Eosinophilic Oesophagitis and Proton Pump Inhibitor-Responsive Oesophageal Eosinophilia Have Similar Clinical, Endoscopic and Histological Findings

F. J. Moawad; A. M. Schoepfer; E. Safroneeva‡, M. R. Ally; Y.-J. Chen; C. L. Maydonovitch; R. K. H. Wong

Disclosures

Aliment Pharmacol Ther. 2014;39(6):603-608. 

In This Article

Abstract and Introduction

Abstract

Background Some patients with a phenotypic appearance of eosinophilic oesophagitis (EoE) respond histologically to PPI, and are described as having PPI-responsive oesophageal eosinophilia (PPI-REE). It is unclear if PPI-REE is a GERD-related phenomenon, a subtype of EoE, or a completely unique entity.

Aim To compare demographic, clinical and histological features of EoE and PPI-REE.

Methods Two databases were reviewed from the Walter Reed and Swiss EoE databases. Patients were stratified into two groups, EoE and PPI-REE, based on recent EoE consensus guidelines. Response to PPI was defined as achieving less than 15 eos/hpf and a 50% decrease from baseline following at least a 6-week course of treatment.

Results One hundred and three patients were identified (63 EoE and 40 PPI-REE; mean age 40.2 years, 75% male and 89% Caucasian). The two cohorts had similar dysphagia (97% vs. 100%, P = 0.520), food impaction (43% vs. 35%, P = 0.536), and heartburn (33% vs. 32%, P= 1.000) and a similar duration of symptoms (6.0 years vs. 5.8 years, P= 0.850). Endoscopic features were also similar between EoE and PPI-REE; rings (68% vs. 68%, P = 1.000), furrows (70% vs. 70%, P = 1.000), plaques (19% vs. 10%, P = 0.272), strictures (49% vs. 30%, P = 0.066). EoE and PPI-REE were similar in the number of proximal (39 eos/hpf vs. 38 eos/hpf, P = 0.919) and distal eosinophils (50 vs. 43 eos/hpf, P = 0.285).

Conclusions EoE and PPI-responsive oesophageal eosinophilia are similar in clinical, histological and endoscopic features and therefore are indistinguishable without a PPI trial. Further studies are needed to determine why a subset of patients with oesophageal eosinophilia respond to PPI.

Introduction

The presence of dense eosinophilia on oesophageal biopsies, especially in the setting of dysphagia and food impaction, suggests a diagnosis of eosinophilic oesophagitis (EoE). This increasingly recognised entity has emerged as the most common cause of dysphagia in adults.[1] According to the most recent consensus guidelines, a trial of acid-suppressants must be administered prior to establishing a diagnosis of EoE.[2] This is primarily to rule out gastro-oesophageal reflux disease (GERD), a common condition that can also result in dense oesophageal eosinophilia. Although previously believed to cause only mild eosinophilia, studies have demonstrated that GERD may also lead to dense eosinophilic infiltration on oesophageal biopsies similar to what is observed in EoE.[3,4] Interestingly, since the publication of the latest consensus guidelines, it has become more apparent that some patients with a phenotypic appearance of EoE and distinct from GERD (i.e. dysphagia, history of atopy, rings/furrows/plaques on endoscopy and dense eosinophilia on biopsies) respond histologically to proton pump inhibitors (PPI).[5] These patients are described as having PPI-responsive oesophageal eosinophilia (PPI-REE), to distinguish them from EoE patients. To date, it is unclear if PPI-REE represents a GERD-related phenomenon, a subtype of EoE, or a completely unique entity.[6–9] The aim of this study was to compare the demographic, clinical, endoscopic and histological features of EoE and PPI-REE in a population of patients from two institutions.

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