Craig C. Reed

Clinical characteristics, treatment outcomes, and resource utilization in children and adults with eosinophilic gastroenteritis

BACKGROUND Eosinophilic gastroenteritis is a rare condition where eosinophilic inflammation occurs in the gastrointestinal tract in the absence of secondary causes. Little is known regarding aetiology, pathogenesis, or natural history. AIMS To characterize the clinical, endoscopic, and histopathologic features of eosinophilic gastroenteritis and to summarize treatment outcomes. METHODS Pathology reports of all patients who had undergone upper endoscopy with biopsy between January 1, 2000 and June 20, 2013 were reviewed. Eosinophilic gastroenteritis was diagnosed if there were ≥20 eosinophils/hpf on either gastric of duodenal biopsy, symptoms attributable to the gastrointestinal tract, and no known secondary cause of eosinophilia. Descriptive statistics characterized patients diagnosed with eosinophilic gastroenteritis and bivariate analysis compared adults and children. RESULTS There were 44 patients diagnosed with eosinophilic gastrointestinal disease. The most common symptoms were vomiting (71%) and abdominal pain (62%). Of the eosinophilic gastroenteritis cases, 12 (30%) had esophageal involvement, and 11 (28%) had colonic involvement. For treatment, 36 (80%) received corticosteroids. Overall, 27 (60%) had symptom resolution and 23 (51%) had endoscopic resolution. Cases underwent a mean of five endoscopic procedures per year. CONCLUSION Eosinophilic gastroenteritis presents with non-specific gastrointestinal symptoms and in almost one-third of cases has concomitant esophageal or colonic involvement. It remains difficult to treat, with high rates of endoscopic utilization.

Diminishing Effectiveness of Long-Term Maintenance Topical Steroid Therapy in PPI Non-Responsive Eosinophilic Esophagitis

OBJECTIVES: While topical corticosteroids are first‐line therapy for eosinophilic esophagitis (EoE), the data regarding long‐term effectiveness are lacking. We aimed to determine long‐term histologic and endoscopic outcomes of maintenance therapy in EoE steroid responders. METHODS: We performed a retrospective study of adults with EoE at UNC Hospitals who had initial histologic response (<15 eos/hpf) after 8 weeks of topical steroids, and maintained on therapy. Endoscopic and the histologic data were recorded at baseline and follow‐up endoscopies. Multivariable logistic regression was performed to assess loss of treatment response by steroid dose at recurrence, and Kaplan–Meier analysis to calculate durability of disease remission. RESULTS: Of 55 EoE patients with initial response to swallowed/topical fluticasone or budesonide over a median 11.7 months, 33 had at least two follow‐up EGDs. Of these patients, 61% had histologic loss of response and worse endoscopic findings. There was no difference in baseline steroid dose (P=0.55) between the groups, but those maintained on their initial dose had lower odds (OR: 0.10; 95% CI: 0.01, 0.90) of loss of response compared to those who had subsequent dose reduction. On survival analysis, 50% had loss of response to steroids by 18.5 months and 75% by 29.6 months. CONCLUSIONS: In adult EoE steroid responders, loss of treatment response is common, and is associated with a steroid dose reduction. Routinely lowering doses for maintenance steroids may provide inferior outcomes.

Food elimination diets are effective for long‐term treatment of adults with eosinophilic oesophagitis

Limited data describe the long‐term efficacy of dietary elimination in eosinophilic oesophagitis (EoE).

Optimal Histologic Cutpoints for Treatment Response in Patients With Eosinophilic Esophagitis: Analysis of Data From a Prospective Cohort Study

BACKGROUND AND AIMS: No prospective studies substantiate 15 eos/hpf as an appropriate endpoint for treatment of eosinophilic esophagitis (EoE). We aimed to determine a histologic cutpoint that identifies successful treatment of EoE by assessing symptomatic and endoscopic improvement. METHODS: We performed a prospective cohort study of 62 consecutive adult patients undergoing outpatient esophagogastroduodenoscopy at the University of North Carolina from 2009 through 2014. At diagnosis of EoE and after 8 weeks of standard treatment, symptom and endoscopic responses were measured using a visual analogue scale and an endoscopic severity score (ESS), and eosinophil counts were assessed. Receiver operator curves and logistic regression models evaluated the histologic threshold that best predicted symptomatic and endoscopic response. For symptoms, analysis was limited to patients without baseline esophageal dilation. RESULTS: The mean eosinophil count at diagnosis was 124 eos/hpf, falling to 35 eos/hpf after treatment. The mean visual analogue scale decreased from 3.4 at baseline to 1.7 after treatment, and the mean ESS decreased from 3 to 1.6. Twenty‐nine patients had symptom responses (47%) and 34 had endoscopic responses (55%). Post‐treatment eosinophil count thresholds of 8, 15, and 5 eos/hpf best predicted symptom, endoscopic and combined responses, respectively. On logistic regression, decreasing eosinophil count was significantly associated with the probability of symptomatic (P = .01) and endoscopic response (P < .001). CONCLUSIONS: In a prospective study of patients with EoE, we found that a cutpoint of <15 eos/hpf identifies most patients with symptom and endoscopic improvements, providing support for the current diagnostic threshold. A lower threshold (<5 eos/hpf) identifies most patients with a combination of symptom and endoscopic responses; this cutpoint might be used in situations that require a stringent histologic threshold.

A visual analogue scale and a Likert scale are simple and responsive tools for assessing dysphagia in eosinophilic oesophagitis

While symptom scores have been developed to evaluate dysphagia in eosinophilic oesophagitis (EoE), their complexity may limit clinical use.

Revisiting the prehypertension debate: increasing evidence for treatment yet randomized clinical trials are lacking.

Abstract In 2009, Blood Pressure featured a debate about whether to treat patients with prehypertension (Kiely et al., Blood Press. 2009;18:300–303; McInnes GT, Blood Press. 2009;18:304–307). Our group supported pharmacotherapy for this condition at that time. Since then, additional evidence linking prehypertension with associated morbidities has emerged. These studies are detailed below and provide further evidence for the treatment of prehypertension.

Patient-Reported Outcomes in Esophageal Diseases

© 2018 by the AGA Institute 1542-3565/

Vedolizumab treatment may reduce steroid burden and improve histology in patients with eosinophilic gastroenteritis

36.00 https://doi.org/10.1016/j.cgh.2017.11.049 In my introductory comments to the practice management section last year, I wrote about cultivating competencies for value-based care. One of the key competencies was patient centeredness. Patient-reported outcomes (PROs) and patient experience measures specifically were highlighted as examples of meaningful tools for achieving patient centeredness. Starting with this month’s contribution by Drs Reed and Dellon on PROs in esophageal disease, we begin a series of articles focused on this important construct. We will follow this article with reports focused on PRO for patients with irritable bowel syndrome, inflammatory bowel disease, and chronic liver disease. These reports will not only review the importance of PROs, but also highlight the most practical approaches to measuring disease-specific PROs in clinical practice all with the goal of improving the care of our patients.

Prolonged Time to Diagnosis of Eosinophilic Esophagitis Despite Increasing Knowledge of the Disease

Eosinophilic gastritis (EG) and eosinophilic gastroenteritis (EGE) are rare diseases characterized by marked eosinophilic infiltration of the gastrointestinal (GI) tract and symptoms which typically reflect the location(s) of GI involvement.1,2 Knowledge of these conditions is limited, and treatments, which are largely based on case series, most frequently involve corticosteroids. As long-term steroid treatment is fraught with complications, novel treatment options are needed. Vedolizumab is a humanized monoclonal antibody to the α4β7 integrin that blocks leukocyte migration into GI mucosa.3 Vedolizumab is approved for treatment of moderate to severe inflammatory bowel disease (IBD), and provides benefit via inhibition of gastrointestinal-homing of T lymphocytes.4 However, there is evidence that increased levels of eosinophils can be associated with IBD and may play a role in IBD pathogenesis, that the α4β7 integrin may play an important role in eosinophil localization in IBD, and that blocking α4β7 may inhibit eosinophil recruitment to intestinal mucosa.5,6 Based on this eosinophil effect, there is a strong rationale that vedolizumab may benefit patients with EG/EGE, but it has not yet been assessed in these conditions. Therefore, this study aimed to assess whether vedolizumab therapy is associated with improved clinical symptoms, endoscopic features, and histologic findings in patients with EG/EGE who failed to respond to prior therapies.

Increasing Rates of Diagnosis, Substantial Co-occurrence, and Variable Treatment Patterns of Eosinophilic Gastritis, Gastroenteritis and Colitis Based on 10 Year Data Across a Multi-Center Consortium

&NA; Eosinophilic esophagitis (EoE) is a chronic condition characterized by eosinophilic‐predominant inflammation and esophageal dysfunction.1,2 EoE represents a rapidly increasing cause of morbidity and a growing health problem.