Briefly noted: ET Jensen et al. JPGN 2019; 68: 50-5. This retrospective study with 409 patients with eosinophilic esophagitis (EoE) examined longitudinal growth over 12 months. “In general, treatment approach was not associated with any significant increase or decrease in expected growth.” In a subset of patients with combined elemental diet and topical steroids (n=13), there was a subtle decrease in linear growth with a change in height z-score of -0.04, CI -0.08 to -0.01. Interestingly, in these patients with EoE, the baseline height z-scores were lower than expected indicating that a subset may have impaired growth prior to treatment.
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pictures from Zabriskie Point at sunrise, Death Valley
Briefly noted: SC Shah, H Khalili et al. Gastroenterol 2018; 155: 1079-89.
This study evaluated pooled data with 207,600 incident cases of IBD from a population of 478 million. Key findings:
- Female patients had lower a lower risk of Crohn’s disease during childhood until 10-14 years of age, but then a risk afterwards
- For ulcerative colitis, there was a divergence in risk after 45 years of age, when men had a significantly higher incidence.
My take: the differences indicate that genetic factors (men with a Y chromosome and only one chromosome X) along with sex hormones play a role in the pathogenesis of IBD.
Graphs depict Female/Male Incidence Rate Ratio
AGREE proceedings: Briefly noted: ES Dellon, CA Liacouras, J Molina-Infante, GT Furuta et al. Gastroenterology 2018; 155: 1022-33. This report provides updated recommendations from AGREE conference –which have been widely cited previously on this blog and elsewhere. One of the remarkable features on this report is the fact that there are 64 authors (by my count) –thus reading the affiliations and the conflict of interest disclosures alone would take some time.
For a good review on this topic:
According to a recent retrospective study (CC Reed et al. Clin Gastroenterol Hepatol 2018; 16: 1667-9) the time to diagnosis of eosinophilic esophagitis (EoE) has NOT improved between 2000 and 2014. In this single tertiary-care center study with 677 cases, the predicted length of symptoms prior to diagnosis was the following:
- 2000-2006: 6.1 years
- 2007-2011: 7.2 years
- 2011-2014: 7.2 years
While in the pediatric cohort the trend was the same, the length of symptoms preceding diagnosis was shorter: 2.8 years, 3.5 years and 3.7 years respectively for the above-mentioned time periods.
My take: In GI circles, EoE is quickly considered for a variety of clinical presentations. This study suggests that
- #1 for families and primary care doctors that many are unaware of this entity
- #2 the symptoms of EoE are often insidious
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Full text: ES Dellon, CA Liacouras, J Molina-Infante, GT Furuta et al. Gastroenterol 2018; 155: 1022-33.
This article provides a thorough review of EoE -including clinical features, differential diagnosis, diagnostic criteria, and treatments.
Key point: “The evidence suggests that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criterion, and we have developed updated consensus criteria for EoE that reflect this change.”
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At a recent morning clinical conference, Dr. Seth Marcus provided a terrific update on eosinophilic esophagitis (EoE). I am placing some of the slides below and the following is a link to the full lecture: The Evolution of EoE -Seth Marcus
During this part of the presentation, there was a discussion regarding the role of allergists. Due to the poor predictive value (negative and positive) of allergy testing (skin tests and blood tests), the consensus is that routine allergy evaluation is NOT needed for children with EoE. However, IgE-mediated food allergies along with other atopic diseases are common in children with EoE and selected patients could benefit from allergy referral.
The slide above reviews the main treatment options: topical corticosteroids, proton pump inhibitor therapy, and elimination diet. While all of these are reasonable as first-line approaches, many in the group favored proton pump inhibitor (PPI) treatment as initial therapy. In those with a very good response (<5 eos/hpf at followup), this would allow lower dose PPI as a maintenance option. Another point of discussion was the fact that PPI responders tend to more favorably metabolize the PPIs to achieve higher therapeutic levels. It is anticipated that future treatment could be influenced by knowing the individual’s CYP2C19*17 Polymporphisms (#NASPGHAN17 EoE Session)
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Reslizumab, a monoclonal recombinant antibody to interleukin-5 did not receive FDA approval for eosinophilic esophagitis. However, a recent report (J Markowitz et al. Journal of Pediatric Gastroenterology and Nutrition: June 2018 – Volume 66 – Issue 6 – p 893–897) describes the outcomes of patients who entered the randomized control trial and continued to receive subsequently via open label extension (OLE, n=6) or through compassionate use (CU, n=4. This study provides data over 9 years of treatment.
- Median eosinophil count dropped from 35 to 3
- No serious adverse events were noted
- Clinical features improved. For example, dysphagia dropped from 42% to 0% and vomiting dropped from 67% to 17%
My take: Though this is a small study, it shows that in selected patients disruption of the inflammatory pathways can result in significant clinical improvement.
Pics from Ameila Island and thereabouts -Not sure whose dog (not ours)
Briefly noted: MA Lowry et al. JPGN 2018; 67: 198-203. This study showed that active eosinophilic esophagitis (EoE) was associated with much lower impedance values that inactive EoE, NERD, and controls. At 2, 5 and 10 cm above the squamo-columnar junction, median values of impedance with active EoE were 1069, 1368, and 1707 respectively. In comparison, inactive EoE had median values were 3663, 3657, and 4494, respectively. My take: Since impedance was also performed during endoscopy with sedation, this does not represent a significant advance in current management.
Sunrise at Amelia Island