Effect of Proton Pump Inhibitor on Esophageal Eosinophilia

Abstract

Objective Differentiation between the common etiologies of dense esophageal eosinophilia such as gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE), can be difficult. We hypothesized that histologic features may provide diagnostic clues concerning the etiology of esophageal eosinophilia. Methods We performed a retrospective chart review of 204 children with the diagnosis of esophagitis characterized by ≥ 15 eos/ HPF in at least one biopsy. We then restricted our analysis to subjects who had received at least 8 weeks of only proton pump inhibitors (PPIs) followed by endoscopy and who had a clinicopathologic response to this treatment. Symptoms, endoscopic findings, and pathologic descriptions were reviewed and an eosinophil peroxidase (EPX) index was determined to assess for degranulation/eosinophil activation. Results Of the 204 identified charts, 7 subjects identified met the inclusion criteria. Five of these 7 patients showed a clinicopathologic response to PPIs after their follow up endoscopy, (mean peak eosinophil count- 92 vs 5 eos/ HPF, and EPX index-39.2 vs 14.6, pre- and post-treatment respectively). Two patients experienced initial resolution of symptoms and esophageal eosinophilia with PPI therapy however; within 17–23 months redeveloped symptoms and esophageal eosinophilia while on PPI therapy at the time of a third endoscopy (mean peak eosinophil count- 40 vs 11 vs 36 eos / HPF, and EPX index- 44 vs 21 vs 36.5, pre-, post- and post-treatment respectively). No clinicopathologic features or degranulation patterns differentiated subjects with GERD / PPI responsive esophageal eosinophilia (PPIREE) from those who had transient response to PPI treatment. Conclusions No clinicopathologic features differentiated subjects who responded to PPI treatment. PPI treatment can be helpful to exclude GERD and PPIREE but long-term follow up is critical in the management of esophagitis.

Systematic review of histological remission criteria in eosinophilic esophagitis

“…Nonetheless, four studies considered remission within the range of 0 to ≤5 eosinophils/hpf, 42, 43, 44, 45 and five studies considered remission as having ≤15 eosinophils/hpf 46, 47, 48, 49, 50…”

Letter: PPI‐responsive oesophageal eosinophilia – from initial skepticism to consistent prospective data; authors' reply

“…Current thinking suggests that eosinophilic oesophagitis is an immune-mediated, antigen-driven disorder; 3 thus, diet elimination and/or corticosteroid therapy would seem the fitting therapeutic strategy. 4 There is now, however, confirmatory evidence available, including our study 2 and their data, 5,6 as well as other studies, [7][8][9][10][11][12][13][14][15] that symptomatic patients with oesophageal eosinophilic infiltration, which is phenotypically indistinguishable from eosinophilic oesophagitis, respond to PPI therapy. In further support of Drs.…”

“…Studies validating these findings come from geographically diverse centres across both sides of the Atlantic 2, 5, 9 and Asia. 10 The benefits are noted in both children 7,8,12 and adult populations. 2,5 The magnitude of the response rates is robust (at least 33%, and as much as 75%).…”

Non-IgE Medicated Food Allergy: Eosinophilic Esophagitis Update on the Pathogenesis, Clinical Features, and Management of Eosinophilic Esophagitis in Children

“…More importantly, 77 % of children showed no PPI response. The data from Schroeder et al [29] emphasize the importance of the PPI trial, but also underscore that these patients need long-term follow-up given disease overlap and unclear differentiating factors between EoE and PPI-REE. These findings closely mirror work by Dohil, Newbury, and Aceves, who described transient response followed by recrudescence of esophageal eosinophilia in four children treated with (and remaining on) PPI, independent of seasonal variation.…”

“…Schroeder et al [29] performed a retrospective analysis of 204 children diagnosed with EoE to identify responders to an 8-week PPI treatment and differentiate responders from non-responders. Seven patients with clinico-pathologic response were identified, two of whom re-developed esophageal eosinophilia within 1.5-2 years of treatment, and there were no clinical indicators to differentiate transient from long-term PPI responders.…”