Kathleen K. Boynton

Elemental diet induces histologic response in adult eosinophilic esophagitis.

OBJECTIVES:Elemental diets have not been studied in adults with eosinophilic esophagitis (EoE). The goal of this trial was to assess the efficacy of an elemental diet in adults with EoE.METHODS:A total of 18 adults with EoE were given an elemental diet for 4 weeks, or just 2 weeks if their response was complete. Symptoms and histologic findings, based on biweekly biopsies, were monitored. Six subjects were rebiopsied 2–7 days after resuming a normal diet.RESULTS:After therapy, esophageal tissue eosinophil content decreased from 54 to 10 per maximal high power field (P=0.0006). There was complete or nearly complete response (≤10 eosinophils) in 72% of subjects. Mast cell content, parabasal layer thickness, and endoscopic furrows and exudates also significantly decreased. Of the 29 qualified subjects, 11 (38%) failed to adhere to the diet. Several subjects had significant weight loss. Symptoms and endoscopic fixed strictures did not improve. After the subjects resumed a normal diet, the eosinophil content increased substantially in 3–7 days.CONCLUSIONS:While symptoms did not improve and dietary compliance was problematic, there was substantial histologic improvement after 4 weeks on the elemental diet. EoE in adults is substantially triggered by foods.

Endoscopic appearance and location dictate diagnostic yield of biopsies in eosinophilic oesophagitis

Acknowledging that eosinophilic esophagitis (EoE) is a disease with variable involvement throughout the oesophagus, studies have suggested a minimum of five biopsies to diagnose EoE. Although it is accepted that furrows and exudates appear to represent areas of inflammation, no research to date has looked specifically at EoE endoscopic findings to see if eosinophilic infiltrate correlates with specific endoscopic findings.

Utility of an Elemental Diet in Adult Eosinophilic Esophagitis

Background: Data suggests that food is a primary trigger for the development of esophageal eosinophilia in children. Six food elimination diets are effective in adults, but the efficacy of an elemental diet in adult patients with eosinophilic esophagitis (EoE) has not been reported. Aims: To determine whether adult patients with EoE exhibit clinical and histologic improvement to an elemental diet compared to their normal diet. To determine the time of response of esophageal eosinophilia to elemental diet. Methods: EoE was diagnosed by esophageal obstructive symptoms (dysphagia, chest pain, food impaction, heartburn) and esophageal biopsies demonstrating >20 eosinophils/HPF in the setting of high dose acid suppression. All subjects underwent a second EGD/biopsies 2-3 weeks after their initial EGD/biopsies to confirm stability of disease while maintaining their normal diet. After the 2nd EGD/biopsies, all patients were started on an elemental diet (Elecare, Abbott Laboratories, Columbus, Ohio) and underwent a 3d EGD/biopsies after 2 weeks of Elecare. If subjects did not completely respond (eos 20/HPF at 2nd EGD) and completed at least 2 weeks of the Elecare diet. Five subjects dropped out of the trial after 2 weeks (2 due to poor tolerance of the diet, 3 for personal reasons). One patient responded completely at 2 weeks (1 eos/hpf). The remaining 20 patients completed a 4 week trial of Elecare. Eosinophil counts did not vary significantly between the 1st and 2nd EGDs (distal 44 to 43 eos/HPF, proximal 33 to 40 eos/HPF respectively, p =0.43, p=0.43). Dramatic decreases in eosinophils were seen at 2 weeks after starting Elecare (average distal 13 eos/HPF and proximal 14 eos/HPF, p <0.001 for both) and decreases correlated with an overall clinical response to therapy at 4 weeks. Response continued less profoundly between 2 and 4 weeks on Elecare (distal 11 eos/HPF and proximal 8 eos/HPF). 11/21 (52%) responded with counts less than 8 eos/HPF by week 4. Discussion: Elemental diet resulted in marked improvement in esophageal eosinophilia in a substantial number of adults with EoE. Histologic response occurs within 2 weeks of starting the elemental diet and profound decreases in eosinophilia at 2 weeks are maintained at 4 weeks on diet. Elemental diets are useful in the treatment of EoE to provide rapid relief of symptoms and tissue eosinophilia.

Co‐occurrence of eosinophilic esophagitis and potential/probable celiac disease in an adult cohort: a possible association with implications for clinical practice

We describe an adult cohort with eosinophilic esophagitis (EoE) and evidence of celiac disease (CD), propose a change in diagnostic practice to better characterize these conditions, and hypothesize new directions for research. Pediatric studies postulate association between gluten sensitivity and EoE. However, few publications describe the prevalence, detection, or therapeutic and pathophysiologic implications of such association in adults. Retrospective chart review was done on patients diagnosed with EoE from 2009 to 2010 at University of Utah Hospitals and Clinics. Data included sex, age, presentation, duodenal pathology, tissue transglutaminase immunoglobulin A antibody (TTG) positivity, human leukocyte antigen (HLA) type (when indicated), and gross and microscopic Esophagogastroduodenoscopy (EGD) findings. Duodenal biopsy, TTG results, and HLA type were correlated. Endoscopy was repeated after gluten-free diet. Forty-four of 75 patients were followed in EoE specialty clinic with duodenal biopsy and TTG testing per protocol. Six EoE patients had potential or probable CD. No sex or age differences were noted between those with findings of CD and EoE and those with EoE alone. Six patients with findings of CD and EoE followed gluten-free diet. Five underwent repeat endoscopy. Three had resolution of esophageal eosinophilia. Potential or probable CD was commonly found in adults with EoE. Diagnosis of CD may be challenging due to nonspecific symptoms and insufficient duodenal biopsy and serologic testing. Furthermore, gluten-free diet resolved EoE findings in some patients, suggesting possible shared pathophysiology in some cases of EoE and CD. TTG testing and adequate duodenal biopsy may further direct clinical care for EoE patients, and studies are needed to elucidate mechanisms linking EoE and CD.

Which Patients with Eosinophilic Esophagitis (EoE) Should Receive Elemental Diets Versus Other Therapies

Eosinophilic esophagitis (EoE) has increasingly been identified in both children and adults. The aim of therapies is to alleviate symptoms while reducing the esophageal inflammation. Mechanical dilation is effective at relieving symptoms, but without the benefit of controlling disease inflammation. Topical steroids appear to be effective at controlling both symptoms and esophageal eosinophilia. Recurrence rates are high once steroids are discontinued. For dietary modification, both the elimination of select, specific foods and the complete elimination of food proteins via amino acid formulas have been looked at. Both forms of dietary modification are effective. Elemental diet, although not an ideal first-line therapy for EoE, provides insight into the etiology of unusual or refractory EoE. The contribution of unusual food antigens to EoE may be determined via the use of amino-acid-based formulas in patients with EoE.

Inflammatory bowel disease education: I can hear the extension for community healthcare outcomes

Article first published online 4 May 2015.

S1090 Celiac Sprue and Eosinophilic Esophagitis: Are Duodenal Biopsies Enough?

Allergy testing or immunotherapy treatments were not included; (4) For pts undergoing endoscopy (EGD) w/o Bx, EoE would be missed. Results: Assuming base case probabilities (Table 1), the EGD w/o Bx arm cost

CMV Disease in IBD: Comparison of Diagnostic Tests and Correlation with Disease Outcome

643 and was associated with 0.953 QALYs. The EGD with Bx arm cost

Esophagitis Dissecans Superficialis Endoscopically Induced in a Patient With Pemphigus Vulgaris and Gastrointestinal Complaints

853 and was associated with 0.957 QALYs. The resulting incremental cost-effectiveness ratio (ICER) was

Eosinophilic Esophagitis in Two Patients with Systemic Sclerosis

52,500 per QALY for the EGD with Bx arm. Tornedo analysis demonstrated that the results were sensitive to the following variables in descending order of influence: cost of EGD with Bx, cost of EGD w/o Bx, probability of EoE in pts with and w/o dysphagia, and symptom resolution on fluticasone. In one-way sensitivity analysis, the ICER exceeded