Eosinophilic esophagitis. The North against the South? A bio-economic-social mechanistic approach and clinical implications

Emerging incidence trends of eosinophilic esophagitis over 25 years: Results of a nationwide register‐based pathology cohort

“…Early childhood is known to be important for immune maturation; hence, developmental susceptibility might be influenced by early‐life experiences 27 . It was therefore hypothesized that modern hygienic conditions may result in less exposure to microbes during infancy, subsequently causing a defect in immune tolerance and increased sensitivity to allergic diseases 28,29 . Moreover, early‐life events (eg, Cesarean section and antibiotic exposure) are considered to cause alterations of the composition and diversity of the microbiome, potentiating a T‐helper type 2 (Th2) immune‐mediated response in certain sensitive individuals 30‐32 .…”

“… 27 It was therefore hypothesized that modern hygienic conditions may result in less exposure to microbes during infancy, subsequently causing a defect in immune tolerance and increased sensitivity to allergic diseases. 28 , 29 Moreover, early‐life events (eg, Cesarean section and antibiotic exposure) are considered to cause alterations of the composition and diversity of the microbiome, potentiating a T‐helper type 2 (Th2) immune‐mediated response in certain sensitive individuals. 30 , 31 , 32 In addition, changes in environmental factors (eg, genetic modification, food additives, and water and/or air pollution) and a Western dietary pattern (ie, diet low in fibers and high in saturated fat) are also associated with microbial dysbiosis.…”

Hospitalization Trends and Outcomes of Eosinophilic Esophagitis in the United States: A Decade-Long Nationwide Analysis

“…In addition, data extrapolated from the rising incidence of other atopic diseases parallels that of EoE giving more credence to the role of environmental allergens in the pathogenesis of EoE [ 23 , 24 ]. It has also been suggested that modern hygienic practices in childhood may have played a part in the observed increase in EoE incidence due to less exposure to microbes, which subsequently leads to increased sensitivity to microbes/allergens in adulthood [ 25 ]. The increased use of proton pump inhibitors over the years has also been suggested to have a role in the increased EoE incidence mainly due to its acid-suppressing effect by reducing peptic digestion of food allergens and microbes increasing exposure of these allergens/microbes to the gastrointestinal mucosa [ 18 , 26 , 27 ].…”

Understanding the Sex, Racial, and Ethnic Disparities in Eosinophilic Esophagitis

“…4,15 The hygiene theory, which holds that early microbial exposure fosters the development of immue system tolerance, is also strongly suggested in atopic disorders, which in term are associated with EoE and also have a rising incidence in developed countries. 16 On the other hand, the clean hypothesis suggests that a lack of early contact to pathogens due to an overly clean household impairs the immune system's development, greatly increasing one's vulnerability to allergic illnesses and thus EoE. Additionally, eosinophil proliferation may be explained by the esophagus being exposed to allergens such as food.…”