Association between endoscopic findings of eosinophilic esophagitis and responsiveness to proton pump inhibitors

Abstract

Background and study aims Endoscopic findings of esophageal eosinophilia sometimes localize to small areas of the esophagus. A previous study suggested that pathogenesis of localized-type eosinophilic esophagitis (LEoE) was associated with acid reflux. However, LEoE treatment outcomes have not been studied. We aimed to analyze the clinical and histologic significance of LEoE in comparison with diffuse-type eosinophilic esophagitis (DEoE). Patients and methods This study included 106 patients with esophageal eosinophilia. Esophageal eosinophilia was defined as a condition where the maximum number of intraepithelial eosinophils was ≥ 15 per high-power field. LEoE was defined as an endoscopic lesion confined to one-third of the esophagus: upper, middle, or lower. Esophageal eosinophilia encompassing more than two-thirds of the esophagus was defined as DEoE. We retrospectively compared LEoE and DEoE in terms of clinical characteristics, histologic findings, and proportion of proton pump inhibitor (PPI) responders. Results Of 106 patients, 12 were classified as having LEoE and 94 were classified as having DEoE. The proportion of asymptomatic patients was significantly higher in the LEoE group than the DEoE group (42 % vs 7 %, P < 0.01). In the LEoE group, 10 patients (84 %) had endoscopic lesions in the lower esophagus. The maximum number of eosinophils did not differ between the groups (54 [24 – 71] for LEoE, 40 [20 – 75] for DEoE, P = 0.65). The prevalence of PPI responders was significantly higher in the LEoE group than the DEoE group (100 % vs 63 %, P = 0.01). Conclusion LEoE can be a sign of good responsiveness to PPI therapy.

Clinical Features of Esophageal Eosinophilia According to Endoscopic Phenotypes

“…Although EoE is known to be common in young to middle-aged men, not only in white populations but also in Japanese populations ( 1 , 25 ), we found a marked male predominance in localized EE compared with diffuse EE in this study. This trend was also shown by another report ( 13 ). Erosive esophagitis, especially mild type, such as grade A or B according to the Los Angeles classification, is significantly more prevalent in young to middle-aged men than in women in Japan ( 30 , 31 ).…”

“…In our present study as well in our previous report, dysphagia and food impaction tended to be less common in patients with localized EE than in those with diffuse EE, but this finding was not statistically significant. Sawada et al reported that asymptomatic patients were more common in the localized group (42%) than in the diffuse group (7%), with statistical significance ( 13 ). Because of the relatively large number of asymptomatic patients included in our diffuse EE group, statistical significance might not have been detected.…”

“…There have been few studies reporting on the medication for localized EoE. Sawada et al showed that the rate of response to PPI therapy was significantly higher in patients with localized EE (100%) than in those with diffuse EE (63%), suggesting that localized EE has a stronger acid-related cause than diffuse EE ( 13 ). Although the available information on medical treatment was largely limited in the present study because of the retrospective nature of the medical chart review, PPI therapy was necessary in only 10% of the patients with localized EE.…”

“…Third, the retrospective assessment of the symptoms was based on the medical charts; therefore, the indications for medical treatment were not uniformly determined, and certain conclusions on the treatment outcome cannot be drawn based on the results of this study. However, at least according to our review of medical charts, aggressive medical treatment seems to be unnecessary for localized EE in clinical practice, as the localized inflammation induces fewer symptoms ( 13 ). Finally, our findings that significant symptoms and endoscopic progression were less likely to occur in asymptomatic EE patients for at least several years were based on a retrospective observation of a small number of patients.…”

“…Recently, Sawada et al reported high rates of responsiveness to therapy with proton pump inhibitors (PPIs) in symptomatic patients with localized EE ( 13 ). However, little information about the proportion of cases of localized EE among all cases of EE is available, and its clinical features, including the practical medical treatment and natural course, compared with those of diffuse EE are unclear.…”