul><ul><ul><li>1/27 (3.7%) Abdominal pain </li></ul></ul><ul><ul><li>Symptoms fluctuated over time; long symptom free intervals </li></ul></ul>6.Croese et al. Clinical and endoscopic features of eosinophilic esophagitis in adults. Gastrointestinal endosc 2003;58:516-22. 8. Straumann et al. Eosinophilic esophagitis: red on microscopy, white on endoscopy. Digestion 2004;70:109–116.
  16. 16. Symptoms (cont) <ul><li>Kaplan 4 reviewed 8 cases of EoE over 10 year period </li></ul><ul><ul><li>8/8 (100%) has dysphagia </li></ul></ul><ul><li>Potter 13 retrospectively reviewed 29 patients with EoE </li></ul><ul><ul><li>24/29 (83%) had dysphagia </li></ul></ul><ul><ul><li>8/29 (28%) had food impaction </li></ul></ul><ul><ul><li>9/29 (31%) had refractory GERD </li></ul></ul><ul><li>Remedios 9 prospectively studied 26 patients with EoE </li></ul><ul><ul><li>26/26 (100%) reported dysphagia </li></ul></ul><ul><ul><li>17/26 (65%) reported food impaction </li></ul></ul><ul><ul><li>17/26 (65%) were previously dx with GERD </li></ul></ul><ul><ul><li>2/26 (7.6%) reported chest pain </li></ul></ul><ul><li>Kaplan et al. Endoscopy in eosinophilic esophagitis. Clinical gastroenterology and hepatology 2003;1:433– 437. </li></ul><ul><li>9 . Remedios et al. Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings, and response to treatment with fluticasone propionate. Gastrointestinal Endosc 2006;63:3-12. </li></ul><ul><li>13. Potter et al. Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features. Gastrointestinal endosc 2004;59:355-61 </li></ul>
  17. 17. Natural History <ul><li>Straumann et al 3 (2003) prospectically studied 30 adults with EoE </li></ul><ul><ul><li>Mean follow up 7.2 years (1.4-11.5) </li></ul></ul><ul><li>Dysphagia </li></ul><ul><ul><li>7/30 (23.3%) reported increasing </li></ul></ul><ul><ul><li>11/30 (36.7%)reported stable persisting </li></ul></ul><ul><ul><li>11/30 (36.7%)improving </li></ul></ul><ul><ul><li>1/30 (3.4%) asymptomatic </li></ul></ul>3. Straumann, et al. Natural history of primary eosinophilic esophagitis. Gastroenterology 2003; 125:1660-69.
  18. 18. Natural History (cont) <ul><li>BMI and nutritional status maintained </li></ul><ul><li>Endoscopic findings remained stable </li></ul><ul><li>Laboratory values remained stable (peripheral eosinophilia, IgE, albumin) </li></ul><ul><li>Histology improved over time </li></ul><ul><ul><li>6/7 subjects with subepithelial tissue sampling had significant fibrosis and sclerosis </li></ul></ul><ul><li>Response to therapy </li></ul><ul><ul><li>11/30 underwent dilation </li></ul></ul><ul><ul><ul><li>10/11 responded well </li></ul></ul></ul>
  19. 19. Natural History (cont)
  20. 20. Diagnosis
  21. 21. Endoscopy <ul><li>Endoscopic findings can be subtle </li></ul><ul><ul><li>Linear furrowing </li></ul></ul><ul><ul><li>Ringed or corrugated (trachealization or felinization) </li></ul></ul><ul><ul><li>White exudates, specks or nodules </li></ul></ul><ul><ul><li>Linear shearing/crepe paper mucosa </li></ul></ul><ul><ul><li>Stricture </li></ul></ul><ul><ul><li>Small caliber esophagus </li></ul></ul><ul><ul><li>Solitary ring </li></ul></ul><ul><ul><li>Normal </li></ul></ul>
  22. 22. Endoscopy <ul><li>Desai et al 5 identified 17/31 (54%) presenting with food impaction with histology consistent with EoE </li></ul><ul><ul><li>17/17 (100%) had rings and furrows </li></ul></ul><ul><ul><li>5/17 (29%) strictures (4 proximal, 1 distal) </li></ul></ul><ul><li>Croese et al 6 retrospectively reviewed 31 patients diagnosed with EoE </li></ul><ul><ul><li>30/31 (97%) had furrows (with or without rings) </li></ul></ul><ul><ul><li>17/31 (54%) had strictures </li></ul></ul>5. Desai et al. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointestinal endoscopy 2005; 61: 795-801.
  23. 23. Endoscopy <ul><li>Straumann et al 8 retrospectively reviewed 30 adult patients with EoE </li></ul><ul><ul><li>16/30 (53%) had white exudates </li></ul></ul><ul><ul><ul><ul><li>13/30 nodules </li></ul></ul></ul></ul><ul><ul><ul><ul><li>12/30 plaques </li></ul></ul></ul></ul><ul><ul><li>15/30 (50%) had concentric rings </li></ul></ul><ul><ul><li>13/30 (43%) had stricture </li></ul></ul><ul><ul><li>11/30 (38%) had a solitary ring </li></ul></ul><ul><ul><li>4/30 (13%) had crepe paper mucosa </li></ul></ul><ul><li>Straumann et al 7 reported a series of 5 patients with EoE and mucosal friability </li></ul><ul><ul><li>5/5 (100%) had “crepe-paper mucosa” leading to lacerations </li></ul></ul><ul><ul><li>Postulated that mucosal fragility is pathognomonic for EoE </li></ul></ul>7. Straumann et al. Fragility of the esophageal mucosa: A pathognomonic endoscopic sign of primary eosinophilic esophagitis? Gastrointestinal endosc 2003; 59: 407-412.
  24. 24. Straumann et al 8 8. Straumann et al. Eosinophilic esophagitis: red on microscopy, white on endoscopy. Digestion 2004;70:109–116.
  25. 25. Endoscopy <ul><li>Remedios et al 9 prospectically enrolled 26 patients with histopathologic EoE (>15 eos/HPF) </li></ul><ul><ul><li>20/26 (77%) had linear furrows </li></ul></ul><ul><ul><li>16/26 (61%) had mucosal rings </li></ul></ul><ul><ul><li>7/26 (27%) had narrow esophagus </li></ul></ul><ul><ul><li>4/26 (15%) had white papules/plaques </li></ul></ul>
  26. 26. Linear Furrows
  27. 27. Mucosal Rings
  28. 28. White Exudates
  29. 29. Crepe Paper Mucosa
  30. 30. Biopsy Procurement <ul><li>Gonsalves et al 10 reviewed 66 patients (341 specimens) with EoE </li></ul><ul><ul><li>Number of biopsies needed varied with threshold </li></ul></ul><ul><ul><ul><li>>15 eos/HPF: 5 biopsies had sensitivity 100% </li></ul></ul></ul><ul><ul><ul><ul><li>1 biopsy had sensitivity of 55% </li></ul></ul></ul></ul><ul><ul><ul><li>>30 eos/HPF: 5 biopsies had sensitivity 89% </li></ul></ul></ul><ul><ul><li>20 patients had biopsies from both proximal and distal sites </li></ul></ul><ul><ul><ul><li>Mean 68 eos/HPF proximally, 82 eos/HPF distally (NS) </li></ul></ul></ul><ul><ul><ul><li>16/20 patients had distal eosinophilia and no proximal eosinophilia </li></ul></ul></ul><ul><li>Remedios reported 1 patient with proximal eosinophilia (25 eos/HPF) and no distal eosinophilia </li></ul>10. Gonsalves et al. Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis. Gastrointestinal Endosc 2006;64:313-9.
  31. 31. Radiology <ul><li>Upper GI contrast studies may demonstrate strictures, rings, corrugations </li></ul><ul><li>May show small caliber esophagus not readily appreciated by endoscopy </li></ul><ul><li>Zimmerman et al 10 reviewed 14 pts with EoE </li></ul><ul><ul><li>10/14 had strictures </li></ul></ul><ul><ul><ul><li>Mean length of 5.1 cm </li></ul></ul></ul><ul><ul><ul><li>7/10 had concentric rings along the stricture </li></ul></ul></ul>10. Zimmeman et al. Idiopathic eosinophilic esophagitis in adults. Radiology 2005; 236:159 –165 .
  32. 32. Radiology
  33. 33. Histology <ul><li>Historically, esophageal eosinophilia thought secondary (pathognomonic) to GERD 1 </li></ul><ul><li>1995, Kelly et al 14 described 10 children with GERD type symptoms, intense esophageal eosinophilia and no response to acid suppressive therapy </li></ul><ul><li>Several more studies described patients with refractory GERD symptoms and eosinophilia 1 </li></ul><ul><li>In GERD, eosinophilia is mild, usually <10 eos/HPF and confined to distal esophagus </li></ul><ul><li>In EoE, the eosinophilia is more intense, >15 eos/HPF (often much greater) and throughout the esophagus </li></ul>14. Kelly KJ et al. Eosinophilic esophagitis attributed to gastroesophageal reflux: improvement with an amino acid-based formula. Gastroenterology 1995;109:1503–1512.
  34. 34. Histology Features <ul><li>Markedly increased intraepithelial eosinophils </li></ul><ul><li>Superficial layering </li></ul><ul><li>Basal zone/papillary hyperplasia </li></ul><ul><li>Eosinophilic micro-abscesses </li></ul><ul><li>Degranulation (MBP) </li></ul><ul><li>Edema </li></ul><ul><li>Other cells (Lymphocytes, PMN, Mast cells) </li></ul><ul><li>Subepithelial fibrosis </li></ul>
  35. 35. Histologic Features <ul><li>Gonsalves 10 studied 66 patients with 341 biopsy specimens </li></ul><ul><ul><li>Median count was 107 eos/HPF (0-557) </li></ul></ul><ul><ul><li>93% Epithelial hyperplasia </li></ul></ul><ul><ul><li>90% Superficial layering </li></ul></ul><ul><ul><li>75% eosinophilic microabscess </li></ul></ul><ul><ul><li>52% degranulation </li></ul></ul>
  36. 36. Histologic Features <ul><li>Straumann et al (peak method) </li></ul><ul><ul><li>Mean count in proximal esophagus was 78 eos/HPF </li></ul></ul><ul><ul><li>Mean count in distal esophagus was 117 eos/HPF </li></ul></ul><ul><ul><li>Papillary hyperplasia was seen in 80% </li></ul></ul><ul><ul><li>Basal zone hyperplasia was seen in 65% </li></ul></ul><ul><li>Remedios et al (mean method) </li></ul><ul><ul><li>Mean count in proximal esophagus was 25 </li></ul></ul><ul><ul><li>Mean count in distal esophagus was 39 </li></ul></ul>
  37. 37. Histology <ul><li>Parfitt 15 studied biopsied from 41 pts with EE (>15 eos/HPF x2) and 116 pts with GERD: </li></ul>15. Parfitt et al. Eosinophilic esophagitis in adults: distinguishing features from gastroesophageal reflux disease: a study of 41 patients. Modern pathology (2006) 19, 90–96.
  38. 38. Histology
  39. 39. Histology
  40. 40. Association with Allergies
  41. 41. History of Allergy or Atopy <ul><li>Remedios 9 et al reviewed 26 pt with EoE </li></ul><ul><ul><li>20/26 (77%) patients had an atopic history (Asthma, hay fever, rhinitis, food allergy or atopic dermatitis) </li></ul></ul><ul><li>Straumann et al 11 </li></ul><ul><ul><li>18/30 (60%) had history of atopy </li></ul></ul><ul><li>Croese et al 6 </li></ul><ul><ul><li>28/30 (93%) had an allergic history </li></ul></ul>
  42. 42. Peripheral Eosinophilia <ul><li>Peripheral eosinophilia associated with atopic conditions </li></ul><ul><li>Problematic in that there was a difference in thresholds </li></ul><ul><li>Straumann 3 reported 12/24 (50%) with mild elevation (350-1500 cells/mm3) </li></ul><ul><li>Parfitt 15 reported 1/10 (10%) with >800 cells/mm3 </li></ul>
  43. 43. Atopic/Allergy Testing <ul><li>Skin prick test and atopic patch test have been used in children in 2 published studies 17,18 </li></ul><ul><ul><li>Resolution of symptoms and histology in 77% with elimination diet in identified allergens </li></ul></ul><ul><ul><li>Elemental diets effective in the rest </li></ul></ul><ul><ul><li>Recent study of 19 adult pts observed documented food and aero-allergies in 18/19 (94.8%) [30] </li></ul></ul><ul><li>Spergel Et Al. Treatment Of Eosinophilic Esophagitis With Specific Food Elimination Diet Directed By A Combination Of Skin Prick And Patch Tests. Ann Allergy Asthma Immunol 2005;95:336 –343. </li></ul><ul><li>Spergel Jm, Beausoleil Jl, Mascarenhas M, Et Al. The Use Of Skin Prick Tests And Patch Tests To Identify Causative Foods In Eosinophilic Esophagitis. J Allergy Clin Immunol 2002;109:363–368. </li></ul>
  44. 44. EoE vs GERD EoE GERD Age Younger Older Gender M>>>F M>F Atopic/Allergic +++ + Dysphagia +++ + Food Impaction +++ + Peripheral Eosinophilia ++ - Rings, Furrows +++ + Hiatal Hernia + +++ Mean Eos/HPF 76 16 Degranulation, microabscess +++ +
  45. 45. Treatment
  46. 46. Treatment <ul><li>PPI </li></ul><ul><li>Topical steroids </li></ul><ul><li>Endoscopic dilation </li></ul><ul><li>LT receptor antagonists and mast cell stabilizers </li></ul><ul><li>Dietary changes </li></ul>
  47. 47. PPI <ul><li>Can be part of diagnosis </li></ul><ul><ul><li>Lack of a clinicopathologic response in patients with esophageal eosinophilia virtually diagnostic of EoE </li></ul></ul><ul><ul><li>Can be used in lieu of 24 hr pH monitoring 1 </li></ul></ul><ul><li>Concomitant therapy </li></ul><ul><ul><li>Remedios 9 showed pts with EE, 10/26 had abnormal 24 hr pH probes </li></ul></ul><ul><ul><li>Recent study in press reported 75% (26/35) response rate in unselected patients with eosinophilic infiltration </li></ul></ul>
  48. 48. Topical Steroids <ul><li>First reported use in 1998 1 </li></ul><ul><li>Arora 22 identified 21 patients with EoE and treated them with swallowed FP 220 ug bid x6 weeks </li></ul><ul><ul><li>All had resolution of their solid food dysphagia </li></ul></ul><ul><ul><li>Rapid relief within several days </li></ul></ul><ul><ul><li>Recurrences occurred 12-18 months later </li></ul></ul><ul><ul><li>Histology was not assessed </li></ul></ul><ul><ul><li>No oral candidiasis </li></ul></ul>22. Arora As, Perrault J, Smyrk Tc. Topical Corticosteroid Treatment Of Dysphagia Due To Eosinophilic Esophagitis In Adults. Mayo Clin Proc 2003;78:830 – 835
  49. 49. Remedios et al <ul><li>19/26 subjects were treated with swallowed FP 440 ug bid x 4 weeks </li></ul><ul><ul><li>All 19 had symptom relief </li></ul></ul><ul><ul><li>18/19 histologic improvement </li></ul></ul><ul><ul><li>Mean proximal eosinophil count decreased from 24.98 to 4.46 </li></ul></ul><ul><ul><li>Mean distal eosinophil count decreased from 39.3 to 3.8 </li></ul></ul><ul><ul><li>3 patients developed asymptomatic esophageal candidiasis </li></ul></ul>
  50. 50. Topical Steroids <ul><li>Pediatric randomized double blind placebo controlled trial by Konikoff 23 et al </li></ul><ul><ul><li>31 patients randomized to swallowed FP 440 bid x 3 months or placebo </li></ul></ul><ul><ul><ul><li>10/20 (50%) had histologic resolution in the FP group </li></ul></ul></ul><ul><ul><ul><li>1/11 (9%) histologic resolution in placebo group (P =.047) </li></ul></ul></ul><ul><li>Recent randomized double blind placebo controlled trial of oral budesonide [37] </li></ul><ul><ul><li>13/18 resonse rate; 4/18 placebo </li></ul></ul><ul><ul><li>Mean eosinophil count 66->5 </li></ul></ul>
  51. 51. Swallowed FP (Flovent) <ul><li>2 puffs swallowed twice daily </li></ul><ul><li>Take after meals </li></ul><ul><li>Do not use a spacer </li></ul><ul><li>Deep breath, hold depress inhaler and swallow aerosol with each puff </li></ul><ul><li>Rinse mouth </li></ul><ul><li>No food or drink for 30-60 minutes </li></ul>
  52. 52. Dilation <ul><li>Small case series by Morrow [20] and Straumann [8] reported 15/16 and 11/19 patients treated with dilation had symptom improvement </li></ul><ul><li>Recently, Dellon [38] reviewed 36 patients undergoing dilation </li></ul><ul><ul><li>83% response rate </li></ul></ul><ul><ul><li>7% complication rate: deep tears and chest pain </li></ul></ul><ul><ul><li>Size improved from 12 to 16mm </li></ul></ul><ul><ul><li>No perforations </li></ul></ul><ul><li>Schoepfer [39] reviewed 207 pts undergoing dilation for EoE </li></ul><ul><ul><li>Significant improvement in dysphagia </li></ul></ul><ul><ul><li>Mean duration 15-17 months </li></ul></ul><ul><ul><li>No perforations </li></ul></ul><ul><ul><li>7% post procedural chest pain </li></ul></ul>
  53. 53. Dilation <ul><li>May be considered in symptomatic patients with fixed narrowing or persistent dysphagia (with or without histologic remission) </li></ul><ul><ul><li>Role for primary therapy? </li></ul></ul><ul><li>Impressive mucosal tears and chest pain </li></ul><ul><li>Bougie preferred over balloon; goal to 15-16 mm </li></ul><ul><li>Good durable response in most patients </li></ul>
  54. 54. Mast Cell Stabilizers and LTRA’s <ul><li>Cromolyn Sodium </li></ul><ul><ul><li>No direct studies have been reported </li></ul></ul><ul><ul><li>14 patients reported by Liacouras with no response </li></ul></ul><ul><li>LTRA </li></ul><ul><ul><li>Attwood 26 reported 7/8 patients had symptomatic improvement, but no histologic remission </li></ul></ul>26. Attwood et al. Eosinophilic oesophagitis: a novel treatment using Montelukast. Gut 2003;52:181– 185.
  55. 55. Dietary Changes <ul><li>No studies in adults </li></ul><ul><li>Specific food elimination as directed by APT or skin test </li></ul><ul><ul><li>112/146 (77%) patients responded both clinically and histologically 19 </li></ul></ul><ul><li>Removal of most common agents </li></ul><ul><ul><li>Kagalwalla 25 reported that 74% improved </li></ul></ul><ul><li>Amino acid formulas </li></ul><ul><ul><li>Resolution in 92-98% of patients 1 </li></ul></ul>25. Kagalwalla AF, Sentongo TA, Ritz S, Et Al. Effect Of Six-food Elimination Diet On Clinical And Histologic Outcomes In Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2006;4:1097–1102
  56. 56. Other Treatment Options <ul><li>Systemic steroids </li></ul><ul><li>Immunomodulators </li></ul><ul><ul><li>1 case report of a patient treated with azathioprine </li></ul></ul><ul><li>Mepolizumab (Il-5 Mab) </li></ul><ul><ul><li>Not FDA approved </li></ul></ul><ul><ul><li>Phase 3 trials in HES </li></ul></ul>
  57. 57. Unresolved Issues <ul><li>Etiology and pathogenesis </li></ul><ul><li>Increased recognition vs true increased incidencce </li></ul><ul><li>Association/overlap with GERD </li></ul><ul><li>Treatment duration and endpoints </li></ul><ul><li>How to best identify possible aero or food allergens </li></ul><ul><li>Long term esophageal sequalae </li></ul>
  58. 58. Summary <ul><li>EoE is an increasingly recognized, male predominant disorder characterized dysphagia and food impaction; characteristic but sometimes subtle endoscopic findings; and intraepithelial eosinophilia not entirely responsive to PPI </li></ul><ul><li>Exact pathogenesis remains unknown, but food allergens, aeroallergens, genetics and acid exposure have been implicated </li></ul><ul><li>The usual accepted treatments include PPI, topical steroids, dilation, and allergy testing/dietary changes </li></ul><ul><li>There appears to be no malignant potential and patients remained nutritionally replete </li></ul><ul><li>Still alot being learned about this disease </li></ul>
  59. 60. References <ul><li>Furuta, et al. Eosinophilic esophagitis in children and adults: A systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 2007; 133: 1342-1363. </li></ul><ul><li>Noel et al. Eosinophilic esophagitis. N England J of medicine 2004; 351:940-941. </li></ul><ul><li>Straumann, et al. Natural history of primary eosinophilic esophagitis. Gastroenterology 2003; 125:1660-69. </li></ul><ul><li>Kaplan et al. Endoscopy in eosinophilic esophagitis. Clinical gastroenterology and hepatology 2003;1:433– 437. </li></ul>
  60. 61. References (cont) <ul><li>5. Desai et al. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointestinal endoscopy 2005; 61: 795-801. </li></ul><ul><li>6.Croese et al. Clinical and endoscopic features of eosinophilic esophagitis in adults. Gastrointestinal endosc 2003;58:516-22. </li></ul><ul><li>7. Straumann et al. Fragility of the esophageal mucosa: A pathognomonic endoscopic sign of primary eosinophilic esophagitis? Gastrointestinal endosc 2003; 59: 407-412. </li></ul><ul><li>8. Straumann et al. Eosinophilic esophagitis: red on microscopy, white on endoscopy. Digestion 2004;70:109–116. </li></ul>
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