Mo1189 Ethnic Distribution of Eosinophilic Esophagitis in the United States

AGA Abstracts

r=0.01, p = 0.892), peak esophageal eosinophil counts per high-power field (r=0.18, p= 0.17), and increasing severity of distinct endoscopic features (exudates: p=0.43; rings: p= 0.19; edema: p=0.53; furrows: p=0.07; strictures: p=0.03). PhysGA of EoE overall activity positively correlated with peak esophageal eosinophil counts (r=0.81, p<0.001) and increasing severity of distinct endoscopic features (exudates: p<0.001; rings: p=0.015; edema: p<0.001; furrows: p<0.001; strictures: p=0.09). Conclusions: Caregiver assessment of EoE symptom severity, in contrast to physician global assessment of EoE activity, poorly correlates with physician global assessment of EoE activity, esophageal eosinophilia, as well as endoscopic disease severity. These findings must be taken into account when defining outcomes for clinical trials in young children with EoE.

combined with ‘dilation' or ‘dilatation'. All articles published from January 1, 1950 through November 15, 2015 were eligible for inclusion. Two authors (TR and SE) independently reviewed article titles and abstracts. Disagreements were resolved by consensus, and then adjudicated by the third author. Studies were included if they described patients with EoE who underwent esophageal dilation and also reported the presence or absence of at least 1 complication (e.g., perforation, bleeding, pain, hospitalization). Review articles, editorials, and letters to the editor were excluded as were studies that reported on patients described in a subsequent publication. We analyzed the overall number of perforations, perforations by dilator type, and perforations over time. Results: We initially identified 812 articles, of which 36 met inclusion criteria (Figure). There was one RCT, 2 prospective cohorts, 14 retrospective cohorts, and 19 case series/reports. These comprised a total of 1,948 dilations performed on 909 patients, most of which (1549/1948, 79.5%) were reported after 2009 (Table). Across all dilations, 9 perforations were documented, yielding a perforation rate of 0.46% per procedure. The method of dilation (balloon vs. bougie) at time of perforation was evident in 27 studies totaling 1782 dilations (976 bougie, 807 balloon). The perforation rate using bougies in these studies was 0.20% (2/976 procedures); with balloon dilators the rate was 0.25% (2/807 procedures). Interestingly, the majority (5/9; 56%) of perforations were reported prior to 2009. The perforation rate prior to 2009 was 2.5% (5/204 procedures); the rate from 2009 on was 0.23% (4/1744). Hospitalization was reported after 13 of 1948 dilations (0.67%). GI Bleeding post-procedure was extremely rare, following only 1 dilation (0.05%). Chest pain was variably measured and reported, but ranged from 1-74%. Conclusions: Perforation rates in the published EoE literature were low, <0.5% per dilation, a figure very near rates published for benign esophageal stricture. Perforation rates were comparable for both balloon and bougie dilators. Increasing recognition of EoE and experience performing dilation in this population may have contributed to decreased perforation risk in the past 5 years.

Mo1187 Control of Inflammation With Topical Steroids Decreases Need for Subsequent Esophageal Dilation in Patients With Eosinophilic Esophagitis Thomas Runge, Swathi Eluri, John T. Woosley, Nicholas J. Shaheen, Evan Dellon Background: Topical steroid treatment decreases inflammation in eosinophilic esophagitis (EoE). However, it is unknown whether response to anti-inflammatory treatment in EoE decreases the need for esophageal dilation. Aim: To determine whether long-term decrease in eosinophilic inflammation with topical steroid treatment decreases the need for subsequent esophageal dilation in EoE patients with fibrostenotic features requiring baseline dilation. Methods: We conducted a retrospective cohort study of the UNC EoE clinicopathologic database from 2001-2014. This database contains clinical, endoscopic, and histologic data on patients with an incident diagnosis of EoE who met consensus guideline criteria for EoE, including non-response to a PPI trial. Patients were included in this study if they had an esophageal dilation performed at their index endoscopy, underwent treatment with topical steroids, and had a subsequent EGD with biopsies on treatment. Histologic responders were defined as patients who had <15 eos/HPF on biopsy while on treatment. Nonresponders had ‡15 eos/HPF on their post-treatment biopsy. The number of total dilations performed in each group was determined. Responders were compared to non-responders. Multiple linear regression was used to compare number of dilations needed in both groups, adjusted for potential confounders, baseline stricture characteristics, and time under observation. Results: 55 patients met inclusion criteria, 27 (49%) of whom were responders to steroid treatment, and 28 who were not. Baseline clinical, endoscopic, and histologic characteristics were similar between responders and non-responders (Table). Baseline stricture diameter was also similar (10.8 vs. 11.7mm, p=0.35). Overall, patients dilated at index endoscopy subsequently underwent a mean of 2.2 dilations per patient over the mean 40 months of the study follow-up period. After stratification by histologic response status, responders required less than half the number of dilations after treatment than nonresponders (1.8 vs 4.1; p=0.03). This response was more prominent (1.9 vs. 4.4, p=0.04) after adjusting for age, presence of stricture, initial esophageal diameter, presence of dysphagia, and time under observation. Despite undergoing significantly fewer dilations per patient, responders achieved a similar increase in esophageal diameter with dilation (4.9 vs. 5.0mm; p=0.92). Conclusions: In EoE patients requiring esophageal dilation at baseline, control of inflammation with topical steroids resulted in a need for less than half as many dilations to achieve the same increase in esophageal caliber. This suggests that suppression of inflammation to a level of <15 eos/hpf is an important goal in patients with fibrostenotic changes of EoE who require baseline dilation.

Mo1189 Ethnic Distribution of Eosinophilic Esophagitis in the United States Robert M. Genta, Kevin Turner, Amnon Sonnenberg Background and Aims: Eosinophilic esophagitis (EoE) is characterized by esophageal dysfunction and dense eosinophilia of the mucosa. Its ethnic distribution may shed light on its yet unknown etiology. Accordingly, the aim of our study was to investigate the ethnic variations of EoE in a large national sample of patients undergoing esophago-gastro-duodenoscopy (EGD). Methods: The Miraca Life Sciences database is an electronic repository of clinicopathologic patient records. Biopsy specimens are submitted to Miraca Life Sciences by approximately 1,500 gastroenterologists from private practices distributed throughout the United States. We extracted the records of 596,479 patients who underwent EGD with biopsy between 1/2008 and 4/2015. The influence of age, gender, and ethnicity on the occurrence of EoE was tested using multivariable logistic regression. The magnitudes of influence were expressed as odds ratios (OR) and their 95% confidence intervals (CI). Results: A total of 25,969 patients met the histopathologic criteria for EoE ( ‡15 eosinophils per high-power field, eos/hpf). The prevalence of EoE was highest in the age group 10-19 years and lowest in the oldest age group (80+ years) with the steepest decline occurring after the age of 40 years. EoE was more common in men than women with OR = 2.20, CI 2.142.26. Compared with the general population (mostly Caucasians and African Americans), EoE was less common among patients of Middle Eastern (0.27, 0.19-0.38), East Asian (0.37, 0.30-0.45), Indian (0.34, 0.25-0.46), Hispanic (0.42, 0.39-0.45), and Jewish ethnicity (0.65, 0.57-0.73), but more common among subjects of Northern European descent (1.21, 1.041.40). Using the EoE criteria of ‡15 eos/hpf with the additional exclusion of any patients with reflux symptoms reduced the case population to 11,915 subjects, but left the general ethnic trends and the corresponding OR values largely unchanged. A more stringent cutoff value of 50 eos/hpf reduced the case population to 6,708 subjects, but still left the general ethnic trends and their respective OR values similar. Conclusion: The prevalence of eosinophilic esophagitis is less common among Americans of Hispanic and Asian descent than among Caucasians and African Americans. It is also less common among subjects of Jewish ethnicity but more common among subjects of Northern European descent. Such

Mo1188 Safety of Esophageal Dilation by Dilator Type in Eosinophilic Esophagitis: A Systematic Review Thomas Runge, Swathi Eluri, Evan Dellon Background: Esophageal dilation has become a commonly performed therapeutic modality in eosinophilic esophagitis (EoE). However, there are no data directly comparing safety of bougienage and balloon dilators in EoE patients. Aims: To evaluate the safety of esophageal dilation in EoE, especially in regard to perforation risk, and to examine perforation risk by dilator type. Methods: We conducted a systematic review of the published literature using Pubmed, EMBASE, and Web of Science. The search terms used were ‘eosinophilic esophagitis'

AGA Abstracts

X : 10052$CH01 03-28-16 00:57:27 PDFd : 10052B : e

S-664

Page 664

clinical features able to distinguish the two entities. However, previous investigations did not systematically assess reflux-related symptoms by means of validated questionnaires. Recently, the GerdQ questionnaire has been validated in comparison with endoscopy and/ or pH-testing for the diagnosis of gastro-oesophageal reflux disease (GERD). Aim: We aimed to apply GerdQ questionnaire in patients with EoE and PPI-REE to assess whether a prospective and systematic evaluation of reflux symptoms may be helpful to distinguish patients with PPI-REE from those with EoE. Methods: Consecutive patients diagnosed with EoE and PPI-REE according to international criteria [a) presence of at least one symptom of esophageal dysfunction; b) at least 15 eosinophils per HPF at mid/proximal esophagus; c) persisting or nor of eosinophils at mid/proximal esophagus after an 8-week PPI trial] prospectively completed a specific GERD-related questionnaire (GerdQ). The GerdQ questionnaire is a simple, self-administered and patient-centered questionnaire including six items. A cut-off value higher ‡ 9 (range of 0-18) was considered diagnostic for GERD. For comparisons, a group of 27 patients with proven reflux disease was used. Results: Thirtyfive EoE patients and 17 PPI-REE were identified. The two cohorts had similar dysphagia (EoE 94% vs. PPI-REE 88%, p=1.000), bolus impaction (66% vs. 70%, p=1.000) and chestpain (20% vs. 41%, p=0.1810), ,but different heartburn (26% vs. 58%, p=0.0315) and regurgitation (17% vs. 47%, p=0.0429). The overall GerdQ score was statistically lower in EoE vs. PPI-REE [1 (0-6) vs. 8 (2.5-11.25), p=0.004]. When compared to control patients with GERD, both EoE and PPI-REE patients showed increased rate in dysphagia parameters, whereas EoE individuals reported less frequently heartburn (26% vs. 85%, p<0.001), regurgitation (17% vs. 74%, p<0.001) and overall GerdQ scores [1 (0-6) vs. 8 (6-12), p= 0.001] than control patients with GERD. In contrast, no difference was found comparing PPI-REE and control patients with GERD for heartburn, regurgitation and overall GerdQ score (p= 0.0754, p=0.1083 and p=1.000, respectively). Two EoE patients (6%), 8 PPI-REE patients (47%) and 15 control patients with GERD (55%) had a total score equal or above 9 (EoE vs. PPI-REE p=0.0010, EoE vs. GERD p<0.001 and PPI-REE vs. GERD p= 0.7577). Conclusions: The GerdQ is a useful complementary tool to distinguish patients with PPIREE from those with EoE. The implementation of GerdQ could reduce the need for more aggressive therapies (i.e. topical steroids and specialised diets) and improve resource utilisation

Mo1190 Comparative Analysis of the Association of Environmental Allergens in Eosinophilic Esophagitis versus PPI-Responsive Esophageal Eosinophilia Vikrant Jagadeesan, Alison Goldin, Karen S. Hsu Blatman, Wai-Kit Lo, Matthew Hamilton, Jason Hornick, Walter W. Chan Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder. A subset of patients with esophageal eosinophilia responds to proton-pump inhibitor (PPI) therapy and has been termed PPI-responsive esophageal eosinophilia (PPI-REE). Both disorders are known to be associated with allergic conditions. The seasonal variation observed in some studies of EoE suggest a possible role for environmental allergens. Defining the distinct environmental allergy profile of patients with EoE compared to PPI-REE may help define pathogenesis and potentially guide therapy. Aim: To compare the prevalence of reaction to environmental allergens of EoE vs PPI-REE on allergy skin testing. Methods: This was a retrospective cohort study of patients diagnosed with esophageal eosinophilia (>15 eos/hpf) on mucosal biopsies from upper endoscopy (EGD) at a tertiary care center from 5/2006-7/ 2015. All included patients underwent a high-dose PPI trial ‡8 weeks, and were classified based on biopsies from post-PPI trial repeat EGD into EoE (>15 eos/hpf) vs PPI-REE (<15 eos/hpf). Allergy skin testing was performed for a standardized battery of food and environmental antigens. Fisher-exact test for binary variables and student t-test for continuous variables were used to assess differences between cohorts. Multivariate analysis was performed using forward stepwise logistic regression. Results: 121 patients (49% EoE, 51%PPI-REE) were diagnosed with esophageal eosinophilia and 33 (27%) patients underwent allergy skin testing. Of the standard environmental antigens, D. pteronyssinus (86% vs 50%, p=0.04), oak (90% vs 42%, p=.006), birch (89% vs 42%, p=.012), grass (79% vs 42%, p=0.035), and hormodendrum mold (89% vs 33%, p=.002) were significantly more prevalent in EoE vs PPI-REE. (Table 1). When categorizing environmental allergens into weed pollen, tree pollen, mold, and dust mites, only tree pollen was significantly more prevalent in EoE compared to PPI-REE [90% vs 58%, p=0.04]. On multivariate analysis, hormodendrum mold was the only independent positive predictor for EoE [OR=16, p=0.002]. By group, tree pollen was the only independent positive predictor for EoE [OR=6.43, p=.04]. There were no significant differences in food allergens between EoE and PPI-REE. Conclusion: Selected environmental allergens are more prevalent among patients with EoE compared to PPI-REE. These include pollens (tree, grass and weed) which peak between Spring and Fall and may help explain the seasonal variation in severity of disease. Given the otherwise similar clinical, endoscopic and food allergy profiles between EoE and PPI-REE, our data suggest that environmental allergens may play a more significant role in the pathogenesis of EoE compared with PPI-REE. Table 1. Prevalence of Environmental Allergens in EoE vs PPI-REE

Mo1192 Lack of PPI Trial Prior to Commencing Therapy for Eosinophilic Esophagitis Is Common Matthew J. Whitson, Kristle Lynch, Yu-Xiao Yang, David C. Metz, Gary W. Falk Background: Eosinophilic esophagitis (EoE) is characterized by eosinophil-predominant inflammation restricted to the esophagus (‡ 15 eos/hpf) and symptoms of esophageal dysfunction. Critical to the diagnosis of EoE is a trial of PPI therapy or use of pH testing to exclude alternative causes of esophageal eosinophilia such as GERD or PPI-responsive esophageal eosinophilia (PPI-REE). Despite multiple guidelines recommending this approach, it remains unknown how often this step is taken in clinical practice and how often failure to properly diagnose EoE leads to unnecessary treatments. Aim: (1) To assess how often patients referred to a tertiary care center with a presumptive diagnosis of EoE underwent a previous PPI trial (2) To assess the frequency of unnecessary treatments in patients misdiagnosed with EoE. Methods: We conducted a single-center, retrospective study of patients referred to the Hospital of the University of Pennsylvania for management of EoE from 2010-2015. Patients were identified using the following keyword search: EoE, esophageal eosinophilia, PPI-REE, or dysphagia. Patients who were referred from community practice with a diagnosis of EoE were identified. Clinical information was abstracted including demographic data, atopic history (asthma, eczema, food allergies), prior evaluation (endoscopy, histology, prior testing on PPI), prior treatments (PPIs, steroids, diet), and final diagnosis after evaluation at our institution (EoE, PPI-REE, GERD). Results: 833 patients were identified on initial search. 125 patients (15.0%) were referred from community practitioners with a diagnosis of EoE (See Table 1). 72% of patients referred (90/125) had not had a prior EGD on BID PPI, high dose PPI (40 mg omeprazole equivalent), or formal pH testing to rule out GERD or PPIREE. Of these patients 62.2% (56/90) had received topical steroid therapy, 46.7% (48/90) received dietary therapy, and 77.8% (70/90) had received either dietary or steroid therapy. On final diagnosis 64/125 patients (51.2%) were confirmed to have EoE, 29/125 patients (23.2%) had an unknown final diagnosis, and 32/125 patients (25.6%) had a definitive diagnosis other than EoE including PPI-REE, GERD, or lichen planus. In this subgroup of 32 patients, 65.6% (21/32) had received steroid therapy, 34.3% (11/32) received some form of dietary therapy, and 79.2% (25/32) had received either dietary or steroid therapy. Limitations: Single tertiary care center retrospective chart review and may not reflect the broader population. Conclusions: (1) Up to 25% of patients referred for management of presumptive diagnosis of EoE may not actually have EoE (2) A substantial number of patients with presumed EoE do not have PPI-REE or GERD appropriately excluded prior to diagnosis (3) These misdiagnoses lead to unnecessary steroid or dietary therapies for many patients who do not have EoE Demographic Information of Patients Referred from Community Practice with EOE diagnosis

Mo1191 The GerdQ Questionnaire Distinguishes Proton Pump Inhibitor-Responsive Esophageal Eosinophilia From Eosinophilic Esophagitis Patients Ottavia Bartolo, Chiara De Cassan, Francesca Galeazzi, Salvatore Tolone, Renato Salvador, Giacomo C. Sturniolo, Mario Costantini, Edoardo Savarino Introduction: Eosinophilic esophagitis (EoE) and Proton Pump Inhibitor-response esophageal eosinophilia (PPI-REE) present similar phenotypic appearance, similar histopathology but different response to antisecretory therapy. Indeed, current studies failed to observe

S-665

X : 10052$CH01 03-28-16 00:57:27 PDFd : 10052B : o

Page 665

AGA Abstracts

AGA Abstracts

ethnic distributions may point at variations in exposure to environmental risk factors during childhood.