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The Changing Faces of Eosinophilic Esophagitis: The Impact of Consensus Guidelines at the University of South Florida

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Abstract

Background and Aims

Prior to the consensus guideline conference in 2007, eosinophilic esophagitis (EoE) was uncommon dominated by the fibrostenotic phenotype, but over the past decade has become a common cause of dysphagia with more inflammatory phenotypes diagnosed. We assessed the impact of guideline definitions on the characteristics of EoE phenotypes over the past 26 years at our institution.

Methods

We reviewed the electronic health record of 75 consecutive patients meeting guideline definition EoE from 1/1988 to 5/2014. We separated groups based on 5-year intervals of diagnosis and phenotype. For continuous data, results were summarized as mean difference and standard deviation with 95 % confidence intervals.

Results

Five groups based on 5-year intervals of diagnosis were identified: group 1—1988–1993 (n = 7), group 2—1994–1999 (n = 7), group 3—2000–2005 (n = 4), group 4—2006–2011 (n = 35), and group 5—2012–2014 (n = 22). Prior to 2000, all patients were diagnosed with fibrostenotic EoE. After the initial 2007 guideline conference, inflammatory EoE has predominated with only one-third diagnosed with fibrostenotic EoE. Prior to 2011, only two were diagnosed with PPI-REE. In the last 3 years, 8 out of 22 patients (32 %) had PPI-REE. Overall, 8 out of 10 (80 %) PPI-REE were the inflammatory phenotype. When comparing pre- (n = 18) and post (n = 57)-consensus definitions, there was a significant difference between age of diagnosis (30.710.2 vs. 41.3 ± 14.3; p = 0.001), age of symptom onset (18.4 +/15.2 vs. 32.4 ± 15.5), and initial esophageal diameter (10.5 ± 2.7 vs. 14.3 ± 4.2; p < 0.0001), respectively.

Conclusions

Fibrostenotic EoE has steadily decreased, and inflammatory EoE is now the most recognized form. Across our 26-year experience, there was a decrease in delay in diagnosis and severity of esophageal stricture. The pivotal change occurred around 2007 corresponding to the first EoE guideline emphasizing the impact and importance of early detection of disease.

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References

  1. Morrow JB, Vargo JJ, Goldblum JR, et al. The ringed esophagus: histological features of GERD. Am J Gastroenterol. 2001;96:984–989.

    Article  CAS  PubMed  Google Scholar 

  2. Langdon DE. Corrugated ringed esophagus. Am J Gastroenterol. 1993;88:1461.

    CAS  PubMed  Google Scholar 

  3. McKinley MJ, Eisner TD, Fisher ML, et al. Multiple rings of the esophagus associated with gastroesophageal reflux [case report]. Am J Gastroenterol. 1996;91:574–576.

    CAS  PubMed  Google Scholar 

  4. Potter JW, Saeian K, Staff D, et al. Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features. Gastrointest Endosc. 2004;59:355–361.

    Article  PubMed  Google Scholar 

  5. Rencken IO, Heyman MB, Perr HA, et al. Ringed esophagus (feline esophagus) in childhood. Pediatr Radiol. 1997;27:773–775.

    Article  CAS  PubMed  Google Scholar 

  6. Langdon DE. “Congenital” esophageal stenosis, corrugated ringed esophagus, and eosinophilic esophagitis. Am J Gastroenterol. 2000;95:2123–2124.

    CAS  PubMed  Google Scholar 

  7. Landres RT, Kuster GG, Strum WB. Eosinophilic esophagitis in a patient with vigorous achalasia. Gastroenterology. 1978;74:1298–1301.

    CAS  PubMed  Google Scholar 

  8. Attwood SE, Smyrk TC, Demeester TR, et al. Esophageal eosinophilia with dysphagia. A distinct clinicopathologic syndrome. Dig Dis Sci. 1993;38:109–116.

    Article  CAS  PubMed  Google Scholar 

  9. Straumann A, Spichtin HP, Bernoulli R, et al. Idiopathic eosinophilic esophagitis: a frequently overlooked disease with typical clinical aspects and discrete endoscopic findings. Schweiz Med Wochenschr. 1994;124:1419–1429.

    CAS  PubMed  Google Scholar 

  10. Straumann A, Spichtin HP, Grize L, et al. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology. 2003;125:1660–1669.

    Article  PubMed  Google Scholar 

  11. Liacouras CA, Spergel JM, Ruchelli E, et al. Eosinophilic esophagitis: a 10-year experience in 381 children. Clin Gastroenterol Hepatol. 2005;3:1198–1206.

    Article  PubMed  Google Scholar 

  12. Assa’ad AH, Putnam PE, Collins MH, et al. Pediatric patients with eosinophilic esophagitis: an 8-year follow-up. J Allergy Clin Immunol. 2007;119:731–738.

    Article  PubMed  Google Scholar 

  13. Spergel JM, Brown-Whitehorn TF, Beausoleil JL, et al. 14 years of eosinophilic esophagitis: clinical features and prognosis. J Pediatr Gastroenterol Nutr. 2009;48:30–36.

    Article  PubMed  Google Scholar 

  14. Lipka S, Keshishian J, Boyce HW, et al. The natural history of steroid-naive eosinophilic esophagitis in adults treated with endoscopic dilation and proton pump inhibitor therapy over a mean duration of nearly 14 years. Gastrointest Endosc. 2014;80:592–598.

    Article  PubMed  Google Scholar 

  15. Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007;133:1342–1363.

    Article  CAS  PubMed  Google Scholar 

  16. Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011;128:3.e6–20.e6 (quiz 21–22).

  17. Ngo P, Furuta GT, Antonioli DA, et al. Eosinophils in the esophagus–peptic or allergic eosinophilic esophagitis? Case series of three patients with esophageal eosinophilia. Am J Gastroenterol. 2006;101:1666–1670.

    Article  PubMed  Google Scholar 

  18. Dellon ES, Speck O, Woodward K, et al. Clinical and endoscopic characteristics do not reliably differentiate PPI-responsive esophageal eosinophilia and eosinophilic esophagitis in patients undergoing upper endoscopy: a prospective cohort study. Am J Gastroenterol. 2013;108:1854–1860.

    Article  CAS  PubMed  Google Scholar 

  19. Dellon ES. Epidemiology of eosinophilic esophagitis. Gastroenterol Clin North Am. 2014;43:201–218.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Bohm ME, Richter JE. Review article: oesophageal dilation in adults with eosinophilic oesophagitis. Aliment Pharmacol Ther. 2011;33:748–757.

    Article  CAS  PubMed  Google Scholar 

  21. Almansa C, Stark ME, DeVault KR, et al. S1071 Eosinophilic esophageal infiltration in PPI responsive versus steroid responsive patients: are there phenotypic differences? Gastroenterology. 2012;138:S-172.

  22. Fox VL. Eosinophilic esophagitis: endoscopic findings. Gastrointest Endosc Clin N Am.. 2008;18:45–57. (viii).

    Article  PubMed  Google Scholar 

  23. Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011;128:3.e6–20.e6.

    Article  Google Scholar 

  24. Straumann A, Aceves SS, Blanchard C, et al. Pediatric and adult eosinophilic esophagitis: similarities and differences. Allergy. 2012;67:477–490.

    Article  CAS  PubMed  Google Scholar 

  25. Keshishian J, Vrcel V, Boyce HW, et al. Eosinophilic esophagitis: a paradigm shift for pathology. J Clin Gastroenterol. 2014;48:607–612.

    Article  PubMed  Google Scholar 

  26. Hirano I, Moy N, Heckman MG, et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut. 2013;62:489–495.

    Article  PubMed  Google Scholar 

  27. Goldschmid S, Boyce HW Jr, Brown JI, et al. A new objective measurement of esophageal lumen patency. Am J Gastroenterol. 1989;84:1255–1258.

    CAS  PubMed  Google Scholar 

  28. Field MJ, Lohr K. Guidelines for Clinical Practice: From Development to Use. Washington, DC: Institute of Medicine, National Academy Press; 1992.

  29. Dellon ES, Gonsalves N, Hirano I, et al. ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am J Gastroenterol. 2013;108:679–692. (quiz 693).

    Article  PubMed  Google Scholar 

  30. Papadopoulou A, Koletzko S, Heuschkel R, et al. Management guidelines of eosinophilic esophagitis in childhood. J Pediatr Gastroenterol Nutr. 2014;58:107–118.

    Article  CAS  PubMed  Google Scholar 

  31. Kelley ML Jr, Frazer JP. Symptomatic mid-esophageal webs. JAMA. 1966;197:143–146.

    Article  PubMed  Google Scholar 

  32. Shiflett DW, Gilliam JH, Wu WC, et al. Multiple esophageal webs. Gastroenterology. 1979;77:556–559.

    CAS  PubMed  Google Scholar 

  33. Attwood SEST, Demeester TR. Eosinophilic asthma-episodic dysphagia with eosinophilic infiltrates. Gut. 1989;30:A1493.

    Google Scholar 

  34. Biller JA, Winter HS, Grand RJ, et al. Are endoscopic changes predictive of histologic esophagitis in children? J Pediatr. 1983;103:215–218.

    Article  CAS  PubMed  Google Scholar 

  35. Brown LF, Goldman H, Antonioli DA. Intraepithelial eosinophils in endoscopic biopsies of adults with reflux esophagitis. Am J Surg Pathol. 1984;8:899–905.

    Article  CAS  PubMed  Google Scholar 

  36. Winter HS, Madara JL, Stafford RJ, et al. Intraepithelial eosinophils: a new diagnostic criterion for reflux esophagitis. Gastroenterology. 1982;83:818–823.

    CAS  PubMed  Google Scholar 

  37. Franciosi JP, Fiorino K, Ruchelli E, et al. Changing indications for upper endoscopy in children during a 20-year period. J Pediatr Gastroenterol Nutr. 2010;51:443–447.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Remedios M, Campbell C, Jones DM, et al. Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings, and response to treatment with fluticasone propionate. Gastrointest. Endosc. 2006;63:3–12.

  39. Croese J, Fairley SK, Masson JW, et al. Clinical and endoscopic features of eosinophilic esophagitis in adults. Gastrointest. Endosc. 2003;58:516–522.

  40. Aceves SS, Newbury RO, Dohil R, et al. Distinguishing eosinophilic esophagitis in pediatric patients: clinical, endoscopic, and histologic features of an emerging disorder. J Clin Gastroenterol. 2007;41:252–256. doi:10.1097/01.mcg.0000212639.52359.f1.

    Article  PubMed  Google Scholar 

  41. Almansa CSM, DeVault K, et al. Eosinophilic esophageal infiltration in PPI response versus steroid responsive patients: are there phenotypic differences? In: Proceedings from the Digestive Disease Week Annual Meeting; May 1–5, 2010; New Orleans, LA. Abstract S1071.

  42. Dellon ES, Kim HP, McConville S, et al. Su1847 Decreasing frequency of the fibrostenotic phenotype of eosinophilic esophagitis: time trends over the past decade. Gastroenterology. 2012;144:S-490.

  43. Schoepfer AM, Safroneeva E, Bussmann C, et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology. 2013;145:1230.e1-2–1236.e1-2.

  44. Dranove JE, Horn DS, Davis MA, et al. Predictors of response to proton pump inhibitor therapy among children with significant esophageal eosinophilia. J Pediatr. 2009;154:96–100.

    Article  CAS  PubMed  Google Scholar 

  45. Sayej WN, Patel R, Baker RD, et al. Treatment with high-dose proton pump inhibitors helps distinguish eosinophilic esophagitis from noneosinophilic esophagitis. J Pediatr Gastroenterol Nutr. 2009;49:393–399.

    Article  CAS  PubMed  Google Scholar 

  46. Peterson KA, Thomas KL, Hilden K, et al. Comparison of esomeprazole to aerosolized, swallowed fluticasone for eosinophilic esophagitis. Dig Dis Sci. 2010;55:1313–1319.

    Article  PubMed  Google Scholar 

  47. Molina-Infante J, Ferrando-Lamana L, Ripoll C, et al. Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults. Clin Gastroenterol Hepatol. 2011;9:110–117.

    Article  CAS  PubMed  Google Scholar 

  48. Abe Y, Iijima K, Ohara S, et al. A Japanese case series of 12 patients with esophageal eosinophilia. J Gastroenterol. 2011;46:25–30.

    Article  PubMed  Google Scholar 

  49. Francis DL, Foxx-Orenstein A, Arora AS, et al. Results of ambulatory pH monitoring do not reliably predict response to therapy in patients with eosinophilic oesophagitis. Aliment Pharmacol Ther. 2012;35:300–307.

    Article  CAS  PubMed  Google Scholar 

  50. Fujiwara Y, Sugawa T, Tanaka F, et al. A multicenter study on the prevalence of eosinophilic esophagitis and PPI-responsive esophageal eosinophilic infiltration. Intern Med. 2012;51:3235–3239.

    Article  PubMed  Google Scholar 

  51. Moawad FJ, Veerappan GR, Dias JA, et al. Randomized controlled trial comparing aerosolized swallowed fluticasone to esomeprazole for esophageal eosinophilia. Am J Gastroenterol. 2013;108:366–372.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA

    Seth Lipka

  2. Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd. MDC 72, Tampa, FL, 33612, USA

    H. Worth Boyce & Joel E. Richter

  3. Division of Evidence Based Medicine and Outcomes Research, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA

    Ambuj Kumar

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  1. Seth Lipka
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  4. Joel E. Richter
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Correspondence to Joel E. Richter.

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Lipka, S., Boyce, H.W., Kumar, A. et al. The Changing Faces of Eosinophilic Esophagitis: The Impact of Consensus Guidelines at the University of South Florida. Dig Dis Sci 60, 1572–1578 (2015). https://doi.org/10.1007/s10620-014-3517-4

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