Proton Pump Inhibitor-responsive Esophageal Eosinophilia: Still a Valid Diagnosis?

Javier Molina-Infante; Pedro L. Gonzalez-Cordero; Alfredo J. Lucendo


Curr Opin Gastroenterol. 2017;33(4):285-292. 

In This Article

Response to Proton Pump Inhibitor Therapy: Quite Common, Frequently Overlooked

A first systematic review with meta-analysis including 619 patients with suspected EoE (based on their symptoms and esophageal histology) recently has been published.[7] Up to 50% of children and adults with suspected EoE achieved both clinical and histologic remission with PPI therapy. Of note, the response to PPI therapy occurred irrespective of whether esophageal pH monitoring results were normal or abnormal. These findings are entirely coincident with those of the first prospective series from 2011.[2] EoE patients responsive to PPI therapy also have been reported in 2016 in reports from Korea,[8,9] Japan,[10] and Australia.[11]

One of the most striking findings in recent literature is the lack of compliance with consensus guidelines published in 2007,[1] 2011,[3] and 2013,[4] specifically regarding the requirement for a failed trial of PPI therapy before making a diagnosis of EoE. A systematic review on studies evaluating the prevalence of EoE in adults between 2008 and 2015[12] has shown that, contrary to the guideline recommendations,[1,3,4] a PPI trial was not administered before making the diagnosis of EoE in 60% of studies. These important data likely underscore the confusing scenario created by arbitrary and, arguably, illogical guidelines.

The lack of well conducted studies evaluating the rate of response to PPI therapy in children with EoE is remarkable, since pediatricians have often taken the lead in conducting EoE studies on topical steroid therapy,[13,14] empiric diets,[15,16] and even on PPI therapy before 2011.[17,18] One of the most important contributions of 2016 is the first prospective series evaluating response to systematic PPI therapy in children with suspected EoE.[19] Among 51 such children, 35 (68%) achieved histological remission (defined by <15 eos/HPF) with PPIs, whereas complete symptomatic remission was accomplished in 24 (47%). As in earlier studies, esophageal pH monitoring results did not adequately predict the response to PPI therapy. As recently reported with other therapeutic modalities like topical steroids and diet, this important study underscores that EoE is likely the same disease in children and adults.