eosinophilic esophagitis | gutsandgrowth

PPI-REE or proton pump inhibitor-responsive esophageal eosinophilia remains a problematic issue for our eosinophilic esophagitis (EoE) patients. PPI-REE and the 3 D’s (Drugs, diet, and dilatation) have been reviewed recently (Clin Gastroenterol Hepatol 2012; 10: 1066-78).

The issues with PPI-REE that are problematic:

If a patient with suspected EoE is pretreated with a PPI and they do not have eosinophils present at the time of endoscopy then a diagnosis of PPI-REE cannot be established.
If patients are not pretreated, then determining that they have PPI-REE compared with typical EoE, requires repeat endoscopy. Furthermore, response to PPI may be transient and/or natural variation in EoE could make definitive diagnosis of PPI-REE quite difficult.
If a patient presents with classic-appearing EoE, choosing to treat with a PPI is difficult as the response rate is much lower than with either dietary therapy or drug therapy. In addition, many symptomatic patients may have been treated to some extent with a PPI. Do they warrant repeat treatment and repeat endoscopy prior to using more typical treatment for EoE?

Beyond this topic, this review covers the recent consensus guidelines and the typical treatments: diets, drugs, and dilatation.

With regard to dilatation, the author notes that it may be safer than previously believed. Furthermore, in a recent trial, 81% were symptom free at 3 months and 46% were symptom free at 1 year. Despite better safety results, 74% of patients in one study complained of retrosternal pain after in endoscopy (moderate in 21% and severe in 17%).

With regard to drug or dietary therapy, the author recommends checking on the effectiveness after 6-8 weeks with a repeat endoscopy. Until better tools for assessing response to therapy become available, endoscopy remains the only accurate way to determine if treatment is working.

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A study from Philadelphia/CHOP offers more insight into food selection diets for eosinophilic esophagitis (EoE) (Spergel JM, et al, J Allergy Clin Immunol 2012; 130: 461-7) –thanks to Seth Marcus for forwarding this article to my attention.

For this study, the authors examined their database of 1187 patients. While the data was collected prospectively, this was a retrospective study. Of this 1187, the authors excluded patients with proton pump inhibitor-responsive EoE (n=191) along with patients with more extensive eosinophilic GI diseases (n=55).

Among the remaining 941, the male-to-female ratio was 2.8:1 and the average age was 6.4 years. Concurrent atopic disorders were common: 64% had rhinitis, 50% had asthma, and 24% had atopic dermatitis. Only 18% had no atopic disorders.

The actual number for the study though was 319. Among the 941 noted above, 148 were receiving medications (n=130 for topical steroids), and causative foods were not identified in 474. In some of these patients, families were content to stick with a multiple food elimination without determining with certainty which foods were truly necessary.

In less than 5% of patients, a strict elemental diet was used. In this group, the population was younger (average 2.8 years). Biopsy improvement was noted in “upward of 98%.”

Key findings:

Elimination of foods based on combined skin prick tests (SPT)/atopy patch tests (APT) had an identical response to the six food group diet –53%. The allergy testing group had less eliminated foods (average 3.2 foods) compared with 8 food groups in SFED.
Elimination of milk with SPT/APT testing resulted in 77% response. Authors note that there was a “particularly high false-negative rate (34%)” with milk testing (SPT/APT).
Elimination of top 8 allergens: milk, soy, egg, wheat, and meats [chicken, turkey, pork, beef] had an identical response of 77%.
Elimination of milk, egg, and wheat had a success rate of 48%. Milk only elimination had a 30% response rate.
Most common foods by biopsy: milk (35%), egg (13%), wheat (12%), soy (9%), corn (6%)
Most common foods by symptoms: milk (19%), egg (11%), wheat (9%), soy (10%), beef (8%)
IgE-mediated foods: milk (10%), egg (17%), soy (4%), peanut (22%)

Additional useful information in the addendum of methods notes their technique for APT testing (which is not standardized across centers). The authors use 2 g of dry foods in 2 mL of isotonic saline solution for most foods; for milk, they use 3 g of powdered milk with 1 mL of isotonic saline. Then these mixtures are placed in aluminum cups (6- or 12-mm Finn chambers on Scanpore). These cups are placed on patient’s backs and removed at 48 hours and read at 72 hours.

In addition, for each food, their tables list predictive values (positive predictive value, negative predictive value, sensitivity, and specificity) for SPTs, and for APTs. Overall, the predictive values are quite variable and much different from the general population. For example, in the general population, the negative predictive value is essentially 100% for combination of SPT/APT.

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