The role of allergy evaluation in children with eosinophilic esophagitis

Background

To our knowledge, in Asia, data on utility of allergy tests in management of eosinophilic esophagitis are lacking. The objective of our study was to determine the role of allergy evaluation in management of Saudi children with eosinophilic esophagitis.

Methods

Children diagnosed as having eosinophilic esophagitis during the period from 2009 to 2012 were referred to an allergist for allergy evaluation. The allergy evaluation consisted of total IgE level, radio-allergosorbent assay, and skin prick test. Depending on the results of the allergy tests, a restricted or elemental diet was established. Swallowed fluticasone inhaler was prescribed to patients who rejected or failed to respond to the diet. Clinical, endoscopic, and histological evaluation was performed in 8 weeks to assess response.

Results

Eighteen children with eosinophilic esophagitis were included (13 males; mean age 5 years, range 1–11). Sensitization to foods was demonstrated in 14 patients: 4 with a positive test for a single food (28.5 %), 1 for 2 food allergens (7 %), and 9 for ≥3 food allergens (64.5 %). The most common food allergens were milk, soybean, wheat, egg, and nuts. Three young children out of the total 14 patients responded to elemental formula. Four of the 10 older children on the allergy testing guided-dietary restriction achieved partial remission and the remaining 6 did not respond. All 10 patients responded to a swallowed fluticasone inhaler.

Conclusion

Although food sensitizations in Saudi children with eosinophilic esophagitis are common, the allergy tests had limited predictive value for the response to dietary elimination.     

Gastric outlet obstruction

BACKGROUND/AIMS: To study causes of gastric outlet obstruction (GOO) in Saudi patients in a tertiary hospital. During one year (between March 2005 and April 2006), twelve patients were referred to the gastroenterology department as possible GOO. METHODOLOGY: All patients had gastroscopy, barium meal and CT scan of abdomen. All patients presented with history of repeated vomiting usually after food. Two of these patients were known to have chronic duodenal ulceration. Gastroscopy in all patients showed food and fluid residue (in spite of fasting more than 12 hours), different lesions were found and biopsied. In patients who had pyloric obstruction, endoscopic dilatation for pyloric canal was done. RESULTS: Four patients had neoplastic disorders (two with adenocarcinomas and one with neuroendocrine tumor and one had lymphoma) and they were referred for surgery. Three patients had chronic duo denal ulceration and two of them were managed by endoscopic pyloric dilatation and medical treatment. One patient had cytomegalovirus (CMV) gastritis together with vitamin B12 deficiency and he improved on medical treatment. One patient had eosinophilic gastroenteritis which improved with medical treatment. One patient had adult congenital pyloric stenosis and serial endoscopic dilatation failed and was referred for surgery. One patient had superior mesenteric artery syndrome and she improved with medical treatment and advises about food and postures and she did not require surgical intervention. Lastly, one patient had GOO secondary to pancreatic tumor and was managed surgically. CONCLUSIONS: There are various causes of GOO as shown in our patients, some of which are rare and interesting such as CMV gastritis, adult congenital pyloric stenosis, eosinophilic gastritis and superior mesenteric artery syndrome. Those patients with rare causes will be included in discussion.     

Successful Food Elimination Therapy in Adult Eosinophilic Esophagitis: Not All Patients are the Same

Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated, esophageal disease characterized by esophageal dysfunction and eosinophilic inflammation, manifested mainly as dysphagia and frequent food impaction. EoE is recognized into the spectrum of food allergy, but food sensitization studies used not to be efficient to identify the triggering food, because of what patients are frequently treated with topic steroids or even endoscopic esophageal dilation. Herein, we describe 3 adult patients-all suffering from EoE, but with different sensitization patterns-who were treated successfully with elimination diets. Allergy tests indicated no food sensitization for patient 1, but challenge with milk and wheat were positive. Food IgE-mediated allergies were found in patients 2 and 3; inflammation was resolved with food elimination. Lack of food allergy sensitization does not exclude the possibility of food allergies as a cause of EoE; elimination diets must therefore be considered as an effective diagnostic and treatment tool.     

Eosinophilic esophagitis: Case report.

Eosinophilic esophagitis is an inflammatory condition of the esophagus characterized by eosinophilic infiltration. It is a condition mainly affecting children; the adult form has only recently gained recognition as a distinct entity. The major symptom among adults with eosinophilic esophagitis is dysphagia. It is often misdiagnosed as gastroesophageal reflux disease because of the similarity in symptoms. An endoscopic biopsy is required to distinguish between the conditions. The cause of eosinophilic esophagitis is poorly understood, but food allergy has been implicated. Topical steroids are the most effective and convenient method for the treatment of eosinophilic esophagitis in adults. The long-term prognosis of eosinophilic esophagitis is uncertain; however, data suggests a benign course. We herein present two eosinophilic esophagitis cases that were the first to be diagnosed in our clinic.     

Gastric vascular ectasia treated by endoscopic mucosal resection

An 80‐year‐old woman consulted our hospital complaining of general weakness. She had iron deficiency anemia, and upper gastrointestinal endoscopy revealed a small lesion accompanying a small amount of fresh bleeding in the stomach. Close observation of the lesion revealed that it was composed of a local assembly of dilated microvessels. The diagnosis of this patient was gastric vascular ectasia causing anemia. Endoscopic ultrasonography demonstrated that the lesion involved the mucosal and submucosal layers of the stomach, and that there were no large vessels inflowing to or outflowing from the lesion. In the present case, we attempted endoscopic mucosal resection (EMR). The lesion was completely resected by only one procedure of EMR without complications such as bleeding. After the endoscopic treatment, iron deficiency anemia improved. Follow‐up endoscopy performed 1 year later revealed that there was no residual or recurrent lesion. Although there have not been any published reports describing the use of EMR for gastric vascular ectasia, EMR may be a useful endoscopic treatment for this condition.     

The spectrum of pediatric eosinophilic esophagitis beyond infancy: a clinical series of 30 children

OBJECTIVES: Eosinophilic esophagitis, previously confused with esophageal inflammation due to gastroesophageal reflux, has recently begun to be distinguished from it. We undertook this analysis of our large series of children with the condition to clarify its spectrum: its presenting symptoms; its relation to allergy, respiratory disease, and reflux; its endoscopic and histological findings; and its diagnosis and therapy. METHODS: We analyzed the details of our clinical series of 30 children with eosinophilic esophagitis, defining it as > or =5 eosinophils per high power field in the distal esophageal epithelium. Retrospective chart review was supplemented by prospective, blinded, duplicate quantitative evaluation of histology specimens, and by telephone contact with some families to clarify subsequent course. Presentation and analysis of the series as a whole is preceded by a case illustrating a typical presentation with dysphagia and recurrent esophageal food impactions. RESULTS: Presenting symptoms encompass vomiting, pain, and dysphagia (some with impactions or strictures). Allergy, particularly food allergy, is an associated finding in most patients, and many have concomitant asthma or other chronic respiratory disease. A subtle granularity with furrows or rings is newly identified as the endoscopic herald of histological eosinophilic esophagitis. Histological characteristics include peripapillary or juxtaluminal eosinophil clustering in certain cases. Association with eosinophilic gastroenteritis occurs, but is not common. Differentiation from gastroesophageal reflux disease is approached by analyzing eosinophil density and response to therapeutic trials. Therapy encompasses dietary elimination and anti-inflammatory pharmacotherapy. CONCLUSION: Awareness of the spectrum of eosinophilic esophagitis should promote optimal diagnosis and treatment of this elusive entity, both in children and in adults.     

嗜酸性粒细胞性消化道炎

原发性嗜酸性粒细胞性消化道炎（eosinophilic gastrointestinal disease,EGID）是以消化道嗜酸性粒细胞异常浸润为特征的炎症性疾病。该病可以累及消化道全长或某一部分,包括嗜酸性粒细胞性食管炎（eosinophilicesophagitis,EE）、胃炎、胃肠炎（eosinophilic gastroenteritis,EG）、小肠炎、结肠炎及直肠炎。在过去的几十年中,文献报道的发病率逐渐增高。其病因及发病机制并不清楚,大多数研究结果都提示,吸入和食物过敏反应可能诱发该病的发作。其临床主要表现为各种消化道症状,无特异性,诊断标准未得到一致公认,多强调以病理为主的综合诊断,同时要除外其他继发性消化道嗜酸性粒细胞增多疾病。治疗以控制饮食和糖皮质激素为主,近年出现针对发病机制的生物制剂治疗,但尚缺少充分的循证医学依据。     

Eosinophilic Esophagitis in Patients with Refractory Gastroesophageal Reflux Disease

Background Eosinophilic esophagitis is among the causes of refractory reflux disease. Biopsy of esophagus is the gold standard for diagnosis. In this study we determined the frequency of eosinophilic esophagitis (EE) in refractory reflux cases referred to Motility Department of Shahid Beheshti Research Center of Gastroenterology and Liver Disease, Tehran, Iran. Methods In this cross-sectional study, 68 cases with refractory reflux disease underwent endoscopy and had biopsies taken. Specimens were stained by hematoxylin and eosin and two independent pathologists confirmed the diagnosis of eosinophilic esophagitis. Results Mean (standard deviation, SD) age at diagnosis was 41.8 (10.94) years. All had allergy or atopy, and unknown dysphagia was noted for 66%. Endoscopic findings were as follows: esophagitis (33.3%), rings (33.3%), and whitish plaques (33.3%). Prevalence of eosinophilic esophagitis was 8.8% (N = 6; one man and five women). No statistical difference in demographic variables was found between eosinophilic esophagitis cases and others, except for history of atopy, food impaction, and endoscopic features (P value <0.005). Conclusion Eosinophilic esophagitis should be considered in the differential diagnosis of any cases with refractory reflux who complain of chronic unexplained dysphagia, with history of recurrent food impaction, and atopy or abnormal endoscopic features.     

Eosinophilic esophagitis: a case report. Effective treatment with systemic corticosteroids for the relapse of the disease

We report on a case of eosinophilic esophagitis in a 33-year-old Japanese woman who visited our hospital with dysphagia and esophageal food impaction in April 2006. She had had the same symptoms in May 2005, and, by endoscopic and histologic examination, she was diagnosed with eosinophilic esophagitis. Biopsy specimens from multiple locations in the esophageal mucosa had shown remarkable infiltration of eosinophils, more than 20 eosinophils per high-power field in squamous mucosa, and she had been treated with Th2 cytokine antagonist and proton pump inhibitor at the time. Her symptoms had not improved, but she had received no further medical treatment. In 2006, upper gastrointestinal endoscopy showed edematous whitish esophageal mucosa, multiple ulcerations with whitish exudates on their surfaces, and white plaques. Biopsy specimens showed the same change as before, and corticosteroid (prednisolone 20 mg/day) was administered orally. After 2 weeks of corticosteroid therapy, her symptom had effectively improved. Endoscopy after 15 weeks of the therapy revealed remarkable improvement, and biopsy specimens from esophageal mucosa revealed the disappearance of the eosinophil infiltrates. We report on a case of eosinophilic esophagitis effectively treated with systemic corticosteroids. Eosinophilic esophagitis has, as yet, no standardized treatment. However, wider recognition of its features on endoscopy may reveal more cases, thereby increasing our understanding of this disease, and will provide new therapeutic possibilities.     

Diagnosis of gastric antral vascular ectasia by transnasal flexible spectral imaging color enhancement

The endoscopic appearance of gastric antral vascular ectasia (GAVE) can be easily misinterpreted as inflammatory changes of gastric mucosa. We report on a case of GAVE that had been missed by conventional transnasal endoscopy but was diagnosed by flexible spectral imaging color enhancement (FICE) with a transnasal endoscope. A 45-year-old woman with severe anemia presented with a 1-month history of increasing fatigue. She was previously diagnosed as having acute antral gastritis by conventional transnasal endoscopy (EG 530N2) because of the presence of reddish mucosal changes on the entire antral rugal fold. However, the FICE images produced using a combination of new processor system (VP4450) and new small-caliber endoscope (EG 530NW), did not show reddish mucosal changes on the entire rugal fold, but gave a clear image of dilated vessels associated with GAVE distinct from the surrounding normal mucosa on the same fold. These findings are useful to differentiate GAVE from ordinary gastritis. The lesions of GAVE were managed with a combination of focal pulse and spray-painting techniques to obliterate the bulk of the disease in two sessions of argon plasma coagulation therapy. Three months later, the patient recovered from iron deficiency anemia with an oral medication of iron tablets.     

Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features

BACKGROUND: Eosinophilic esophagitis is an inflammatory condition in which there is dense eosinophilic infiltration of the surface lining of the esophagus. Reports of eosinophilic esophagitis pertain almost exclusively to pediatric populations. However, eosinophilic esophagitis is emerging as a clinical affliction of adults. This report describes the clinical and endoscopic findings of eosinophilic esophagitis in the largest cohort of adult patients reported to date. METHODS: Twenty-nine patients (21 men, 8 women; mean age 35 years) with documented eosinophilic esophagitis (>/=15 eosinophils per high-power field in biopsy specimens) and a significant history of chronic dysphagia for solid food (24 patients) were evaluated clinically and endoscopically during a 3-year period (1999-2002). Fourteen patients (48%) had a history of asthma, environmental allergy, or atopy. In a subset of 15 patients, the diagnostic accuracy of endoscopy was compared with that of barium contrast esophagography. RESULTS: Twenty-seven patients (93%) had abnormal endoscopic findings; 25 (86%) had unique esophageal structural changes, associated with a preserved mucosal surface, that were highly atypical for acid reflux injury. Structural alterations seen in adult patients with eosinophilic esophagitis may occur in combination or as a primary characteristic, e.g., uniform small-caliber esophagus, single or multiple corrugations (rings), proximal esophageal stenosis, or 1 to 2 mm whitish vesicles scattered over the mucosal surface. Barium contrast radiography combined with swallow of a barium-coated marshmallow identified 10 (67%) of the primary features observed endoscopically in 15 patients. However, radiography failed to detect other features noted at endoscopy (e.g., only 3/6 patients with proximal stenosis, 5/9 patients with concentric rings and none of 4 patients with small caliber esophagus). Eight of the 29 patients (20%) had a history of chronic heartburn. Twelve patients had been treated with a proton pump inhibitor and only 3 reported some improvement in the severity of dysphagia. CONCLUSIONS: Relatively young age, a history of chronic dysphagia for solid food, and endoscopic detection of unique structural alterations atypical for GERD in an adult patient should prompt a suspicion of EE and subsequent biopsy confirmation. Acid reflux appears to have a secondary role in eosinophilic esophagitis. In an uncontrolled comparison, endoscopy was superior to barium contrast radiography for the diagnosis of eosinophilic esophagitis. The incidence of eosinophilic esophagitis in adults appears to be increasing.     

Coexistence of Megaloblastic Anemia and Iron Deficiency Anemia in a Young Woman with Chronic Lymphocytic Thyroiditis

Pernicious anemia is a megaloblastic anemia caused by vitamin B12 deficiency, and is the end-stage of autoimmune gastritis that typically affects persons older than 60 years. It is the most common cause of vitamin B12 deficiency. Pernicious anemia can also be diagnosed concurrently with other autoimmune diseases. We report the occurrence of megaloblastic anemia in a 22-year-old woman with chronic autoimmune thyroiditis for 10.5 years. Recently, she presented with microcytic anemia, and iron deficiency anemia was diagnosed initially. After administration of ferrous sulfate, macrocytic anemia was revealed and vitamin B12 deficiency was detected. Pernicious anemia was highly suspected because of the endoscopic finding of atrophic gastritis, and high titer of antigastric parietal cell antibody, as well as elevated serum gastrin level. After intramuscular injections of hydroxycobalamine 100 microg daily for 10 days, and monthly later, her blood counts returned to normal.     

A female with asymptomatic primary biliary cirrhosis associated with pernicious anemia

We experienced a female case with asymptomatic primary biliary cirrhosis that was associated with pernicious anemia after 16 years from the onset. She was 52 years old when she first visited a clinic in 1981 for liver dysfunction treatment. Antimitochondrial antibody was negative and antipyruvate dehydrogenase complex antibody was positive in a low titer in its immunoglobulin (Ig)M type. Histological examination of her liver revealed a presence of definite chronic non-suppurative destructive cholangitis with numerous epithelioid cell granuloma. She had been given 600 mg of the oral daily dose of ursodeoxycholic acid since 1992. Macrocytic anemia incidiously appeared in September 1999. An immunological examination detected negative antiparietal cell antibodies and positive anti-intrinsic factor antibodies. Her bone marrow smear showed numerous megaloblasts and serum vitamin B12 in her blood was low at 99 pg/mL. Severe reversed atrophic-type gastritis (type A gastritis) was demonstrated by the use of dye-endoscopy with Congo red. Her macrocytic anemia dramatically improved after intramuscular administration of vitamin B12. In conclusion, attention should be given to the association of pernicious anemia during the follow up of primary biliary cirrhosis.     

Treatment of solitary gastric carcinoid tumor by endoscopic polypectomy in a patient with pernicious anemia

Type I gastric carcinoid tumors result from hypergastrinemia in 1%-7% of patients with pernicious anemia. We diagnosed pernicious anemia in a 48-year-old female patient with complaint of fatigue for three months. She had no gastrointestinal symptoms. Endoscopic examination ot the upper gastrointestinal tract revealed atrophic gastritis and a polypoid lesion in the corpus of 3-4 mm in size. Endoscopic polypectomy was performed. Histopathological examination of the specimen revealed positive chromogranin A and synaptophysin stainings compatible with the diagnosis of a carcinoid tumor. Serum gastrin level was increased, urinary 5-hydroxyindoleacetic acid was within the normal range. There was no other symptom, sign, or laboratory finding of a carcinoid syndrome in the patient. No metastasis was found with indium-111 octreotide scan, computed tomographies of abdomen and thorax. Type I gastric carcinoid tumors are only rarely solitary and patients with tumors < 1 cm in size may benefit from endoscopic polypectomy.     

Surveilling Russell body Helicobacter pylori-negative gastritis: A case report and review of literature

BACKGROUND Russell body gastritis(RBG) is very rare type of chronic inflammation of gastric mucosa. The pathologic hallmark of the disease is Russell bodies(RB) which represent accumulation of eosinophilic cytoplasmic inclusions in endoplasmic reticulum of mature plasma cells(Mott cells). Most published cases are associated with Helicobacter pylori(H. pylori) infection because of correlation between plasma cell activation and antigenic stimulation. There are insufficient data about H. pylori-negative RBG and very little is known about the natural course of the disease.CASE SUMMARY A 51-year-old male patient underwent endoscopic screening for mild iron deficiency anemia. Gastroscopy revealed diffuse hyperemia, edema and nodularity of the fundic and corpus mucosa. Due to non-specific endoscopic findings and iron-deficiency anemia our preliminary diagnosis was diffuse type of gastric carcinoma or gastric lymphoma. Biopsy specimens of gastric mucosa showed inflammatory infiltrate rich in Mott cells, consisting entirely of cytoplasmic RB. Absence of nuclear atypia and mitosis of the plasma cells, polyclonal pattern of the Mott cells and negative staining for cytokeratins favored diagnosis of RBG. The patient was treated with proton-pump inhibitor for 8 wk. Long-term clinical and endoscopic surveillance was scheduled. Albeit, there was no improvement in endoscopic features of the gastric mucosa in three consecutive gastroscopies, histopathological findings demonstrated that the chronic inflammatory infiltrate in the fundic mucosa is less pronounced, rich in plasma cells, with almost absent RB and Mott cells.CONCLUSION The prognosis of this entity is uncertain, that is why these patients are subjects of continuous follow up.     

Argon plasma coagulation therapy for a hemorrhagic radiation-induced gastritis in patient with pancreatic cancer

Radiation-induced gastritis is a serious complication of radiation therapy for pancreatic cancer which is difficult to manage. A 79-year-old man had been diagnosed as having inoperable pancreatic cancer (stage IVa). We encountered this patient with hemorrhagic gastritis induced by external radiotherapy for pancreatic cancer that was well-treated using argon plasma coagulation (APC). After endoscopic treatment using APC, anemia associated with hemorrhagic radiation gastritis improved and required no further blood transfusion.     

Endoscopic classification of chronic gastritis based on a pilot study by the research society for gastritis

Background : Various types of classification of gastritis have been proposed, but no plausible classification has been available until now. The Research Society for Gastritis performed a pilot study to establish an endoscopic classification, taking into consideration the following: (i) ease of use; (ii) permitting everyone the common image; and (iii) presence of histopathological evidence. Methods : One hundred and fifty‐five patients were enrolled and underwent gastroscopy. Eight basic endoscopic and histological types of gastritis (superficial, hemorrhagic, erosive, verrucous, atrophic, metaplastic, hyperplastic and special types) were defined. Gastritis was endoscopically diagnosed according to the definition of the endoscopic types of gastritis. Four or more biopsy specimens were obtained from the lesser and the greater curvatures of the antrum and the corpus of each patient, and the histological findings of gastritis and Helicobacter pylori infection were assessed. The histological diagnosis of gastritis was made according to the definition of histology types of gastritis. The endoscopic and the histological diagnoses were then compared in a blinded fashion. Results : Endoscopic diagnosis was 62% as sensitive as histological diagnosis for erosive gastritis, 67% for verrucous gastritis and 84% for atrophic gastritis in the antrum. In superficial gastritis, sensitivity was approximately 25% in the corpus, but only 8% in the antrum. Metaplastic and hyperplastic gastritis were correctly diagnosed only in severe cases. Conclusion : Five basic types of gastritis (superficial, erosive, verrucous, atrophic and special types) should be employed for the new endoscopic gastritis classification. Metaplastic and hyperplastic gastritis are considered to be subtypes of atrophic gastritis and they should be excluded from the basic endoscopic classification. A new definition of gastritis in the antrum accompanied by redness still remains to be investigated.     

Systematic review: Eosinophilic esophagitis in Asian countries

AIM: To investigate the prevalence and the clinical characteristics of Asian patients with eosinophilic esophagitis.METHODS: We conducted a systematic search of the PubMed and Web of Science databases for original studies, case series, and individual case reports of eosinophilic esophagitis in Asian countries published from January 1980 to January 2015. We found 66 and 80 articles in the PubMed and Web of Science databases, respectively; 24 duplicate articles were removed. After excluding animal studies, articles not written in English, and meeting abstracts, 25 articles containing 217 patients were selected for analysis.RESULTS: Sample size-weighted mean values were determined for all pooled prevalence data and clinical characteristics. The mean age of the adult patients with eosinophilic esophagitis was approximately 50 years, and 73% of these patients were male. They frequently presented with allergic diseases including bronchial asthma, allergic rhinitis, food allergy, and atopic dermatitis. Bronchial asthma was the most frequent comorbid allergic disease, occurring in 24% of patients with eosinophilic esophagitis. Dysphagia was the primary symptom reported; 44% of the patients complained of dysphagia. Although laboratory blood tests are not adequately sensitive for an accurate diagnosis of eosinophilic esophagitis, endoscopic examinations revealed abnormal findings typical of this disease, including longitudinal furrows and concentric rings, in 82% of the cases. One-third of the cases responded to proton pump inhibitor administration.CONCLUSION: The characteristics of eosinophilic esophagitis in Asian patients were similar to those reported in Western patients, indicating that this disease displays a similar pathogenesis between Western and Asian patients.     

Eosinophilic Esophagitis: Allergic Contribution,Testing, and Management

Both basic science and clinical data indicate a strong role for allergy as a cause of eosinophilic esophagitis. As a result, one of the desired goals of therapy is identification and elimination of food antigens that trigger the allergic inflammatory pathway. Traditional methods for identification of causative food antigens include induction of symptoms with exposure to the antigen, demonstration of serum IgE antibodies against antigens and induction of immediate (IgE) or delayed (Th2) reactions against dermal instillation of antigens. Although some data support the use of these tests in patients with eosinophilic esophagitis, they are limited in this disease. This limitation results from an inability to provoke recognizable symptoms and a lack of concordance between allergies identified in the skin and the blood with the antigens that trigger esophageal disease. As a result, allergy therapy in eosinophilic esophagitis consists of global elimination of food antigens with an elemental diet or exclusion of the most common antigens. As compliance is difficult with these strategies, the mainstay of allergy therapy in eosinophilic esophagitis has become the use of medications that blunt the allergic pathway such as steroids with a future aimed toward more specific inhibitors of this pathway in eosinophilic esophagitis specifically.