- Email: [email protected]
S1979 Eosinophilic Esophagitis, Barrett Esophagus, and Dysplasia Is There a Relationship?
AGA Abstracts
surrogates of EE to maximize case identification. The clinical course of all patients was defined prospectively using a telephone questionnaire and medical records. Results: 3456 patient charts were reviewed : 82 patients with EE and 80 patients with idiopathic FI were identified. The incidence of EE increased significantly over the last 3 decades (see Fig 1). The prevalence of EE was 104.7 (87.5, 122.0)/100000 population as of 1/1/2007 in Olmsted County, MN. The clinical course of patients with EE was characterized by recurrent symptoms in 40% of EE and 19% of idiopathic FI patients, responding to medical and/or endoscopic treatment (see table). Recurrence rates were comparable in the EE and idiopathic FI cohorts. Conclusions: In this first large population based study from the US providing long term data,the prevalence and incidence of EE are higher than previously reported. The incidence of EE increased significantly over the last three decades indicating the presence of a yet unidentified etiology for EE in the environment. EE is a relapsing disease in a substantial proportion of patients. Recurrence in patients with EE
GER play a synergistic role in BE. Purpose: Evaluate the prevalence of BE in patients with EoE and compare to the prevalence of EoE in patients with BE. Methods: This study evaluated patients with BE undergoing endoscopic (EGD) surveillance. All consecutive patients seen during a 6 month period were reviewed. The inclusion criteria required BE of any length (visible glandular epithelium confirmed to be intestinal metaplasia).The length of BE and dysplasia or lack of it were noted. BE patients were using at least once daily proton pump inhibitor therapy and any patient with erosive esophagitis was excluded from the study. To search for eosinophilic infiltration biopsies were obtained from at least two sites above the visible BE: 3-4 cm and 7-8 cm. Histological findings were classified as: 0-5 eos/hpf (negative), 6-20 eos/hpf (indeterminate) or ≥ 21 eos/hpf (EoE). The microscopic field with the highest density of intraepithelial eosinophils was chosen for count (magnification x 400, field area 0.20mm2). Abnormal eosinophilic infiltration was defined as an eosinophil count of ≥6/ hpf. For comparison, the prevalence of BE (defined above) was investigated in a cohort of consecutive patients with EoE (≥ 21 eos/hpf) diagnosed in a 4 year period. Results: 110 patients with BE were identified and entered the study. Abnormal eosinophilc infiltration was observed in 8 (7.2 %): four ≥ 21 eos/hpf, four 6-20 eos/hpf (mean 11 eos, range 813). The mean BE length in this group was 3.5 cm (0.6-10 cm). Five had no dysplasia, two low grade dysplasia, and one high grade dysplasia. The EoE group comprised 91 patients. 15 (16.4%) had BE. Conclusions: BE coexisted in 16% of our patient population with EoE, while an abnormal eoinophilic infiltration was also observed in 7% of patients with BE undergoing surveillance. Current review did not suggest a relationship of EoE and the length of BE or the degree of dysplasia since the small number of cases preclude formal statistical analysis. The relationship between esophageal mucosal eosinophilc infiltration, EoE, GER and BE deserves further study.
Median follow-up in EE and FI cases with no recurrence:EE (n=49): 2.6 years ; FI (n=65): 4.1 years
S1980 Prevalence of Eosinophilic Esophagitis in An Adult Population Undergoing Upper Endoscopy: A Prospective Study Ganesh R. Veerappan, Joseph L. Perry, Timothy J. Duncan, Thomas P. Baker, Corinne Maydonovitch, Jason M. Lake, Roy K. Wong, Eric M. Osgard Introduction: Eosinophilic esophagitis (EE) is a condition characterized by eosinophilic infiltration of the esophagus. Specific symptoms, clinical history and endoscopic findings have been associated with EE in prior retrospective studies. The purpose of our study was to determine the prevalence of EE in all patients undergoing elective upper endoscopy and identify any specific symptomatic or endoscopic findings predictive of EE. Methods: 400 consecutive adults undergoing outpatient upper endoscopy were prospectively enrolled. Patients with known EE, esophageal varices, thrombocytopenia, or coagulopathy were excluded. Prior to endoscopy, patients completed a symptom questionnaire assessing the presence of dysphagia, heartburn, nocturnal heart burn, chest pain, regurgitation, nausea, and abdominal pain. All endoscopic findings were documented and biopsies were obtained from the upper and lower esophagus. A blinded gastrointestinal pathologist reviewed all specimens. EE positive (EE+) patients were those that had greater than 20 eosinophils per high power field. Results: 25/385 EE+ patients were identified (6.5%, 95% CI 4.3 to 9.4%). EE+ patients, compared to EE negative (EE-) patients, were more likely to be male (80.0% vs. 48.1%, respectively, p value =0.003), younger (46.8 +/- 16.8 vs. 52.6 +/- 15.2, respectively, p=0.019), have a history of asthma (32.0% vs. 10.8%, respectively, p=0.006) or food impactions (32.0% vs.8.9%, respectively, p=0.002). Dysphagia was more common in EE+ patients versus EE- patients (64.0% vs. 38.1%, respectively, p=0.018). All other symptoms were similar in both groups. Endoscopic findings including rings, furrows, plaques and strictures were more commonly noted in EE+ patients compared to EE- patients (all p<0.01). There was no difference in the amount of proton pump inhibitor use, esophagitis and gastroesophageal reflux symptoms reported between EE+ and EE- patients. 28% (7/25) of EE+ patients had no “classic” endoscopic findings and 36% (9/25) of EE+ patients presented with no dysphagia. Conclusion: This prospective study estimated the prevalence of EE (6.5%) in our referral population. EE+ patients were significantly younger and predominantly male. Histories of asthma or food impaction were significantly more common in EE+ patients. Dysphagia was the only symptom that significantly correlated with EE. Multiple rings, furrows, plaques and strictures were more commonly noted endoscopically in EE+ patients. EE is seen in 6.5% of all adult patients undergoing endoscopy for a variety of indications, however only a minority of EE+ patients present without any of the hallmark clinical or endoscopic findings of EE.
S1978 Long Term Response to Topical Corticosteroid (TCS) Therapy in a Cohort of Children with Eosinophilic Esophagitis (EE) Kenneth B. Quinto, Ranjan Dohil, John Bastian, Bryce Arii, Robert Newbury, Seema Aceves Background: EE is a disorder with no established maintenance therapy regimens. To evaluate long-term response to TCS therapy, we retrospectively analyzed a cohort of children with EE who had been on TCS therapy for a minimum of nine months. Methods: Clinical, esophagogastroduodenoscopy (EGD), and pathology data collected for 26 children diagnosed with EE from 2004 through 2007 who had at least three EGDs and were on continuous TCS therapy for at least nine months. TCS therapy consisted of either fluticasone propionate or oral viscous budesonide. Esophageal eosinophilia of <20 eosinophils per high-powered field (eos/hpf) at the first EGD following TCS therapy define initial responders, while ≥20 eos/hpf defined initial non-responders. Prolonged responders were defined as children with esophageal eosinophilia <20 eos/hpf following at least nine months of TCS while ≥20 eos/ hpf defined prolonged non-responders. Results: A total of 26 patients met inclusion criteria for this study. Seventeen out of twenty-six patients (65%), were initial responders to TCS therapy, and nine out of twenty-six patients (35%) were initial non-responders. 76% of the initial responders continued as prolonged responders and 33% of the initial non-responders had subsequent histologic disease resolution on prolonged TCS therapy. Of the initial responders, 24% had histologic EE recurrence on prolonged TCS; 67% of the initial nonresponders continued to be unresponsive to prolonged TCS therapy. Upon creation of a 2x2 contingency table using initial response as the independent variable, there was a significant statistical association between initial response and prolonged response to TCS therapy, p= 0.03. Conclusions: The majority of EE patients have histologic disease resolution upon treatment with TCS. Initial histologic response was significantly associated with prolonged response to TCS therapy. A subset of patients have histologic disease recurrence despite continued TCS therapy while subset of patients had a clinical response to prolonged TCS therapy despite a lack of initial histologic response. The clinical differences between these groups of patients merit further study.
S1981 Eosinophilic Esophagitis and Gastroesophageal Reflux: Independent or Interactive Relationship? Mary Kovalak, Kathryn A. Peterson, Kristen Thomas, Mae F. Go, Barbara Chadwick, Frederic Clayton, John C. Fang PURPOSE The relationship between eosinophilic esophagitis (EoE) and gastroesophageal reflux (GER) is not fully understood. Recent literature has suggested that the histologic finding of eosinophils in biopsies of the distal esophagus is, at least in part, related to pathologic reflux. However, the distribution of eosinophils in the esophageal epithelium is patchy. We suspect the histologic finding of increased eosinophils in the distal esophagus may be diagnostic of EoE and independent of acid reflux. AIMS 1) To evaluate the association of EoE and GER in a cohort of patients with dysphagia referred for upper endoscopy (EGD) and esophageal pH testing. 2) To determine specifically whether acid reflux enhances distal esophageal eosinophilia. METHODS A retrospective chart review was performed on a series of consecutive patients with EoE evaluated between 2003 and 2007. Patients included in the analysis had both proximal and distal esophageal biopsies obtained during initial EGD as well as 24-hour esophageal pH monitoring. Pathologic reflux was defined as abnormal 24-hour pH monitoring or endoscopic evidence of reflux (Los Angeles Grade B, C or D esophagitis). Additional patient characteristics included age, gender, and proton pump inhibitor (PPI) use. EoE was defined as >20 eosinophils per high power field in any of the distal and/or the proximal esophageal biopsies. RESULTS 46 EoE patients were included in the analysis. Patient age ranged from 18 to 73 years old (median 43). 32 of the 46 patients (70%) were men. 31 of 46 (67%) had pathologic reflux. There was no statistically significant
S1979 Eosinophilic Esophagitis, Barrett Esophagus, and Dysplasia Is There a Relationship? Sami R. Achem, Cristina Almansa, Kenneth R. DeVault, Murli Krishna, Herbert C. Wolfsen Introduction: The interaction between gastroesophageal reflux (GER) and eosinophilic esophagitis (EoE) is complex. Patients with GER have increased eosinophils in the esophageal epithelium. EoE may cause mucosal exudates and strictures but it is unknown whether long-term complications such as Barrett esophagus (BE) occur in EoE or vice-versa. We recently noted a number of patients with both EoE and BE. Hypothesis: Eosinophils and
AGA Abstracts
A-290
surrogates of EE to maximize case identification. The clinical course of all patients was defined prospectively using a telephone questionnaire and medical records. Results: 3456 patient charts were reviewed : 82 patients with EE and 80 patients with idiopathic FI were identified. The incidence of EE increased significantly over the last 3 decades (see Fig 1). The prevalence of EE was 104.7 (87.5, 122.0)/100000 population as of 1/1/2007 in Olmsted County, MN. The clinical course of patients with EE was characterized by recurrent symptoms in 40% of EE and 19% of idiopathic FI patients, responding to medical and/or endoscopic treatment (see table). Recurrence rates were comparable in the EE and idiopathic FI cohorts. Conclusions: In this first large population based study from the US providing long term data,the prevalence and incidence of EE are higher than previously reported. The incidence of EE increased significantly over the last three decades indicating the presence of a yet unidentified etiology for EE in the environment. EE is a relapsing disease in a substantial proportion of patients. Recurrence in patients with EE
GER play a synergistic role in BE. Purpose: Evaluate the prevalence of BE in patients with EoE and compare to the prevalence of EoE in patients with BE. Methods: This study evaluated patients with BE undergoing endoscopic (EGD) surveillance. All consecutive patients seen during a 6 month period were reviewed. The inclusion criteria required BE of any length (visible glandular epithelium confirmed to be intestinal metaplasia).The length of BE and dysplasia or lack of it were noted. BE patients were using at least once daily proton pump inhibitor therapy and any patient with erosive esophagitis was excluded from the study. To search for eosinophilic infiltration biopsies were obtained from at least two sites above the visible BE: 3-4 cm and 7-8 cm. Histological findings were classified as: 0-5 eos/hpf (negative), 6-20 eos/hpf (indeterminate) or ≥ 21 eos/hpf (EoE). The microscopic field with the highest density of intraepithelial eosinophils was chosen for count (magnification x 400, field area 0.20mm2). Abnormal eosinophilic infiltration was defined as an eosinophil count of ≥6/ hpf. For comparison, the prevalence of BE (defined above) was investigated in a cohort of consecutive patients with EoE (≥ 21 eos/hpf) diagnosed in a 4 year period. Results: 110 patients with BE were identified and entered the study. Abnormal eosinophilc infiltration was observed in 8 (7.2 %): four ≥ 21 eos/hpf, four 6-20 eos/hpf (mean 11 eos, range 813). The mean BE length in this group was 3.5 cm (0.6-10 cm). Five had no dysplasia, two low grade dysplasia, and one high grade dysplasia. The EoE group comprised 91 patients. 15 (16.4%) had BE. Conclusions: BE coexisted in 16% of our patient population with EoE, while an abnormal eoinophilic infiltration was also observed in 7% of patients with BE undergoing surveillance. Current review did not suggest a relationship of EoE and the length of BE or the degree of dysplasia since the small number of cases preclude formal statistical analysis. The relationship between esophageal mucosal eosinophilc infiltration, EoE, GER and BE deserves further study.
Median follow-up in EE and FI cases with no recurrence:EE (n=49): 2.6 years ; FI (n=65): 4.1 years
S1980 Prevalence of Eosinophilic Esophagitis in An Adult Population Undergoing Upper Endoscopy: A Prospective Study Ganesh R. Veerappan, Joseph L. Perry, Timothy J. Duncan, Thomas P. Baker, Corinne Maydonovitch, Jason M. Lake, Roy K. Wong, Eric M. Osgard Introduction: Eosinophilic esophagitis (EE) is a condition characterized by eosinophilic infiltration of the esophagus. Specific symptoms, clinical history and endoscopic findings have been associated with EE in prior retrospective studies. The purpose of our study was to determine the prevalence of EE in all patients undergoing elective upper endoscopy and identify any specific symptomatic or endoscopic findings predictive of EE. Methods: 400 consecutive adults undergoing outpatient upper endoscopy were prospectively enrolled. Patients with known EE, esophageal varices, thrombocytopenia, or coagulopathy were excluded. Prior to endoscopy, patients completed a symptom questionnaire assessing the presence of dysphagia, heartburn, nocturnal heart burn, chest pain, regurgitation, nausea, and abdominal pain. All endoscopic findings were documented and biopsies were obtained from the upper and lower esophagus. A blinded gastrointestinal pathologist reviewed all specimens. EE positive (EE+) patients were those that had greater than 20 eosinophils per high power field. Results: 25/385 EE+ patients were identified (6.5%, 95% CI 4.3 to 9.4%). EE+ patients, compared to EE negative (EE-) patients, were more likely to be male (80.0% vs. 48.1%, respectively, p value =0.003), younger (46.8 +/- 16.8 vs. 52.6 +/- 15.2, respectively, p=0.019), have a history of asthma (32.0% vs. 10.8%, respectively, p=0.006) or food impactions (32.0% vs.8.9%, respectively, p=0.002). Dysphagia was more common in EE+ patients versus EE- patients (64.0% vs. 38.1%, respectively, p=0.018). All other symptoms were similar in both groups. Endoscopic findings including rings, furrows, plaques and strictures were more commonly noted in EE+ patients compared to EE- patients (all p<0.01). There was no difference in the amount of proton pump inhibitor use, esophagitis and gastroesophageal reflux symptoms reported between EE+ and EE- patients. 28% (7/25) of EE+ patients had no “classic” endoscopic findings and 36% (9/25) of EE+ patients presented with no dysphagia. Conclusion: This prospective study estimated the prevalence of EE (6.5%) in our referral population. EE+ patients were significantly younger and predominantly male. Histories of asthma or food impaction were significantly more common in EE+ patients. Dysphagia was the only symptom that significantly correlated with EE. Multiple rings, furrows, plaques and strictures were more commonly noted endoscopically in EE+ patients. EE is seen in 6.5% of all adult patients undergoing endoscopy for a variety of indications, however only a minority of EE+ patients present without any of the hallmark clinical or endoscopic findings of EE.
S1978 Long Term Response to Topical Corticosteroid (TCS) Therapy in a Cohort of Children with Eosinophilic Esophagitis (EE) Kenneth B. Quinto, Ranjan Dohil, John Bastian, Bryce Arii, Robert Newbury, Seema Aceves Background: EE is a disorder with no established maintenance therapy regimens. To evaluate long-term response to TCS therapy, we retrospectively analyzed a cohort of children with EE who had been on TCS therapy for a minimum of nine months. Methods: Clinical, esophagogastroduodenoscopy (EGD), and pathology data collected for 26 children diagnosed with EE from 2004 through 2007 who had at least three EGDs and were on continuous TCS therapy for at least nine months. TCS therapy consisted of either fluticasone propionate or oral viscous budesonide. Esophageal eosinophilia of <20 eosinophils per high-powered field (eos/hpf) at the first EGD following TCS therapy define initial responders, while ≥20 eos/hpf defined initial non-responders. Prolonged responders were defined as children with esophageal eosinophilia <20 eos/hpf following at least nine months of TCS while ≥20 eos/ hpf defined prolonged non-responders. Results: A total of 26 patients met inclusion criteria for this study. Seventeen out of twenty-six patients (65%), were initial responders to TCS therapy, and nine out of twenty-six patients (35%) were initial non-responders. 76% of the initial responders continued as prolonged responders and 33% of the initial non-responders had subsequent histologic disease resolution on prolonged TCS therapy. Of the initial responders, 24% had histologic EE recurrence on prolonged TCS; 67% of the initial nonresponders continued to be unresponsive to prolonged TCS therapy. Upon creation of a 2x2 contingency table using initial response as the independent variable, there was a significant statistical association between initial response and prolonged response to TCS therapy, p= 0.03. Conclusions: The majority of EE patients have histologic disease resolution upon treatment with TCS. Initial histologic response was significantly associated with prolonged response to TCS therapy. A subset of patients have histologic disease recurrence despite continued TCS therapy while subset of patients had a clinical response to prolonged TCS therapy despite a lack of initial histologic response. The clinical differences between these groups of patients merit further study.
S1981 Eosinophilic Esophagitis and Gastroesophageal Reflux: Independent or Interactive Relationship? Mary Kovalak, Kathryn A. Peterson, Kristen Thomas, Mae F. Go, Barbara Chadwick, Frederic Clayton, John C. Fang PURPOSE The relationship between eosinophilic esophagitis (EoE) and gastroesophageal reflux (GER) is not fully understood. Recent literature has suggested that the histologic finding of eosinophils in biopsies of the distal esophagus is, at least in part, related to pathologic reflux. However, the distribution of eosinophils in the esophageal epithelium is patchy. We suspect the histologic finding of increased eosinophils in the distal esophagus may be diagnostic of EoE and independent of acid reflux. AIMS 1) To evaluate the association of EoE and GER in a cohort of patients with dysphagia referred for upper endoscopy (EGD) and esophageal pH testing. 2) To determine specifically whether acid reflux enhances distal esophageal eosinophilia. METHODS A retrospective chart review was performed on a series of consecutive patients with EoE evaluated between 2003 and 2007. Patients included in the analysis had both proximal and distal esophageal biopsies obtained during initial EGD as well as 24-hour esophageal pH monitoring. Pathologic reflux was defined as abnormal 24-hour pH monitoring or endoscopic evidence of reflux (Los Angeles Grade B, C or D esophagitis). Additional patient characteristics included age, gender, and proton pump inhibitor (PPI) use. EoE was defined as >20 eosinophils per high power field in any of the distal and/or the proximal esophageal biopsies. RESULTS 46 EoE patients were included in the analysis. Patient age ranged from 18 to 73 years old (median 43). 32 of the 46 patients (70%) were men. 31 of 46 (67%) had pathologic reflux. There was no statistically significant
S1979 Eosinophilic Esophagitis, Barrett Esophagus, and Dysplasia Is There a Relationship? Sami R. Achem, Cristina Almansa, Kenneth R. DeVault, Murli Krishna, Herbert C. Wolfsen Introduction: The interaction between gastroesophageal reflux (GER) and eosinophilic esophagitis (EoE) is complex. Patients with GER have increased eosinophils in the esophageal epithelium. EoE may cause mucosal exudates and strictures but it is unknown whether long-term complications such as Barrett esophagus (BE) occur in EoE or vice-versa. We recently noted a number of patients with both EoE and BE. Hypothesis: Eosinophils and
AGA Abstracts
A-290