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Mo1830 Optimized Four-Food Elimination Diet (Dairy, Gluten, Egg and Legumes) Followed by Rescue Six-Food Elimination Diet for Adult Eosinophilic Esophagitis: A Spanish Multicenter Study
Mo1832 What Cut-Point Should Be Used to Define a Histologic Response to Topical Steroid Use in Eosinophilic Esophagitis? A Data-Driven Approach Using Symptoms and Endoscopic Findings W. Asher Wolf, Daniel J. Green, Julia T. Hughes, Cary C. Cotton, John T. Woosley, Nicholas J. Shaheen, Evan S. Dellon Background: There is controversy about which histologic cut-point should be used to determine response to topical steroid treatment in eosinophilic esophagitis (EoE). Histologic end-points vary substantial between different studies of EoE. Aim: To determine potential histologic cut-points for treatment response in EoE, and delineate the clinical implications (associated symptom and endoscopic response) of these cut-points. Methods: We performed a retrospective cohort study of the UNC EoE Clinicopathologic database from 2001-2013. Subjects with an incident diagnosis of EoE who met consensus guidelines and did not respond to a PPI-trial were included. We identified patients who were treated with topical steroids (fluticasone 880-1760mcg/day or budesonide 1-2mg/day) for a 2 month course and had histologic follow-up data. Data were extracted from medical records. We examined the distribution of eosinophil counts (eos/hpf; hpf=0.24mm2) and the percent change from baseline after treatment. We assessed symptom response (patient-reported global improvement) and endoscopic response (endoscopist-reported improvement). Logistic regression was performed to determine predicted odds of symptom and endoscopic response based on post-treatment eosinophil counts. Results: A total of 189 EoE patients met inclusion criteria (mean age 27 yrs; 71% male; 83% white). The mean and median post-treatment eosinophil counts were 27 and 4 eos/hpf, and the mean and median percent decrease from baseline were 51 and 92 (Figure 1). Histologic response cut-points of <15, <10, <5, ≤1, and 0 were associated with symptom response rates of 87%, 87%, 86%, 92%, and 94%, respectively, and endoscopic response rates of 92%, 93%, 92%, 93%, and 93%, respectively. On regression analysis, a 10 point drop in eosinophil count was associated with a 20% increase in the odds of symptom improvement (OR 1.20, 95% CI 1.09-1.32) and a 37% increase in the odds of an endoscopic improvement (OR 1.37, 1.22-1.53). For a 50% decrease in eosinophil count, the OR for symptom improvement was 1.56 (1.23-1.99) and for endoscopic improvement was 1.96 (1.49-2.58). Predicted probabilities of symptomatic and endoscopic response for varying levels of eosinophil counts are shown in Figure 2. For a response level of <5 eos/hpf, the predicted probabilities of symptom and endoscopic response were 0.84 and 0.86, respectively. Conclusions: Lower eosinophil counts after topical steroid therapy for EoE are associated with an increased likelihood of symptomatic and endoscopic response. Because of the high degree of symptom improvement associated with counts <5 eos/hpf, we recommend this threshold to identify adequate histologic response to steroid therapy. These data may be useful for researchers and regulatory agencies when determining appropriate end-points for EoE treatment.
Mo1830 Optimized Four-Food Elimination Diet (Dairy, Gluten, Egg and Legumes) Followed by Rescue Six-Food Elimination Diet for Adult Eosinophilic Esophagitis: A Spanish Multicenter Study Javier Molina-Infante, Angel Arias-Arias, Joaquín Rodríguez-Sánchez, Jesus Barrio, Marta Sanchez-Cazalilla, Alfredo J. Lucendo Introduction: Eosinophilic esophagitis (EoE) is a chronic immune-mediated esophageal disorder triggered by food antigens. A six-food elimination diet (SFED) achieves histological remission in around 75% of adult EoE patients. The most common food triggers identified have been milk, wheat, egg and soy and/or legumes, with a minor role for nuts and fish/ seafood. Less restrictive dietary interventions might improve patient acceptance of dietary limitations and reduce the number of endoscopies and overall time to complete the food reintroduction process. Methods: Prospective multicenter study in consecutive adult patients with EoE, defined by consensus guidelines. An optimized four-food elimination diet (FFED) (dairy products, gluten, egg and legumes, including soy and peanut) was designed to avoid to the maximum cross-reactivity between food allergens. All patients underwent histological re-evaluation after 6 weeks on FFED. Response to FFED was defined by clinical and histological (< 15 eos/HPF) remission. Responders underwent reintroduction of each food over 6 weeks followed by endoscopy and esophageal biopsies. Non-responders were offered rescue SFED. Results: 43 consecutive adult EoE patients (60% male, median age 36 yrs-old, 100% dysphagia or food impaction) were reassessed after FFED. 27 patients (62%) achieved clinical remission and >50% reduction in their peak eosinophil density, whereas clinical and histological remission was accomplished in 22 patients (51%). To date, 10 patients have finished the food reintroduction process (5 patients with a single food trigger, 5 patients with two food triggers). The most common causative food allergens have been dairy (58%), egg (50%), gluten (26%) and legumes (20%). Among 21 non-responders to FFED, 12 patients underwent rescue SFED, of whom 6 (50%) achieved clinico-pathological remission. Conclusion: Clinico-pathologic remission was accomplished in 50% of EoE patients following a FFED and in 50% of FFED non-responders undergoing rescue SFED. FFED is a cheaper, faster and less inconvenient dietary intervention, effective in 2 out of every 3 adult EoE patients responder to SFED. Mo1831 Trans-Nasal Gastroscopy Without Sedation for Eosinophilic Esophagitis; Safe, Effective and the Ideal Method of Assessment? Hamish Philpott, Peter R. Gibson, Sanjay Nandurkar, Simon G. Royce Introduction Trans-nasal gastroscopy without sedation (TGWS) has been shown to be a safe and well tolerated technique in unselected patients presenting for upper gastrointestinal endoscopy. Purpose To assess the efficacy, safety and tolerability of TGWS in patients with eosinophilic esophagitis (EoE) Methods Adult patients with known EoE were prospectively enrolled at the time of outpatient appointments. Participants were offered the choice of TGWS or standard trans-oral gastroscopy with propofol sedation. Exclusion criteria included previous ear nose and throat procedures, nasal or facial fractures, haematological disorders including coagulopathy and thrombocytopenia. Duration of the procedure was recorded. Outcome measures were; successful nasal intubation, successful esophageal biopsy, histological quality and depth of sampling and the need for conversion to trans-oral gastroscopy. Adverse events (desaturation, epistaxis, vomiting, odynophagia) were noted. The patient satisfaction according to a Likert scale was recorded in the two hours post-operative and at
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AGA Abstracts
AGA Abstracts
face - to face interview 2 weeks after the procedure. Results 32 trans-nasal gastroscopies were performed by expert gastroenterologists (Pentax EG1870k video endoscope, lignocaine 10% spray to nose and oropharynx) on 16 patients with EoE (Feb 2013 - Nov 2013).75% (12) were male with a mean age of 32 years (range 19-54 years) All patients had previously undergone trans-oral gastroscopy. Nasal intubation and esophageal biopsy were successful in 14 out of 16 patients (30 of 32 procedures).Of the 14 patients who had a successful procedure, 5 had more than one TGWS, and all subsequent TGWS were successful in this subgroup. Nasal intubation was unsuccessful due to inflamed nasal turbinates (1 patient) and esophageal intubation was unsuccessful (1 patient) due to a vigorous gag reflex. A subsequent TGWS was not attempted for these patients. The histological sampling was adequate in all cases (epithelial tissue in 100%, lamina propria in 81%, muscularis in 25%). 1 patient developed epistaxis (minor, resolved spontaneously). Of the 14 patients who had a successful intubation, 10 (71%) preferred trans-nasal gastroscopy. Of the 26 recorded Likert discomfort scores, 12 (46%) recorded moderate discomfort with the procedure. Conclusion This study shows for the first time that TGWS is safe, well tolerated and an effective procedure for patients with EoE. TGWS should be considered as the first line endoscopic technique in monitoring treatment response in this patient group.
Mo1830 Optimized Four-Food Elimination Diet (Dairy, Gluten, Egg and Legumes) Followed by Rescue Six-Food Elimination Diet for Adult Eosinophilic Esophagitis: A Spanish Multicenter Study Javier Molina-Infante, Angel Arias-Arias, Joaquín Rodríguez-Sánchez, Jesus Barrio, Marta Sanchez-Cazalilla, Alfredo J. Lucendo Introduction: Eosinophilic esophagitis (EoE) is a chronic immune-mediated esophageal disorder triggered by food antigens. A six-food elimination diet (SFED) achieves histological remission in around 75% of adult EoE patients. The most common food triggers identified have been milk, wheat, egg and soy and/or legumes, with a minor role for nuts and fish/ seafood. Less restrictive dietary interventions might improve patient acceptance of dietary limitations and reduce the number of endoscopies and overall time to complete the food reintroduction process. Methods: Prospective multicenter study in consecutive adult patients with EoE, defined by consensus guidelines. An optimized four-food elimination diet (FFED) (dairy products, gluten, egg and legumes, including soy and peanut) was designed to avoid to the maximum cross-reactivity between food allergens. All patients underwent histological re-evaluation after 6 weeks on FFED. Response to FFED was defined by clinical and histological (< 15 eos/HPF) remission. Responders underwent reintroduction of each food over 6 weeks followed by endoscopy and esophageal biopsies. Non-responders were offered rescue SFED. Results: 43 consecutive adult EoE patients (60% male, median age 36 yrs-old, 100% dysphagia or food impaction) were reassessed after FFED. 27 patients (62%) achieved clinical remission and >50% reduction in their peak eosinophil density, whereas clinical and histological remission was accomplished in 22 patients (51%). To date, 10 patients have finished the food reintroduction process (5 patients with a single food trigger, 5 patients with two food triggers). The most common causative food allergens have been dairy (58%), egg (50%), gluten (26%) and legumes (20%). Among 21 non-responders to FFED, 12 patients underwent rescue SFED, of whom 6 (50%) achieved clinico-pathological remission. Conclusion: Clinico-pathologic remission was accomplished in 50% of EoE patients following a FFED and in 50% of FFED non-responders undergoing rescue SFED. FFED is a cheaper, faster and less inconvenient dietary intervention, effective in 2 out of every 3 adult EoE patients responder to SFED. Mo1831 Trans-Nasal Gastroscopy Without Sedation for Eosinophilic Esophagitis; Safe, Effective and the Ideal Method of Assessment? Hamish Philpott, Peter R. Gibson, Sanjay Nandurkar, Simon G. Royce Introduction Trans-nasal gastroscopy without sedation (TGWS) has been shown to be a safe and well tolerated technique in unselected patients presenting for upper gastrointestinal endoscopy. Purpose To assess the efficacy, safety and tolerability of TGWS in patients with eosinophilic esophagitis (EoE) Methods Adult patients with known EoE were prospectively enrolled at the time of outpatient appointments. Participants were offered the choice of TGWS or standard trans-oral gastroscopy with propofol sedation. Exclusion criteria included previous ear nose and throat procedures, nasal or facial fractures, haematological disorders including coagulopathy and thrombocytopenia. Duration of the procedure was recorded. Outcome measures were; successful nasal intubation, successful esophageal biopsy, histological quality and depth of sampling and the need for conversion to trans-oral gastroscopy. Adverse events (desaturation, epistaxis, vomiting, odynophagia) were noted. The patient satisfaction according to a Likert scale was recorded in the two hours post-operative and at
S-665
AGA Abstracts
AGA Abstracts
face - to face interview 2 weeks after the procedure. Results 32 trans-nasal gastroscopies were performed by expert gastroenterologists (Pentax EG1870k video endoscope, lignocaine 10% spray to nose and oropharynx) on 16 patients with EoE (Feb 2013 - Nov 2013).75% (12) were male with a mean age of 32 years (range 19-54 years) All patients had previously undergone trans-oral gastroscopy. Nasal intubation and esophageal biopsy were successful in 14 out of 16 patients (30 of 32 procedures).Of the 14 patients who had a successful procedure, 5 had more than one TGWS, and all subsequent TGWS were successful in this subgroup. Nasal intubation was unsuccessful due to inflamed nasal turbinates (1 patient) and esophageal intubation was unsuccessful (1 patient) due to a vigorous gag reflex. A subsequent TGWS was not attempted for these patients. The histological sampling was adequate in all cases (epithelial tissue in 100%, lamina propria in 81%, muscularis in 25%). 1 patient developed epistaxis (minor, resolved spontaneously). Of the 14 patients who had a successful intubation, 10 (71%) preferred trans-nasal gastroscopy. Of the 26 recorded Likert discomfort scores, 12 (46%) recorded moderate discomfort with the procedure. Conclusion This study shows for the first time that TGWS is safe, well tolerated and an effective procedure for patients with EoE. TGWS should be considered as the first line endoscopic technique in monitoring treatment response in this patient group.