Kathryn Peterson

Eosinophilic oesophagitis in patients presenting with dysphagia – a prospective analysis

Background  Eosinophilic oesophagitis (EoO) may be a common finding in adults presenting with dysphagia.

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.

Obscure gastrointestinal bleeding

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Retrospective Analysis of Esophageal Food Impaction: Differences in Etiology By Age and Gender

Eosinophilic Esophagitis (EE) is an emerging cause of esophageal food impaction (EFI) not accounted for in previous studies. We sought to determine the causes of EFI in a recent cohort with recognition of EE. A retrospective chart review of all patients with EFI during the past 5 years was performed. Etiology was determined by endoscopy report, pathology results, and follow-up studies. A total of 85 EFIs occurred, in 79 patients (55 men, 30 women, age 18–100). The most common etiologies of EFI were Schatzkis ring (n=18), peptic stricture (n=18), EE (n=9), esophagitis (n=9), and no underlying diagnosis (n=20). EE was significantly more frequent in men (P < .025) and those <50 years old (P < .025). There was a significant difference in the age at which men (median age=44) and women (median age=71) present with EFI (P < .001). The etiology of EFI differs significantly by age and gender. This information may be useful in evaluation and management of EFI.

Electron microscopy elucidates eosinophil degranulation patterns in patients with eosinophilic esophagitis

BACKGROUND In patients with eosinophilic esophagitis (EoE), eosinophils accumulate and release granule proteins onto esophageal epithelium. However, little is understood about the mechanism of eosinophil degranulation. OBJECTIVE To determine and quantify eosinophil degranulation patterns, we studied esophageal biopsy specimens from both the proximal and distal esophagi of 9 randomly selected patients with EoE. METHODS The specimens were fixed in glutaraldehyde, embedded, sectioned, and imaged by means of transmission electron microscopy. Eosinophils and their granules were identified by their distinctive morphology, and all eosinophils and granules were imaged. A total of 1672 images from 18 esophageal specimens were evaluated and graded. Eosinophils were categorized based on membrane integrity and by cytoplasmic vesiculation as evidence of piecemeal degranulation. Granules were categorized based on reversal of staining (eosinophil granule core lightening) and localization within and outside the cells. RESULTS The results revealed that greater than 98% of eosinophils infiltrating the esophagus in patients with EoE demonstrate morphologic abnormalities ranging from granule changes with reversal of staining to marked cytoplasmic vesiculation to loss of cellular membrane integrity with cytolytic disruption and release of intact membrane-bound granules into the tissues. Approximately 81% of eosinophils showed membrane disruption. Extracellular granules were abundant in at least 70% of the images, and approximately 50% of these granules showed reversal of staining. On the basis of the prominence of tubulovesicular development, piecemeal degranulation appears closely related to the other morphologic changes seen in patients with EoE. CONCLUSION These findings reveal that eosinophils in esophageal biopsy specimens from patients with EoE are abnormal, with greater than 80% showing cytolysis, and therefore that evaluation by means of light microscopy after hematoxylin and eosin staining might not accurately reflect eosinophil involvement.

Complications involving the mediastinum after injection of Enteryx for GERD

The Food and Drug Administration approved the use of Enteryx (Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass) for the treatment of GERD in April 2003. Enteryx is a biocompatible polymer that is injected intramuscularly into the lower esophageal sphincter (LES). The injections are made under fluoroscopy to ensure correct placement of the substance and to avoid inadvertent submucosal or transmural injection. The injection solution contains ethylene vinyl alcohol, which is dissolved in dimethyl sulfoxide (DMSO) and is mixed with tantalum, a radiopaque contrast agent. After injection into tissue, the DMSO rapidly dissipates by diffusion and the polymer precipitates as a spongy material. The latter initiates an acute and, eventually, chronic inflammatory response, leading to fibrous encapsulation of the polymer. Preliminary studies have shown Enteryx to be efficacious for control of symptoms and allows discontinuation of pharmacotherapy for GERD. The most common complication with Enteryx injection is chest pain, which occurs in over 90% of patients and usually is mild. Dysphagia also is fairly common, occurring in approximately 20% of patients, but this usually is of short duration and does not require therapy. To date, a major complication of Enteryx injection has not been reported. However, reported here are two cases of serious complications involving the mediastinum after Enteryx injection for GERD.

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.

Gene Expression Changes of Inflammatory Mediators in Posterior Laryngitis Due to Laryngopharyngeal Reflux and Evolution With PPI Treatment: A Preliminary Study

Hypothesis: Standard of care in laryngopharyngeal reflux (LPR) is acid suppression therapy. Its treatment efficacy and mechanism of action are not well documented. No objective study investigating the molecular patterns of inflammation in LPR or in response to proton pump inhibitor (PPI) treatment has been accomplished. We hypothesized that gene expression levels of mediators of inflammation—interleukin 6 (IL6), interleukin 8 (IL8), interleukin 1a (IL1a), interleukin 1b (IL1b), transforming growth factor beta 1 (TGFβ1), vascular endothelial growth factor (VEGF), fibroblast growth factor‐2 (FGF2), and tumor necrosis factor alpha (TNFα)—in posterior larynx tissue would be increased in those with diagnosed LPR and would be then reduced with PPI treatment.

Risk of Autoimmunity in EoE and Families: A Population-Based Cohort Study.

Objectives:Recent genome-wide association studies have suggested possible genetic associations between eosinophilic esophagitis (EoE) and genes associated with autoimmunity. No studies to date have looked at potential genetic association of EoE with specific autoimmune diseases by evaluating such diagnoses within family members. Investigate the risk of specific autoimmune disease within EoE probands and their extended family members.Methods:The Utah Population Database offers a unique opportunity to link medical records from over 85% of Utah’s population to genealogy records representing Utah. We searched for associations of specific autoimmune diseases in probands diagnosed with EoE and their extended family members (e.g., first cousins). Comparisons were made to age- and sex-matched controls and their respective families at a 5:1 ratio.Results:Excess risk for multiple autoimmune conditions was detected in subjects with a diagnosis of EoE. Celiac, Crohn’s, ulcerative colitis (UC), rheumatoid arthritis, IgA deficiency, CVID, multiple sclerosis (MS), and Hashimoto’s thyroiditis were found at increased risk in first-degree relatives of EoE subjects. UC, systemic sclerosis, and MS had nominally significant associations within second-degree family members of EoE subjects; and, in reverse analysis, probands and their families with the above three conditions were at an increased risk for EoE suggesting shared genetic factors with EoE.Conclusions:Patients with EoE have an increased risk of multiple autoimmune diseases. Possible shared genetic etiologies were observed between EoE and UC, systemic sclerosis, and MS. Practitioners should be aware of these comorbid associations and query all EoE patients and family members for symptoms of these diseases.

Serotonin syndrome as a complication of fentanyl sedation during esophagogastroduodenoscopy.

To the Editor, Fentanyl is a medication commonly used to induce and maintain conscious sedation during endoscopic procedures. Fentanyl, a direct serotonin agonist, has many advantages, including its relatively short half-life and lack of histaminereleasing effect [1]. It can precipitate serotonin syndrome when prescribed with other serotogenic medications such as monoamine oxidase inhibitors, lithium, ondansetron, selective serotonin reuptake inhibitors, serotonin, norepinephrine reuptake inhibitors, tricyclic antidepressants, amphetamines, and others [2]. To our knowledge, serotonin syndrome has not been described as a complication of fentanyl use during esophagogastroduodenoscopy nor colonoscopy. Here we report the first case of serotonin syndrome secondary to fentanyl in a patient undergoing esophagogastroduodenoscopy.