COMMENTARY

Eosinophilic Esophagitis: Disease Du Jour

Digestive Disease Week 2011

David A. Johnson, MD; Philip O. Katz, MD

Disclosures

May 20, 2011

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Eosinophilic Esophagitis: An Increasingly Important Disease

David A. Johnson, MD: Welcome to Medscape Peer to Peer. I'm Dr. David Johnson, Professor of Medicine, and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. It's my pleasure today to be speaking with Dr. Phil Katz, Chairman of the Division of Gastroenterology at the Albert Einstein Medical Center in Philadelphia.

We're here at Digestive Disease Week (DDW) in Chicago. We're going to be discussing the latest developments in eosinophilic esophagitis, the hottest topic we have in the esophagus, as it relates to this year's meeting. Eosinophilic esophagitis (EoE) is an entity of increasing importance and a focus in gastroenterology, especially with respect to its differentiation from gastroesophageal reflux disease (GERD).

Phil, can you bring me up to date? There is a tremendous amount of information here. Put some perspective on it. What did you find most enlightening?

Eosinophilic Esophagitis and Gastroesophageal Reflux Disease

Philip O. Katz, MD: You're absolutely right. This meeting is incredibly replete with information on EoE and it is the disease du jour in gastroenterology these days, certainly in esophagology.

The first abstract is The Role of GERD in Eosinophilic Esophagitis.[1] This was a prospective study from the Mayo Clinic looking at a group of patients who had high eosinophil counts on biopsy. The investigators did pH monitoring studies in all the patients. Patients who had a positive or abnormal pH monitoring study were put on a proton pump inhibitor (PPI) twice a day. Those who had a negative pH monitoring study were given budesonide.

They found that the GERD patients, those with positive pH studies, responded very nicely to a PPI. Those with negative studies responded very nicely to budesonide, suggesting that there are a group of people who have high eosinophil counts and who are PPI-responsive and there are those who have what we would call true EoE and will need a steroid or some other treatment.

Dr. Johnson: Is this group the phenotype of EoE, GERD responsive to therapy, or is it just GERD mislabeled as EoE?

Dr. Katz: I suspect that I can't answer that in a short period of time. It could be either. For the patient, if he or she is PPI-responsive, the outcome will be good. For the physician or the clinician, it means you've got to differentiate the 2 in a patient who is not getting better.

Dr. Johnson: Your take-home message from this would be start with a PPI or do pH monitoring?

Dr. Katz: Ideally, practically speaking, I'd start with a PPI and then consider pH monitoring if they weren't getting better.

Dr. Johnson: What else has been new?

Esophageal Dilation in Eosinophilic Esophagitis

Dr. Katz: We have long debated the role of esophageal dilation in EoE. When we started out, we did that for a lot of people, but then we stopped doing it because it was deemed to be very risky because of tears and perforation. Another study from the Walter Reed Army Medical Center in DC,[2] with a cohort of patients with EoE, basically reaffirmed that in the right setting, dilation is safe whether performed with a bougie, a Savory, or a balloon. They found no perforations, no hospitalizations, and no negative outcomes in a reasonably large cohort of patients.

Dr. Johnson: The early trials were reporting high complication rates. We are actually describing rents, and if you want to be scared, take another look after you dilate one of these people and you sleep unsettled that night. That's not really a complication. A disruption of mucosa is actually a physiologic endpoint we want to achieve when we're dilating a stricture, correct?

Dr. Katz: Absolutely. It simply means that you doing what you are supposed to, and you are probably not doing any harm if you are doing it carefully and you do it right.

Dr. Johnson: Emphasis on do it carefully. What else is hot?

Dietary Approaches to Eosinophilic Esophagitis

Dr. Katz: The next area in therapy is diet control. In kids, we often put them on elemental diets and restrictive diets. It's not very palatable in adults. This is really the first study of long-term maintenance therapy, with dietary restriction, that looked at food groups and restrictive diets; eliminating milk, nuts, and seafood as a way of treating these patients. The Northwestern group[3] that has been interested in EoE and has a large cohort of patients, actually did a 1-year study in which they put patients on dietary restriction. They identified triggers (some people had one, some had more) and with dietary restriction, they showed improvement in eosinophil counts, improvement in symptoms; and even nicer, patients were able to stay on the elimination diet. Some of them couldn't; they had to be switched over to other therapy, but it worked. The good news is that dietary restriction with some limited restrictions might be helpful in many of these patients.

Dr. Johnson: Wheat, soy, and egg are the other 3 foods in kids in particular. Do you test these people for allergies first? What's the take on that? Do we send them to an allergist, have them skin tested for food sensitivities or do we just start eliminating stuff?

Dr. Katz: I think the right answer is to talk to the patient. If they are willing to do this without testing, that would be my preference. It's practical, it's straightforward, and it's relatively easy. If you have to get into allergy testing you have some sensitivity and specificity issues and you might find out you're allergic to things that you like. I would eliminate the groups first, but you could go either way.

Dr. Johnson: The only element of caution that I use in my practice is to work with a nutritionist so that as you start to restrict foods you're not missing something that you and I don't deal with as far as micronutrients, vitamins, elements, or things that you might be otherwise missing if you take away a specific food group.

Dr. Katz: I agree. Patient education here is crucial and collaboration with your colleagues is terrific. To follow up on that, the group from Salt Lake City, Utah[4] looked at elemental diets in adults. I couldn't believe it, because it just doesn't have any taste, but they actually did a prospective study. They took a small cohort of people with EoE and put them on an elemental diet for 2 weeks, looked at their biopsy specimens before and after, looked at their symptom scores before and after, and were able to show that in an adult population, you can get a clinical remission and a histologic remission in a proportion of patients on an elemental diet. I'm not sure that this is practical, but the clinician should know that it's possible and keep it in their armamentarium.

Dr. Johnson: It's a standard in pediatrics. They've done this for a long while. The idea of an adult complying with this is very challenging, although in the study, only 2 patients were not able to tolerate the diet. They were probably lying about that -- the patients were tolerating it but they were not happy about it.

Dr. Katz: I'm reticent and I don't believe that this will last for a long time in the average person because eating is too much fun. You could see a good short-term remission; feel well for awhile, and then go on to something else.

Dr. Johnson: Another element of "sometimes the treatment is worse than the disease." Let's see what else you have.

Biopsy Practice Patterns

Dr. Katz: We have had a fair amount of debate about the optimal biopsy protocol, and this next abstract deals with the importance of doing it right to get the right answer. This was a very large study[5] from a huge pathology database that attempted to look at the biopsy practice patterns and the relationship of the diagnostic yield in EoE-suspected esophageal cases. Basically they looked at the number of biopsies performed, where they were taken from (proximal, middle, or distal), and tried to correlate that with the eosinophil counts. They showed that if you took multiple biopsies from multiple parts of the esophagus, the diagnosis of EoE was made in greater frequency than if you only took a single biopsy and/or a distal biopsy.

It reinforces the consensus guideline and the working diagnosis of performing 5-6 proximal, middle, and distal biopsies, and you will increase your diagnostic yield in a patchy disease.

Dr. Johnson: The compliance is key. I don't think that's being done that often, performing multiple biopsies at multiple levels, and not just at the esophageal junction.

Oral Budesonide

Dr. Katz: The other issue is therapy. We know that in kids, steroids have been effective -- oral corticosteroids or fluticasone. Another study showed that oral budesonide suspension works in pediatric subjects[6] and that probably will work in adults as well. Another way to deliver the steroid is oral budesonide in a paste-type material and it's a different way to get the drug in. That's another way to give someone a steroid.

Dr. Johnson: Certainly an option beyond the inhaled and swallowed fluticasone, which has really been a challenge.

Fantastic news on EoE; it continues to be in the mainstream of esophagus news as far as research and exciting new information. I'd like to thank you for joining us. This is Dr. David Johnson with Dr. Philip Katz for Medscape from DDW. Thanks for watching.

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