OBJECTIVES: The prevalence of psychiatric disease in patients with eosinophilic esophagitis (EoE) is not fully characterized. We aimed to determine the prevalence of psychiatric disease and centrally acting medication use in a cohort of children and adults with EoE and evaluated whether psychiatric disease affects the EoE clinical presentation. METHODS: We conducted a retrospective study of newly diagnosed cases with EoE at the University of North Carolina from 2002 to 2018. Psychiatric comorbidities and relevant treatments were extracted from the medical records. The demographic and clinical features of patients with EoE with and without psychiatric diagnoses, and those with and without psychiatric medication use, were compared. RESULTS: Of 883 patients (mean age 26.6 years, 68% men, 79% white), 241 (28%) had a psychiatric comorbidity. The most common diagnosis was anxiety (23%) followed by depression (17%); 28% of patients were treated pharmacologically. There were 45 patients (5%) treated pharmacologically without a psychiatric diagnosis for chronic pain syndromes, insomnia, and/or epilepsy. Cases with EoE with a psychiatric diagnosis were more likely to be women, white, and 18 years or older and to have a longer symptom duration before diagnosis. DICUSSION: Psychiatric comorbidities were common in EoE, seen in a third of adults and more than 1 in 7 children, and with similar proportions receiving a prescription medication. These illnesses affected the EoE presentation because psychiatric comorbidities were more likely in older, female, and white patients with a longer duration of symptoms preceding diagnosis.
Background and Aims: A proportion of patients with active eosinophilic esophagitis (EoE) have a normal appearing esophagus on endoscopy (EGD). We aimed to determine associations between baseline clinical features and the endoscopically normal esophagus in EoE as well as time trends in reporting. Methods: In this retrospective study of active EoE cases from 2002-2018, patients with and without esophageal endoscopic abnormalities were compared. Multivariable logistic regression identified independent predictors of a normal EGD. The proportion of patients with a normal EGD was determined per year and before and after introduction of the first EoE guidelines and EoE Endoscopic Reference Score (EREFS). Results: Of 878 EoE patients, 101 (11.5%) had an endoscopically normal esophagus. They were younger (8.3 vs. 25.4 years), had shorter symptom duration before diagnosis (median 2.8 vs. 5.0 yrs), less likely to have dysphagia (40% vs. 76%) and food impaction (8% vs. 33%), and more likely to have abdominal pain (37% vs. 19%) (p<0.01 for all). On multivariable logistic regression, independent predictors of a normal esophagus were younger age (OR=0.96, 95% CI:0.94-0.98), abdominal pain (OR=2.03, 1.13-3.67), and lack of dysphagia (OR=0.49, 0.26-0.93). The proportion of patients with a normal esophagus decreased from 21% before the first EoE guidelines to 7% (p<0.01) after introduction of EREFS. Conclusions: An endoscopically normal esophagus is seen in ~10% of active EoE patients and should not preclude biopsies. Younger age, abdominal pain, and lack of dysphagia are independent predictors. The proportion of normal EGDs decreased over time, suggesting improved recognition of endoscopic findings.
SUMMARY While strictures are common in eosinophilic esophagitis (EoE), there are few data on stricture distribution and characteristics. Our primary aim was to characterize strictures by location in the esophagus in EoE and associated clinical, endoscopic, and histologic features. This was a retrospective study from the UNC EoE Clinicopathologic Database of subjects with esophageal strictures or narrowing from 2002 to 2017. Strictures were categorized as distal esophagus/gastroesophageal junction, mid-esophagus, proximal esophagus, or diffusely narrowed. Stricture location was assessed and compared with clinical, endoscopic, and histologic features, and also with treatment response to diet or topical steroids. Efficacy of combination therapy with dilation and intralesional steroid injection was assessed in a sub-group of patients with strictures. Of 776 EoE cases, 219 (28%) had strictures, 45% of which were distal, 30% were proximal, 5% were mid-esophageal, and 20% had diffuse narrowing. Those with mid-esophageal strictures were younger (P = 0.02) and had shorter symptom duration (P < 0.01). Those with diffuse esophageal narrowing were more likely to be women (57%) and have abdominal pain (25%). There was no association between other clinical, endoscopic, and histologic findings and treatment response based on stricture location. Fourteen patients (8%) received intralesional triamcinolone injection and subsequently achieved a higher mean dilation diameter after injection (13.7 vs. 15.5 mm; P < 0.01). In conclusion, almost half of strictures in EoE patients were in the distal esophagus. Therefore, EoE should be a diagnostic consideration in patients with focal distal strictures and not presumed to be secondary to gastroesophageal reflux disease.
E osinophilic esophagitis (EoE) is a chronic immune/antigen-mediated disorder defined by eosinophilic-predominant inflammation and esophageal dysfunction. 1,2 EoE represents an important cause of esophageal morbidity and a leading cause of esophagitis. 3 Topical corticosteroids (tCS) and food elimination diets (FED) improve the clinical and histologic features of EoE. 4 However, appreciable rates of treatment failure exist, 3,5 tCS may elicit side effects, and FED may impair quality of life. 6 An alternative to monotherapy may be a combined treatment strategy. Few data exist describing combined treatment 7 and none examined a combined treatment strategy in adults. This study assesses the impact of combined therapy on EoE disease activity in a cohort of adolescents and adults.
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