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58 Long-Term Efficacy of PPI Therapy in Patients With PPI-Responsive Esophageal Eosinophilia: An International Multicenter Study
Dysphagia Scores at Baseline, Day 30, and Day 60 58 Long-Term Efficacy of PPI Therapy in Patients With PPI-Responsive Esophageal Eosinophilia: An International Multicenter Study Javier Molina-Infante, Jan Martinek, Carmen Martinez-Alcala, Jana Krajciova, Fouad J. Moawad, Evan S. Dellon 60
Introduction: At least one third of patients with clinical, endoscopic and histological findings suggestive of eosinophilic esophagitis (EoE) achieve clinicopathologic remission after proton pump inhibitor (PPI) therapy. This new condition is termed PPI-responsive esophageal eosinophilia (PPI-REE). The durability and long-term efficacy of PPI therapy for these patients is unknown. Methods: Observational study in a cohort of adult patients with PPI-REE, defined by baseline symptoms of esophageal dysfunction (dysphagia/food impaction) and esophageal eosinophilia (> 15 eos/HPF), both resolved (clinical remission and < 15 eos/ HPF) after a course of PPI therapy for at least 8 weeks. PPI dosage was defined as: quadruple (e.g. omeprazole 40 mg bid or its equivalent), double (omeprazole 40 mg/day) and single (omeprazole 20 mg/day). After initial PPI response, acid suppressive therapy was progressively tapered based on clinical symptoms and maintained at the lowest dose with the target endpoint of clinical remission. Follow-up endoscopy was performed at 12 months or longer on PPI maintenance dose with histologic examination of both the distal and proximal esophagus. Results: 40 PPI-REE patients have been included to date with a median followup time of 27 months (12-79). Baseline characteristics: 88% males, median age 39 yearsold (19-71), heartburn and/or regurgitation (49%), reflux esophagitis (14%), pH monitoring in 7 patients (4 normal/3 pathological). PPI dosage in the initial PPI trial for diagnosing PPI-REE was quadruple-dose in 18 patients and double-dose in 22 patients. Regarding the step-down process, 19 patients were maintained on double-dose PPI and 21 on single-dose PPI. Overall, 26 out of 40 (63%) maintained clinical and histologic (< 15 eos/HPF) remission during follow-up. Among the 14 relapsers, 8 occurred on double-dose and 6 on single-dose PPI. In 10/14 of the relapsers, esophageal eosinophilia recurred exclusively at the distal esophagus, but not at proximal esophagus. Intensification to quadruple-dose PPI was carried out in 8 out of these 10 distal relapsers, all of whom achieved clinical and histological remission. Conclusions: Sustained clinico-histological remission on low-dose maintenance PPI therapy was observed in 64% of adult PPI-REE patients. A majority of relapsers showed recurrent eosinophilic inflammation limited to the distal esophagus, which resolved after PPI-dose intensification. It is rare for adult PPI-REE patients to fully lose PPI response and be reclassified as EoE.
Chronic Stress-Induced Visceral Hyperalgesia: Evidence for Glucocorticoid Receptor (GR)-Mediated Down-Regulation of Claudin-1 Transcription in the Rat Colon Gen Zheng, Shuangsong Hong, John W. Wiley Introduction: We reported previously that chronic stress and corticosterone (CORT) treatment in healthy rats resulted in visceral hyperalgesia associated with down-regulation of colon epithelial tight junction protein levels and increased permeability to macromolecules. These changes were prevented by treatment with the GR antagonist RU486. The regulatory pathways that mediate chronic stress-induced changes in colon epithelial tight junction protein expression and function during stress are largely unknown. Objectives: We examined the hypothesis that chronic intermittent water avoidance (WA) stress-induced down-regulation of claudin-1 is mediated by GR binding to glucocorticoid response elements (GREs) at claudin-1 promoter regions. Methods: Male rats were subjected to WA stress 1h per day for 10 consecutive days. RU-486 (2 mg/kg s.c. daily, during the stress phase) was used to block GR. Healthy rats were treated with CORT (3 mg/kg s.c. daily) to mimic the elevation of CORT observed during WA stress. Rat colon segments were harvested for real-time PCR analysis for the tight junction proteins claudin-1, occludin, ZO-1 and GR. Biotin labeled claudin-1 promoter GRE elements were used for pull-down analysis in Caco2 cells. The Claudin-1 promoter transcription activity was measured by dual luciferase assay. Transcriptional binding of GR to claudin-1 promoter was analyzed by chromosome immunoprecipitation (ChIP). Results: Significant decreases in claudin-1 (46.6%±10.1%) and GR (29.6±7.9%) mRNA levels were detected in colon samples from the WA stress rats compared to controls which were prevented by treatment with RU486. This effect was reproduced by CORT treatment in healthy rats. Two GRE elements (-18 to -47 and -459 to -488 from transcription start site) at Claudin-1 promoter regions were identified and dexamethasone (1 μM) activation of GR increased GR binding to GREs at the claudin-1 promoter. A claudin-1 promoter truncation construct containing the first GRE (-18 to -47) displayed highest transcription activity in Caco2 cells. ChIP analysis revealed that GR binds to these regions, colon epithelia samples from stressed rat showed decreased GR binding to the claudin-1 promoter and that this decrease can be prevented by RU486. Conclusion: These data suggest that the GR receptor plays a pivotal role in regulation of claudin-1 transcription during chronic stress and represents a potential target for treatment of chronic stress-induced visceral hyperalgesia.
59 Immunohistochemical Evidence of Inflammation Is Similar in Patients With Eosinophilic Esophagitis and PPI-Responsive Esophageal Eosinophilia: A Prospective Cohort Study Evan S. Dellon, Shannon Covey, Olga Speck, Kimberly Woodward, Spencer Rusin, Jessica H. Gebhart, Xiaoxin L. Chen, John T. Woosley, Nicholas J. Shaheen
61 Interferon-Gamma Interplay With Serotonin Metabolism and Mucosal Permeability in Irritable Bowel Syndrome M. Raffaella Barbaro, Cesare Cremon, Annalisa Altimari, Michelangelo Fiorentino, Roberto De Giorgio, Vincenzo Stanghellini, Giovanni Barbara
Background: Proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE) and eosinophilic esophagitis (EoE) can be difficult to distinguish by clinical or endoscopic features. It is unknown whether staining for inflammatory markers in PPI-REE patients prior to a PPI trial has utility for discriminating EoE and PPI-REE. Aim: To determine whether major basic protein (MBP), eotaxin-3, and tryptase staining in the esophageal epithelium differentiates EoE cases from patients with PPI-REE prior to a PPI trial. Methods: This prospective study conducted at University of North Carolina from 2009-2012 enrolled consecutive adults undergoing outpatient EGD. Research protocol biopsies determined the maximum esophageal eosinophil count (eos/hpf; hpf=0.24mm2). Incident cases of EoE were diagnosed as per consensus guidelines (symptoms of esophageal dysfunction, ≥15 eos/hpf, no response to a twice daily 8 week PPI trial, and other causes excluded). PPI-REE was defined as a symptomatic and histologic response (<15 eos/hpf) to the PPI trial. Immunohistochemistry was performed for MBP, eotaxin-3, and tryptase on biopsies from confirmed EoE cases and on pre-PPI biopsies from PPI-REE patients. After masking, the maximum epithelial staining density (positive cells/mm2) was quantified for all three stains using image analysis software. Staining levels were compared between the EoE and PPI-REE groups, and receiver operator characteristic (ROC) curves were constructed. Results: A total of 50 EoE patients
BACKGROUND AND AIM : A variety of peripheral mechanisms may be involved in the pathophysiology of irritable bowel syndrome (IBS). These include alterations in serotonin metabolism, epithelial permeability, composition of microbiota and immune system. In vitro studies demonstrated that interferon-gamma (IFN-γ) enhanced paracellular permeability and decreased serotonin reuptake transporter (SERT) expression. In this study we assessed the potential role of IFN-γ in IBS pathophysiology. MATERIAL AND METHODS : We included a total of 10 healthy controls (HC) and 26 patients with Rome III IBS. In all cases, we obtained 6 mucosal biopsies from the descending colon. Paraffin-embedded colonic biopsies were used to evaluate IFN-γ mRNA expression. Total RNA was retrotranscribed into cDNA and analysed in real-time PCR assays. Enzyme-linked immunosorbent assays (ELISA) were used to evaluate IFN-γ levels both in colonic biopsy homogenates and into supernatants of cultured biopsies. Supernatants of cultured biopsies were used to treat Caco-2 cell line to evaluate their effect on SERT expression level by real-time RT-PCR assays. Supernatants
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AGA Abstracts
AGA Abstracts
(mean age 36; 62% male; 94% white; mean 120 eos/hpf) and the 23 PPI-REE patients (mean age 48; 87% male; 87% white; mean 65 eos/hpf) were included in this study. Staining levels for all three inflammatory markers were similar for both groups (see Figure). For MBP, EoE patients had a median of 951 cells/mm2 (IQR: 322-1849) and the PPI-REE patients had 987 (655-1917) (p=0.18). For eotaxin-3, the values were 155 (63-783) and 160 (53-334), respectively (p=0.33). For tryptase, the values were 249 (163-378) and 243 (163-280), respectively (p=0.28). The area under the ROC curves (AUC) for distinguishing EoE from PPI-REE were 0.60, 0.58, and 0.58, for MBP, eotaxin-3, and tryptase, respectively. The AUC for the combination of all three stains was 0.72. Conclusions: Patients with EoE demonstrate similar levels of MBP, eotaxin-3, and tryptase positive mast cells in the esophageal epithelium to PPI-REE patients at baseline prior to their PPI-trial. Therefore, staining for these markers did not differentiate EoE from PPI-REE. These data raise the question of whether EoE and PPI-REE share a common pathogenic mechanism. This research was supported by the CURED Foundation and the AGA-Castell Esophageal Research Award.
Introduction: At least one third of patients with clinical, endoscopic and histological findings suggestive of eosinophilic esophagitis (EoE) achieve clinicopathologic remission after proton pump inhibitor (PPI) therapy. This new condition is termed PPI-responsive esophageal eosinophilia (PPI-REE). The durability and long-term efficacy of PPI therapy for these patients is unknown. Methods: Observational study in a cohort of adult patients with PPI-REE, defined by baseline symptoms of esophageal dysfunction (dysphagia/food impaction) and esophageal eosinophilia (> 15 eos/HPF), both resolved (clinical remission and < 15 eos/ HPF) after a course of PPI therapy for at least 8 weeks. PPI dosage was defined as: quadruple (e.g. omeprazole 40 mg bid or its equivalent), double (omeprazole 40 mg/day) and single (omeprazole 20 mg/day). After initial PPI response, acid suppressive therapy was progressively tapered based on clinical symptoms and maintained at the lowest dose with the target endpoint of clinical remission. Follow-up endoscopy was performed at 12 months or longer on PPI maintenance dose with histologic examination of both the distal and proximal esophagus. Results: 40 PPI-REE patients have been included to date with a median followup time of 27 months (12-79). Baseline characteristics: 88% males, median age 39 yearsold (19-71), heartburn and/or regurgitation (49%), reflux esophagitis (14%), pH monitoring in 7 patients (4 normal/3 pathological). PPI dosage in the initial PPI trial for diagnosing PPI-REE was quadruple-dose in 18 patients and double-dose in 22 patients. Regarding the step-down process, 19 patients were maintained on double-dose PPI and 21 on single-dose PPI. Overall, 26 out of 40 (63%) maintained clinical and histologic (< 15 eos/HPF) remission during follow-up. Among the 14 relapsers, 8 occurred on double-dose and 6 on single-dose PPI. In 10/14 of the relapsers, esophageal eosinophilia recurred exclusively at the distal esophagus, but not at proximal esophagus. Intensification to quadruple-dose PPI was carried out in 8 out of these 10 distal relapsers, all of whom achieved clinical and histological remission. Conclusions: Sustained clinico-histological remission on low-dose maintenance PPI therapy was observed in 64% of adult PPI-REE patients. A majority of relapsers showed recurrent eosinophilic inflammation limited to the distal esophagus, which resolved after PPI-dose intensification. It is rare for adult PPI-REE patients to fully lose PPI response and be reclassified as EoE.
Chronic Stress-Induced Visceral Hyperalgesia: Evidence for Glucocorticoid Receptor (GR)-Mediated Down-Regulation of Claudin-1 Transcription in the Rat Colon Gen Zheng, Shuangsong Hong, John W. Wiley Introduction: We reported previously that chronic stress and corticosterone (CORT) treatment in healthy rats resulted in visceral hyperalgesia associated with down-regulation of colon epithelial tight junction protein levels and increased permeability to macromolecules. These changes were prevented by treatment with the GR antagonist RU486. The regulatory pathways that mediate chronic stress-induced changes in colon epithelial tight junction protein expression and function during stress are largely unknown. Objectives: We examined the hypothesis that chronic intermittent water avoidance (WA) stress-induced down-regulation of claudin-1 is mediated by GR binding to glucocorticoid response elements (GREs) at claudin-1 promoter regions. Methods: Male rats were subjected to WA stress 1h per day for 10 consecutive days. RU-486 (2 mg/kg s.c. daily, during the stress phase) was used to block GR. Healthy rats were treated with CORT (3 mg/kg s.c. daily) to mimic the elevation of CORT observed during WA stress. Rat colon segments were harvested for real-time PCR analysis for the tight junction proteins claudin-1, occludin, ZO-1 and GR. Biotin labeled claudin-1 promoter GRE elements were used for pull-down analysis in Caco2 cells. The Claudin-1 promoter transcription activity was measured by dual luciferase assay. Transcriptional binding of GR to claudin-1 promoter was analyzed by chromosome immunoprecipitation (ChIP). Results: Significant decreases in claudin-1 (46.6%±10.1%) and GR (29.6±7.9%) mRNA levels were detected in colon samples from the WA stress rats compared to controls which were prevented by treatment with RU486. This effect was reproduced by CORT treatment in healthy rats. Two GRE elements (-18 to -47 and -459 to -488 from transcription start site) at Claudin-1 promoter regions were identified and dexamethasone (1 μM) activation of GR increased GR binding to GREs at the claudin-1 promoter. A claudin-1 promoter truncation construct containing the first GRE (-18 to -47) displayed highest transcription activity in Caco2 cells. ChIP analysis revealed that GR binds to these regions, colon epithelia samples from stressed rat showed decreased GR binding to the claudin-1 promoter and that this decrease can be prevented by RU486. Conclusion: These data suggest that the GR receptor plays a pivotal role in regulation of claudin-1 transcription during chronic stress and represents a potential target for treatment of chronic stress-induced visceral hyperalgesia.
59 Immunohistochemical Evidence of Inflammation Is Similar in Patients With Eosinophilic Esophagitis and PPI-Responsive Esophageal Eosinophilia: A Prospective Cohort Study Evan S. Dellon, Shannon Covey, Olga Speck, Kimberly Woodward, Spencer Rusin, Jessica H. Gebhart, Xiaoxin L. Chen, John T. Woosley, Nicholas J. Shaheen
61 Interferon-Gamma Interplay With Serotonin Metabolism and Mucosal Permeability in Irritable Bowel Syndrome M. Raffaella Barbaro, Cesare Cremon, Annalisa Altimari, Michelangelo Fiorentino, Roberto De Giorgio, Vincenzo Stanghellini, Giovanni Barbara
Background: Proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE) and eosinophilic esophagitis (EoE) can be difficult to distinguish by clinical or endoscopic features. It is unknown whether staining for inflammatory markers in PPI-REE patients prior to a PPI trial has utility for discriminating EoE and PPI-REE. Aim: To determine whether major basic protein (MBP), eotaxin-3, and tryptase staining in the esophageal epithelium differentiates EoE cases from patients with PPI-REE prior to a PPI trial. Methods: This prospective study conducted at University of North Carolina from 2009-2012 enrolled consecutive adults undergoing outpatient EGD. Research protocol biopsies determined the maximum esophageal eosinophil count (eos/hpf; hpf=0.24mm2). Incident cases of EoE were diagnosed as per consensus guidelines (symptoms of esophageal dysfunction, ≥15 eos/hpf, no response to a twice daily 8 week PPI trial, and other causes excluded). PPI-REE was defined as a symptomatic and histologic response (<15 eos/hpf) to the PPI trial. Immunohistochemistry was performed for MBP, eotaxin-3, and tryptase on biopsies from confirmed EoE cases and on pre-PPI biopsies from PPI-REE patients. After masking, the maximum epithelial staining density (positive cells/mm2) was quantified for all three stains using image analysis software. Staining levels were compared between the EoE and PPI-REE groups, and receiver operator characteristic (ROC) curves were constructed. Results: A total of 50 EoE patients
BACKGROUND AND AIM : A variety of peripheral mechanisms may be involved in the pathophysiology of irritable bowel syndrome (IBS). These include alterations in serotonin metabolism, epithelial permeability, composition of microbiota and immune system. In vitro studies demonstrated that interferon-gamma (IFN-γ) enhanced paracellular permeability and decreased serotonin reuptake transporter (SERT) expression. In this study we assessed the potential role of IFN-γ in IBS pathophysiology. MATERIAL AND METHODS : We included a total of 10 healthy controls (HC) and 26 patients with Rome III IBS. In all cases, we obtained 6 mucosal biopsies from the descending colon. Paraffin-embedded colonic biopsies were used to evaluate IFN-γ mRNA expression. Total RNA was retrotranscribed into cDNA and analysed in real-time PCR assays. Enzyme-linked immunosorbent assays (ELISA) were used to evaluate IFN-γ levels both in colonic biopsy homogenates and into supernatants of cultured biopsies. Supernatants of cultured biopsies were used to treat Caco-2 cell line to evaluate their effect on SERT expression level by real-time RT-PCR assays. Supernatants
S-17
AGA Abstracts
AGA Abstracts
(mean age 36; 62% male; 94% white; mean 120 eos/hpf) and the 23 PPI-REE patients (mean age 48; 87% male; 87% white; mean 65 eos/hpf) were included in this study. Staining levels for all three inflammatory markers were similar for both groups (see Figure). For MBP, EoE patients had a median of 951 cells/mm2 (IQR: 322-1849) and the PPI-REE patients had 987 (655-1917) (p=0.18). For eotaxin-3, the values were 155 (63-783) and 160 (53-334), respectively (p=0.33). For tryptase, the values were 249 (163-378) and 243 (163-280), respectively (p=0.28). The area under the ROC curves (AUC) for distinguishing EoE from PPI-REE were 0.60, 0.58, and 0.58, for MBP, eotaxin-3, and tryptase, respectively. The AUC for the combination of all three stains was 0.72. Conclusions: Patients with EoE demonstrate similar levels of MBP, eotaxin-3, and tryptase positive mast cells in the esophageal epithelium to PPI-REE patients at baseline prior to their PPI-trial. Therefore, staining for these markers did not differentiate EoE from PPI-REE. These data raise the question of whether EoE and PPI-REE share a common pathogenic mechanism. This research was supported by the CURED Foundation and the AGA-Castell Esophageal Research Award.