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Tu1114 Familial Eosinophilic Esophagitis (EoE) Uncovers a New EoE-Like Syndrome Without Tissue Eosinophilia
identified in four EoE-families totally five members with an EoE-like syndrome, presenting with typical symptoms of EoE but without tissue eosinophilia. The purpose of this study was to investigate this intriguing syndrome of "EoE without eosinophilia", in order to improve the understanding of this inflammatory condition. Methods: The five patients suffering from EoE-like syndrome were evaluated by laboratory analyses, endoscopy, histologic and quantitative immuno-histologic examinations and genome-wide association analysis. In addition, we searched in all 46 members of these EoE-families for EoE-associated molecular abnormalities. Results: Using immunohistochemistry we detected in the esophagus of patients with EoE-like syndrome a chronic, Th2 type inflammation, but definitely a lack of eosinophils. Some gene known to be dysregulated in conventional EoE patients were found dysregulated in EoE-like syndrome. In addition, we found the EoE-risk allele TSLP rs3806932 in their genome. First generation offspring of EoE-like syndrome patients had on average a 40% risk of being affected by conventional EoE. Conclusions: These five members of EoE families suffering from "EoE without eosinophilia" do formally not fulfill the diagnostic criteria of EoE. However, clinical manifestation, symptom-response to corticosteroid-treatment, the finding of a Th2 type inflammation and the bequeath of conventional EoE to their offspring suggests a uniform underlying pathogenesis. Conventional EoE with the predominant eosinophilia might therefore be only one phenotype of this dysphagia syndrome and the role of the eosinophils must be reconsidered.
Tu1112 Global Health Curriculum in Gastroenterology Fellowship: A National Survey Pichamol Jirapinyo, Ying P. Tabak, Rachel S. Hunt, Deborah D. Proctor, Frederick L. Makrauer Background: Interest in global health during postgraduate training is increasing across disciplines. Attitudes and curricular needs in gastroenterology appear supportive based on a recent pilot survey. Aim: To assess the current status and opinions on global health training during GI fellowship Methods: Design: A nationwide survey study. Setting: The questionnaire was circulated to all US GI fellowship programs from October to November 2014 with the assistance of the American Gastroenterological Association (AGA). Participants: Gastroenterology Program Directors and Fellows from programs accredited by the ACGME. Results: There were 126 respondents including 47 Program Directors and 77 Fellows from 55 programs (36% of all ACGME-accredited programs). Of these respondents, 60% had prior experience in global health. Only 17% reported that their program currently offered global health activities with an international elective (54%), didactics (37%) and research activities (30%) being the most common approaches. Relevant global health topics that were part of standard curricula included viral hepatitis other than hepatitis C (90%), GI complications of HIV (82%) and GI complications of TB (64%). Fellows reported having adequate experience managing cholangiocarcinoma (46%), hepatitis B (40%) and intrahepatic duct stones (37%) during fellowship. Most had little to no experience managing TB mesenteritis (3%), hepatitis E (5%), hepatitis D (7%), epidemic infectious enteritis (7%) and parasitic disease (7%). Most fellows reported that they would participate in an elective in an underserved area locally (80%) or a 4-week global health elective abroad (70%). Preferred training methods for global health education were working in an underserved community locally (77%), attending lectures on global health (77%) and caring for immigrants at a refugee clinic (76%). 43% of fellows planned on working or volunteering abroad after fellowship. The majority of both faculty and fellows believed that global health training would strengthen trainees' cultural competency (86%), awareness of socioeconomic factors (85%) and medical knowledge (85%). Barriers to establishing global health curriculum included funding (94%), scheduling (88%) and lack of standardized learning objectives (78%). Lack of interest at the institution level was not a concern. Fellows (49%) felt more strongly than faculty (29%, p= 0.002) that global health training should be included in the standard fellowship curriculum. Conclusion: Program directors and trainees recognize the importance of global health training. However, only 17% of these responding programs currently offer clinical or other educational opportunities. Global health curriculum will enhance gastroenterology training.
Tu1115 Prevalence of Eosinophilic Esophagitis (EoE) in Non Selected Adult Patients: A Systematic Review Diego Garcia-Compean, Jose A Gonzalez, Erick J. Barrera Villarreal, Hector J. Maldonado Background: The diagnosis of EoE requires, according to consensus recommendation (1), the presence of esophageal symptoms and esophageal eosinophilic infiltration (EEI) showing non response to PPI treatment . The reported prevalence of EoE in non selected adult individuals is wide (0.01 to 7.6%). This ample range may be due to different factors such as study design, clinical characteristics of population, etc. Aims: We performed a systematic review of published literature in order to estimate the prevalence of EoE in non selected adults and to identify factors which may be involved in variation of prevalence. Material and Methods: We conducted systematic literature searches in PubMed, MedLine and Ovid from January 2000 to august 2014. Only written in English publications, with non selected adult patients describing prevalence rates or sufficient data for calculation were included. Careful analysis of each one of the studies was done in order to determine: Type of methodological design, source of cases, clinical and demographic characteristics of patients including atopia history, endoscopic findings, and protocol of esophageal and gastric endoscopic biopsy. Results: Forty five studies were detected, only 12 fulfilled the criteria. Five were prospective and 7 retrospective. Four were hospital setting, one was population-based sampling and 7 were population- based center. Sample size varied from 122 to 233,649 individuals. Age and gender of patients were described in only 7 studies. Clinical and endoscopic characteristics of patients as well as esophageal biopsy protocol were described in all prospective and none retrospective ones. Gastric biopsy was performed in only 3 prospective studies. Definition of EEI (> 15 eosinophils / HPF) was adequate in all studies, nevertheless the use of PPI and type of response was documented in only 4 studies. Therefore prevalence of EoE could be determined only in these studies. It was 0.69 in a retrospective study and 1.2, 1.9 and 6.5% in prospective ones. Conclusions: This systematic review showed that most of studies (67%) describing EoE prevalence have based the diagnosis exclusively on EEI. It is currently known that about 30 to 40% of patients with EEI may have EoE, therefore prevalence rates in these publications may be overestimated. Influence of risk factors could not be assessed due to inhomogenous documentation in these publications. 1.- Furuta GT et al. Gastroenterology. 2007 ;133:1342-63.
Tu1113 Endoscopic and Histologic Remission Correlation With Biomarkers in UC Patients Treated With Adalimumab Ignacio Fernández-Blanco, Carlos Taxonera, Carlos Cara, Guillermo Fernandez-Diaz
Tu1116
Background: Mucosal healing, based on endoscopic and histological analysis, constitutes an endpoint of therapies for patients with ulcerative colitis (UC). We investigated if both endoscopic and histological evaluation correlate with biochemical markers of mucosal inflammation. Methods: We performed a prospective observational study of 34 patients receiving adalimumab (ADA) treatment for moderate-severe UC. Surveillance colonoscopy at week 8 and 52 were performed and clinical biomarkers C reactive protein (CRP) and fecal calprotectin (f-CAL) were measured at the same time. Endoscopic remission was defined as a Mayo subendoscopic score % 1 and histologic remission when Geboes score was <3.1. Statistical significance was calculated using the U-Mann Whitney test. Results: Both biomarkers were elevated in patients who did not reach endoscopic or histologic mucosal healing. In presence of endoscopic remission in the induction phase to week 8, these differences did not reach statistical significance (p=0.38 and 0.27), but they did at final follow-up after maintenance phase of treatment at week 52 (p=0.01 and 0.003) respectively. In patients with histological remission, we observed a lack of significance and statistical correlation between plasmatic CRP level and the absence of histological lesions in the induction phase, although close to significance (p=0.09), while f-Cal showed a good correlation in absence of lesions (p=0.002). However at week 52, the plasmatic level of CRP correlated with the absence of histological injury (p=0.02). Conclusion: In UC patients treated with ADA, mucosal healing and endoscopic / histologic features of remission correlate with biological markers. CRP and f-CAL can be used as a surrogate marker of remission or mucosal healing.
Eosinophilic Infiltration in the Upper Gastrointestinal Tract in Patients With Bronchial Asthma Hiroyuki Imaeda, Minoru Yamaoka, Kazuaki Yoneno, Hideki Ohgo, Takehito Kobayashi,, Toru Noguchi, Yoshitaka Uchida, Tomoyuki Soma, Hidekazu Kayano, Minoru Kanazawa, Hidetomo Nakamoto, Makoto Nagata Background and Aim: Eosinophilic esophagitis is related with allergic diseases such as bronchial asthma, allergic dermatitis or allergic rhinitis. The aim of this study was to examine the eosinophilic infiltration in the upper gastrointestinal (GI) tract in patients with bronchial asthma by esophagogastroduodenoscopy. METHODS: Patients with bronchial asthma who had upper GI tract symptoms were enrolled. Patients who received not inhalation but systemic administration of steroid hormone were excluded. Eosinophilic infiltrations in the esophagus, stomach and duodenum were examined in regards to the endoscopic findings and pathological findings of biopsy specimens (UMIN000010132). RESULTS: Eighty-six patients were enrolled from October in 2012 to September in 2014. Male patients were Thirty three patients were male and 53 were female, and mean age was 58.6 years old. Inhaled drugs of steroid hormone were administered in 78 patients (90.7%). Proton pump inhibitors (PPIs) were administered in 13 patients (16.7%). Twelve patients (14%) had reflux esophagitis, 8 of whom had grade A and 4 had grade B. None had typical endoscopic findings of eosinophilic esophagitis. One patient had marked eosinophilic infiltration in the esophagus, stomach and duodenum, who had taken PPI and an inhaled drug of steroid hormone. However, endoscopic findings showed only mucosal edema in the antrum. As she had severe epigastralgia and eosinophilia, she was diagnosed of eosinophilic gastroenteritis (EGE). The administration of oral prednisolone improved her symptoms and eosinophilia. Three patients had eosinophilic infiltration in the stomach, however, none of them had severe symptoms and eosinophilia. None but one with EGE had eosinophilic infiltration. CONCLUSION: Patients with bronchial asthma rarely had eosinophilic infiltration in the GI tract in this study. However, it is important to take biopsies in order to detect eosinophilic infiltration in the upper GI tract even if EGD shows no abnormal findings.
Tu1114 Familial Eosinophilic Esophagitis (EoE) Uncovers a New EoE-Like Syndrome Without Tissue Eosinophilia Alex Straumann, Carine Blanchard, Christian Bussmann, Susanne Radonjic-Hoesli, Petr Hruz, Ekaterina Safroneeva, Alain Schoepfer, Dagmar Simon, Hans-Uwe Simon Background & Aims: Eosinophilic esophagitis (EoE) is a chronic-inflammatory disease of the esophagus characterized clinically by symptoms of esophageal dysfunction and pathologically by an eosinophil-predominant infiltration. EoE has a strong genetic component. We
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AGA Abstracts
AGA Abstracts
(N=452, 12%). 1828 (47%) operations were performed for perforation, 1411 (36%) for obstruction, 226 (6%) for bleeding, and 404 (10%) for intractability. The overall mortality for peptic ulcer disease was 7.8%. Mortality varied with indication for operation: 15% for perforation, 6.3% for bleeding, 3.7% for obstruction, and 3% for intractability. Conclusion Peptic ulcer disease remains a significant indication for surgery in sub-Saharan Africa. Most reports were from a limited number of countries. Mortality in this population was relatively high, especially amongst those with perforated peptic ulcer disease. With increasing access to acid-reducing medications and therapy targeted towards H.pylori, further improvements in mortality for peptic ulcer disease could be realized. Recognizing the continued importance of surgery for peptic ulcer disease in sub-Saharan Africa is valuable towards developing and strengthening surgical training programs in the region.
Tu1112 Global Health Curriculum in Gastroenterology Fellowship: A National Survey Pichamol Jirapinyo, Ying P. Tabak, Rachel S. Hunt, Deborah D. Proctor, Frederick L. Makrauer Background: Interest in global health during postgraduate training is increasing across disciplines. Attitudes and curricular needs in gastroenterology appear supportive based on a recent pilot survey. Aim: To assess the current status and opinions on global health training during GI fellowship Methods: Design: A nationwide survey study. Setting: The questionnaire was circulated to all US GI fellowship programs from October to November 2014 with the assistance of the American Gastroenterological Association (AGA). Participants: Gastroenterology Program Directors and Fellows from programs accredited by the ACGME. Results: There were 126 respondents including 47 Program Directors and 77 Fellows from 55 programs (36% of all ACGME-accredited programs). Of these respondents, 60% had prior experience in global health. Only 17% reported that their program currently offered global health activities with an international elective (54%), didactics (37%) and research activities (30%) being the most common approaches. Relevant global health topics that were part of standard curricula included viral hepatitis other than hepatitis C (90%), GI complications of HIV (82%) and GI complications of TB (64%). Fellows reported having adequate experience managing cholangiocarcinoma (46%), hepatitis B (40%) and intrahepatic duct stones (37%) during fellowship. Most had little to no experience managing TB mesenteritis (3%), hepatitis E (5%), hepatitis D (7%), epidemic infectious enteritis (7%) and parasitic disease (7%). Most fellows reported that they would participate in an elective in an underserved area locally (80%) or a 4-week global health elective abroad (70%). Preferred training methods for global health education were working in an underserved community locally (77%), attending lectures on global health (77%) and caring for immigrants at a refugee clinic (76%). 43% of fellows planned on working or volunteering abroad after fellowship. The majority of both faculty and fellows believed that global health training would strengthen trainees' cultural competency (86%), awareness of socioeconomic factors (85%) and medical knowledge (85%). Barriers to establishing global health curriculum included funding (94%), scheduling (88%) and lack of standardized learning objectives (78%). Lack of interest at the institution level was not a concern. Fellows (49%) felt more strongly than faculty (29%, p= 0.002) that global health training should be included in the standard fellowship curriculum. Conclusion: Program directors and trainees recognize the importance of global health training. However, only 17% of these responding programs currently offer clinical or other educational opportunities. Global health curriculum will enhance gastroenterology training.
Tu1115 Prevalence of Eosinophilic Esophagitis (EoE) in Non Selected Adult Patients: A Systematic Review Diego Garcia-Compean, Jose A Gonzalez, Erick J. Barrera Villarreal, Hector J. Maldonado Background: The diagnosis of EoE requires, according to consensus recommendation (1), the presence of esophageal symptoms and esophageal eosinophilic infiltration (EEI) showing non response to PPI treatment . The reported prevalence of EoE in non selected adult individuals is wide (0.01 to 7.6%). This ample range may be due to different factors such as study design, clinical characteristics of population, etc. Aims: We performed a systematic review of published literature in order to estimate the prevalence of EoE in non selected adults and to identify factors which may be involved in variation of prevalence. Material and Methods: We conducted systematic literature searches in PubMed, MedLine and Ovid from January 2000 to august 2014. Only written in English publications, with non selected adult patients describing prevalence rates or sufficient data for calculation were included. Careful analysis of each one of the studies was done in order to determine: Type of methodological design, source of cases, clinical and demographic characteristics of patients including atopia history, endoscopic findings, and protocol of esophageal and gastric endoscopic biopsy. Results: Forty five studies were detected, only 12 fulfilled the criteria. Five were prospective and 7 retrospective. Four were hospital setting, one was population-based sampling and 7 were population- based center. Sample size varied from 122 to 233,649 individuals. Age and gender of patients were described in only 7 studies. Clinical and endoscopic characteristics of patients as well as esophageal biopsy protocol were described in all prospective and none retrospective ones. Gastric biopsy was performed in only 3 prospective studies. Definition of EEI (> 15 eosinophils / HPF) was adequate in all studies, nevertheless the use of PPI and type of response was documented in only 4 studies. Therefore prevalence of EoE could be determined only in these studies. It was 0.69 in a retrospective study and 1.2, 1.9 and 6.5% in prospective ones. Conclusions: This systematic review showed that most of studies (67%) describing EoE prevalence have based the diagnosis exclusively on EEI. It is currently known that about 30 to 40% of patients with EEI may have EoE, therefore prevalence rates in these publications may be overestimated. Influence of risk factors could not be assessed due to inhomogenous documentation in these publications. 1.- Furuta GT et al. Gastroenterology. 2007 ;133:1342-63.
Tu1113 Endoscopic and Histologic Remission Correlation With Biomarkers in UC Patients Treated With Adalimumab Ignacio Fernández-Blanco, Carlos Taxonera, Carlos Cara, Guillermo Fernandez-Diaz
Tu1116
Background: Mucosal healing, based on endoscopic and histological analysis, constitutes an endpoint of therapies for patients with ulcerative colitis (UC). We investigated if both endoscopic and histological evaluation correlate with biochemical markers of mucosal inflammation. Methods: We performed a prospective observational study of 34 patients receiving adalimumab (ADA) treatment for moderate-severe UC. Surveillance colonoscopy at week 8 and 52 were performed and clinical biomarkers C reactive protein (CRP) and fecal calprotectin (f-CAL) were measured at the same time. Endoscopic remission was defined as a Mayo subendoscopic score % 1 and histologic remission when Geboes score was <3.1. Statistical significance was calculated using the U-Mann Whitney test. Results: Both biomarkers were elevated in patients who did not reach endoscopic or histologic mucosal healing. In presence of endoscopic remission in the induction phase to week 8, these differences did not reach statistical significance (p=0.38 and 0.27), but they did at final follow-up after maintenance phase of treatment at week 52 (p=0.01 and 0.003) respectively. In patients with histological remission, we observed a lack of significance and statistical correlation between plasmatic CRP level and the absence of histological lesions in the induction phase, although close to significance (p=0.09), while f-Cal showed a good correlation in absence of lesions (p=0.002). However at week 52, the plasmatic level of CRP correlated with the absence of histological injury (p=0.02). Conclusion: In UC patients treated with ADA, mucosal healing and endoscopic / histologic features of remission correlate with biological markers. CRP and f-CAL can be used as a surrogate marker of remission or mucosal healing.
Eosinophilic Infiltration in the Upper Gastrointestinal Tract in Patients With Bronchial Asthma Hiroyuki Imaeda, Minoru Yamaoka, Kazuaki Yoneno, Hideki Ohgo, Takehito Kobayashi,, Toru Noguchi, Yoshitaka Uchida, Tomoyuki Soma, Hidekazu Kayano, Minoru Kanazawa, Hidetomo Nakamoto, Makoto Nagata Background and Aim: Eosinophilic esophagitis is related with allergic diseases such as bronchial asthma, allergic dermatitis or allergic rhinitis. The aim of this study was to examine the eosinophilic infiltration in the upper gastrointestinal (GI) tract in patients with bronchial asthma by esophagogastroduodenoscopy. METHODS: Patients with bronchial asthma who had upper GI tract symptoms were enrolled. Patients who received not inhalation but systemic administration of steroid hormone were excluded. Eosinophilic infiltrations in the esophagus, stomach and duodenum were examined in regards to the endoscopic findings and pathological findings of biopsy specimens (UMIN000010132). RESULTS: Eighty-six patients were enrolled from October in 2012 to September in 2014. Male patients were Thirty three patients were male and 53 were female, and mean age was 58.6 years old. Inhaled drugs of steroid hormone were administered in 78 patients (90.7%). Proton pump inhibitors (PPIs) were administered in 13 patients (16.7%). Twelve patients (14%) had reflux esophagitis, 8 of whom had grade A and 4 had grade B. None had typical endoscopic findings of eosinophilic esophagitis. One patient had marked eosinophilic infiltration in the esophagus, stomach and duodenum, who had taken PPI and an inhaled drug of steroid hormone. However, endoscopic findings showed only mucosal edema in the antrum. As she had severe epigastralgia and eosinophilia, she was diagnosed of eosinophilic gastroenteritis (EGE). The administration of oral prednisolone improved her symptoms and eosinophilia. Three patients had eosinophilic infiltration in the stomach, however, none of them had severe symptoms and eosinophilia. None but one with EGE had eosinophilic infiltration. CONCLUSION: Patients with bronchial asthma rarely had eosinophilic infiltration in the GI tract in this study. However, it is important to take biopsies in order to detect eosinophilic infiltration in the upper GI tract even if EGD shows no abnormal findings.
Tu1114 Familial Eosinophilic Esophagitis (EoE) Uncovers a New EoE-Like Syndrome Without Tissue Eosinophilia Alex Straumann, Carine Blanchard, Christian Bussmann, Susanne Radonjic-Hoesli, Petr Hruz, Ekaterina Safroneeva, Alain Schoepfer, Dagmar Simon, Hans-Uwe Simon Background & Aims: Eosinophilic esophagitis (EoE) is a chronic-inflammatory disease of the esophagus characterized clinically by symptoms of esophageal dysfunction and pathologically by an eosinophil-predominant infiltration. EoE has a strong genetic component. We
S-791
AGA Abstracts
AGA Abstracts
(N=452, 12%). 1828 (47%) operations were performed for perforation, 1411 (36%) for obstruction, 226 (6%) for bleeding, and 404 (10%) for intractability. The overall mortality for peptic ulcer disease was 7.8%. Mortality varied with indication for operation: 15% for perforation, 6.3% for bleeding, 3.7% for obstruction, and 3% for intractability. Conclusion Peptic ulcer disease remains a significant indication for surgery in sub-Saharan Africa. Most reports were from a limited number of countries. Mortality in this population was relatively high, especially amongst those with perforated peptic ulcer disease. With increasing access to acid-reducing medications and therapy targeted towards H.pylori, further improvements in mortality for peptic ulcer disease could be realized. Recognizing the continued importance of surgery for peptic ulcer disease in sub-Saharan Africa is valuable towards developing and strengthening surgical training programs in the region.