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Association of Eosinophilic Esophagitis and Persistent Esophagitis in Barrett's Esophagus
AGA Abstracts
*p value calculated using Student's t-test for all parameters except clinical impression of EoE, for which Fisher's exact test was used Sa1158 Association of Eosinophilic Esophagitis and Persistent Esophagitis in Barrett's Esophagus Maria McIntire, Carissa A. Sanchez, David Cowan, Brian J. Reid, Patricia L. Blount, Robert D. Odze Background: Some patients with Barrett's esophagus (BE) show persistent esophagitis in squamous mucosa despite proton pump inhibitor therapy (PPI). In addition, some investigators have recently suggested that there is an association, and possibly an increased incidence, of idiopathic eosinophilic esophagitis (EOE) in patients with BE and gastrostroesophageal reflux disease. The aim of this study was to evaluate the clinical and pathologic features of BE patients with persistent esophagitis, and to determine the prevalence rate of EOE in this patient population. Design: Mucosal biopsies of squamous epithelium proximal to areas of BE were evaluated from 184 consecutive patients who are part of a long-term prospective surveillance program of high risk BE patients in Seattle, Washington. Biopsies were evaluated for the number [per high power field (HPF)] and location of eosinophils (eos) and the data was correlated with clinical, endoscopic, and pathologic features, such as length of BE, dysplasia occurrence, and aneuploidy, as measured by flow cytometry. Results: Overall, the mean number of eos per patient was 6.7 (range 0-48.7). 60 patients revealed persistent squamous esophagitis, characterized by biopsies with inflammatory features and ≥ 1 eos/ HPF, and 124 patients had no evidence of persistent esophagitis. Patients with persistent squamous esophagitis were significantly younger in age (63 years versus 68, p=0.003), but did not differ from patients without persistent squamous esophagitis for any other clinical, endoscopic, or pathologic variable, including the incidence of dysplasia or aneuploidy. Linear trend analysis showed a positive correlation between the mean number of eos per patient and length of BE in patients with persistent esophagitis. Only 5 patients fulfilled the pathologic criteria for EOE (>15 eos/HPF), but none of these patients showed eosinophilic microabscesses, or surface layering of eosinophils, typical of EOE, and none showed endoscopic evidence of EOE as well. Patients with >15 eos/HPF did not differ from the rest of the cohort with regard to any of the demographic, clinical, or pathologic features. Conclusions: In this high-risk BE cohort, 33% of patients showed persistent squamous esophagitis proximal to BE despite long term PPI therapy. These patients are younger in age and show longer lengths of BE, but the risk of dysplasia or aneuploidy was not influenced by persistent esophagitis. The incidence of EOE in this patient population was 0%. This study does not support the theory that BE is a risk factor for EOE.
Figure 1: ROC curve for MDQ-30 Scores Sa1157 Predictive Value of Histologic Features to Distinguish the Presence of Pathologic Esophageal Acid Exposure in Patients With Dense Esophageal Eosinophilic Infiltration Karthik Ravi, Thomas C. Smyrk, David A. Katzka, Jeffrey A. Alexander, Amy E. FoxxOrenstein, Dawn L. Francis Background: The presence of basal cell hyperplasia, spongiosis, and other histologic features have been suggested to be discriminatory between dense esophageal eosinophilia attributable to allergic eosinophilic esophagitis (EoE) opposed to that attributable to gastroesophageal reflux (GERD). However, well designed comparative studies are lacking. Aim: To assess the ability of histologic features to predict the presence of pathologic esophageal acid exposure in patients with esophageal eosinophilic infiltration. Methods: Twelve patients with ≥ 15 eos per HPF on esophageal biopsy who underwent 24 hour pH testing and failed either acid suppressing or steroid therapy given based on pH results were studied. Esophagogastroduodenoscopy (EGD) was performed and 6 mid and 6 distal esophageal biopsies was performed 6 weeks later. A histologic scoring system, illustrated in Table 1, was used by a single experienced, blinded pathologist (TCS) to assign a score to each patient and a clinical impression was made as to whether the findings were consistent with allergic EoE or GERD. The correlation between individual histologic features and GERD was assessed using student's t-test while that between the histologic score and GERD was assessed using Fisher's exact test. Results: Of the 12 patients, 6 had pathologic esophageal acid exposure (Table 2). The density of esophageal eosinophils was higher in patients with an abnormal pH study compared to those with a normal pH study. The histologic score was similar between patients with and without pathologic acid reflux. The clinical impression of EoE by the pathologist was not predictive of the presence or absence of pathologic acid reflux. Conclusion: This study suggests that a histologic scoring system does not predict the etiology of dense esophageal eosinophilic infiltration as determined by the presence or absence of abnormal acid exposure. TABLE 1: Histologic Scoring System
Sa1159 Effect of Guidelines for Eosinophilic Esophagitis on Variability of Diagnostic Criteria in the Medical Literature Sarah L. Sperry, Nicholas J. Shaheen, Evan S. Dellon Background: Consensus guidelines for diagnosis of eosinophilic esophagitis (EoE) have recently been published. Whether these guidelines have standardized diagnostic criteria for EoE is unknown. Aim: To determine if the EoE guidelines had an impact on the diagnostic criteria reported in the EoE literature, and whether the previously observed variability in diagnostic criteria has become more uniform. Methods: Two investigators independently conducted a MEDLINE search from January 1, 2007 through June 30, 2010 for all publications studying EoE in human subjects, and also searched the proceedings of the 20072010 American College of Gastroenterology and American Gastroenterological Association meetings, using a pre-defined search strategy. Data were extracted from all relevant publications. Results: Of the 799 publications identified in the initial search, 149 original reports, 99 reviews and 165 abstracts were included. Thirty two original reports (21%) used diagnostic criteria consistent with the consensus guidelines. There was a significant increase when comparing original articles published after the release of the guidelines with those published earlier (31% vs. 6%, p< 0.001, see Figure). A similar trend was noted for the reviews and abstracts, and by 2010 the majority of the reviews were using the consensus guidelines. The proportion of original articles using 15 eos/hpf as a histologic cut-point increased significantly (p=0.001). However, there was still substantial variability in biopsy protocols and eosinophil count methodology. Of the original articles, 59% did not state a specific eosinophil counting protocol. Of those that did report a method, the peak eosinophil count was most commonly used. The majority of original articles also did not report microscope high-power field (hpf) area. In the 35 (23%) original articles that did report the hpf size, there was a 6-fold difference, ranging from 0.12 mm2 to 0.625 mm2. Using the eosinophil cut-points and hpf sizes from the 35 original reports, the eosinophil density ranged from 24 eos/mm2 to 200 eos/mm2, an 8.3-fold difference. Conclusions: The proportion of original reports with diagnostic criteria consistent with the consensus guidelines has increased significantly. However, the majority of articles were not consistent with the guidelines, and biopsy and eosinophil count protocols continue to demonstrate significant variability. Standardization of biopsy and eosinophil count protocols is needed.
TABLE 2: Histologic Score and Clinical Impression
AGA Abstracts
S-240
*p value calculated using Student's t-test for all parameters except clinical impression of EoE, for which Fisher's exact test was used Sa1158 Association of Eosinophilic Esophagitis and Persistent Esophagitis in Barrett's Esophagus Maria McIntire, Carissa A. Sanchez, David Cowan, Brian J. Reid, Patricia L. Blount, Robert D. Odze Background: Some patients with Barrett's esophagus (BE) show persistent esophagitis in squamous mucosa despite proton pump inhibitor therapy (PPI). In addition, some investigators have recently suggested that there is an association, and possibly an increased incidence, of idiopathic eosinophilic esophagitis (EOE) in patients with BE and gastrostroesophageal reflux disease. The aim of this study was to evaluate the clinical and pathologic features of BE patients with persistent esophagitis, and to determine the prevalence rate of EOE in this patient population. Design: Mucosal biopsies of squamous epithelium proximal to areas of BE were evaluated from 184 consecutive patients who are part of a long-term prospective surveillance program of high risk BE patients in Seattle, Washington. Biopsies were evaluated for the number [per high power field (HPF)] and location of eosinophils (eos) and the data was correlated with clinical, endoscopic, and pathologic features, such as length of BE, dysplasia occurrence, and aneuploidy, as measured by flow cytometry. Results: Overall, the mean number of eos per patient was 6.7 (range 0-48.7). 60 patients revealed persistent squamous esophagitis, characterized by biopsies with inflammatory features and ≥ 1 eos/ HPF, and 124 patients had no evidence of persistent esophagitis. Patients with persistent squamous esophagitis were significantly younger in age (63 years versus 68, p=0.003), but did not differ from patients without persistent squamous esophagitis for any other clinical, endoscopic, or pathologic variable, including the incidence of dysplasia or aneuploidy. Linear trend analysis showed a positive correlation between the mean number of eos per patient and length of BE in patients with persistent esophagitis. Only 5 patients fulfilled the pathologic criteria for EOE (>15 eos/HPF), but none of these patients showed eosinophilic microabscesses, or surface layering of eosinophils, typical of EOE, and none showed endoscopic evidence of EOE as well. Patients with >15 eos/HPF did not differ from the rest of the cohort with regard to any of the demographic, clinical, or pathologic features. Conclusions: In this high-risk BE cohort, 33% of patients showed persistent squamous esophagitis proximal to BE despite long term PPI therapy. These patients are younger in age and show longer lengths of BE, but the risk of dysplasia or aneuploidy was not influenced by persistent esophagitis. The incidence of EOE in this patient population was 0%. This study does not support the theory that BE is a risk factor for EOE.
Figure 1: ROC curve for MDQ-30 Scores Sa1157 Predictive Value of Histologic Features to Distinguish the Presence of Pathologic Esophageal Acid Exposure in Patients With Dense Esophageal Eosinophilic Infiltration Karthik Ravi, Thomas C. Smyrk, David A. Katzka, Jeffrey A. Alexander, Amy E. FoxxOrenstein, Dawn L. Francis Background: The presence of basal cell hyperplasia, spongiosis, and other histologic features have been suggested to be discriminatory between dense esophageal eosinophilia attributable to allergic eosinophilic esophagitis (EoE) opposed to that attributable to gastroesophageal reflux (GERD). However, well designed comparative studies are lacking. Aim: To assess the ability of histologic features to predict the presence of pathologic esophageal acid exposure in patients with esophageal eosinophilic infiltration. Methods: Twelve patients with ≥ 15 eos per HPF on esophageal biopsy who underwent 24 hour pH testing and failed either acid suppressing or steroid therapy given based on pH results were studied. Esophagogastroduodenoscopy (EGD) was performed and 6 mid and 6 distal esophageal biopsies was performed 6 weeks later. A histologic scoring system, illustrated in Table 1, was used by a single experienced, blinded pathologist (TCS) to assign a score to each patient and a clinical impression was made as to whether the findings were consistent with allergic EoE or GERD. The correlation between individual histologic features and GERD was assessed using student's t-test while that between the histologic score and GERD was assessed using Fisher's exact test. Results: Of the 12 patients, 6 had pathologic esophageal acid exposure (Table 2). The density of esophageal eosinophils was higher in patients with an abnormal pH study compared to those with a normal pH study. The histologic score was similar between patients with and without pathologic acid reflux. The clinical impression of EoE by the pathologist was not predictive of the presence or absence of pathologic acid reflux. Conclusion: This study suggests that a histologic scoring system does not predict the etiology of dense esophageal eosinophilic infiltration as determined by the presence or absence of abnormal acid exposure. TABLE 1: Histologic Scoring System
Sa1159 Effect of Guidelines for Eosinophilic Esophagitis on Variability of Diagnostic Criteria in the Medical Literature Sarah L. Sperry, Nicholas J. Shaheen, Evan S. Dellon Background: Consensus guidelines for diagnosis of eosinophilic esophagitis (EoE) have recently been published. Whether these guidelines have standardized diagnostic criteria for EoE is unknown. Aim: To determine if the EoE guidelines had an impact on the diagnostic criteria reported in the EoE literature, and whether the previously observed variability in diagnostic criteria has become more uniform. Methods: Two investigators independently conducted a MEDLINE search from January 1, 2007 through June 30, 2010 for all publications studying EoE in human subjects, and also searched the proceedings of the 20072010 American College of Gastroenterology and American Gastroenterological Association meetings, using a pre-defined search strategy. Data were extracted from all relevant publications. Results: Of the 799 publications identified in the initial search, 149 original reports, 99 reviews and 165 abstracts were included. Thirty two original reports (21%) used diagnostic criteria consistent with the consensus guidelines. There was a significant increase when comparing original articles published after the release of the guidelines with those published earlier (31% vs. 6%, p< 0.001, see Figure). A similar trend was noted for the reviews and abstracts, and by 2010 the majority of the reviews were using the consensus guidelines. The proportion of original articles using 15 eos/hpf as a histologic cut-point increased significantly (p=0.001). However, there was still substantial variability in biopsy protocols and eosinophil count methodology. Of the original articles, 59% did not state a specific eosinophil counting protocol. Of those that did report a method, the peak eosinophil count was most commonly used. The majority of original articles also did not report microscope high-power field (hpf) area. In the 35 (23%) original articles that did report the hpf size, there was a 6-fold difference, ranging from 0.12 mm2 to 0.625 mm2. Using the eosinophil cut-points and hpf sizes from the 35 original reports, the eosinophil density ranged from 24 eos/mm2 to 200 eos/mm2, an 8.3-fold difference. Conclusions: The proportion of original reports with diagnostic criteria consistent with the consensus guidelines has increased significantly. However, the majority of articles were not consistent with the guidelines, and biopsy and eosinophil count protocols continue to demonstrate significant variability. Standardization of biopsy and eosinophil count protocols is needed.
TABLE 2: Histologic Score and Clinical Impression
AGA Abstracts
S-240