PPI-responsive esophageal eosinophilia cannot be distinguished from eosinophilic esophagitis by endoscopic signs

Warners, Marijn J.; Rhijn, Bram D. van; Curvers, Wouter L.; Smout, Andreas J.; Bredenoord, Albert J.

doi:10.1097/meg.0000000000000331

Cited by 39 publications

(26 citation statements)

References 28 publications

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“…Available studies have identified that demographics, atopic history and clinical manifestations do not reliably discriminate EoE from PPI-REE. [4,7–11] Paediatric presentations of EoE are more heterogeneous and include abdominal pain, nausea, reflux-like symptoms not responsive to acid suppression, feeding difficulties, and growth failure. It remains unclear if this difference in symptom profile reflects inadequate symptom reporting by young children, initial symptoms related to inflammation prior to onset of oesophageal remodelling or in part functional symptoms caused by comorbid conditions, such as irritable bowel syndrome.…”

Section: Differences and Similarities Between Gord Ppi-ree And Eoementioning

confidence: 99%

“…[3] Endoscopically, nearly all adult EoE patients demonstrate one or more characteristic features of loss of vascular markings, rings, white exudates, longitudinal furrows, narrow caliber oesophagus and strictures, whereas some children may have a visually normal mucosa. [11,12] Reflecting the natural history of oesophageal remodelling, rings and strictures are common in adults but rare findings in children with EoE. [5] Typical EoE endoscopic signs are useful in distinguishing GORD from EoE, but not PPI-REE from EoE [4,7–8,10–11].…”

Section: Differences and Similarities Between Gord Ppi-ree And Eoementioning

confidence: 99%

“…[11,12] Reflecting the natural history of oesophageal remodelling, rings and strictures are common in adults but rare findings in children with EoE. [5] Typical EoE endoscopic signs are useful in distinguishing GORD from EoE, but not PPI-REE from EoE [4,7–8,10–11]. …”

Section: Differences and Similarities Between Gord Ppi-ree And Eoementioning

confidence: 99%

“…Multiple studies have noted that these histologic features are found in both EoE and PPI-REE. These include evidence of superficial distribution of epithelial eosinophils, eosinophil degranulation and microabscess formation, [4,7,8,11], basophil infiltration[10] and the expression of major basic protein and tryptase. [15] Interestingly, a lower rate of response to PPI therapy has been reported in patients with more severe histologic findings including either ≥ 15 eos/HPF at 3 levels of biopsies[16] or increasing degrees of oesophageal eosinophilia.…”

Section: Differences and Similarities Between Gord Ppi-ree And Eoementioning

confidence: 99%

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Proton pump inhibitor-responsive oesophageal eosinophilia: an entity challenging current diagnostic criteria for eosinophilic oesophagitis

Molina–Infante

Bredenoord

Cheng

et al. 2015

Gut

288

216

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Consensus diagnostic recommendations to distinguish gastro-oesophageal reflux disease (GORD) from eosinophilic oesophagitis (EoE) by response to a trial of proton pump inhibitors (PPI) unexpectedly uncovered an entity called “PPI-responsive oesophageal eosinophilia” (PPI-REE). PPI-REE refers to patients with clinical and histologic features of EoE that remit with PPI treatment. Recent and evolving evidence, mostly from adults, shows that PPI-REE and EoE patients at baseline are clinically, endoscopically and histologically indistinguishable, and have significant overlap in terms of features of Th2 immune-mediated inflammation and gene expression. Furthermore, PPI therapy restores oesophageal mucosal integrity, reduces Th2 inflammation and reverses the abnormal gene expression signature in PPI-REE patients, similar to the effects of topical steroids in EoE patients. Additionally, recent series have reported that EoE patients responsive to diet/topical steroids may also achieve remission on PPI therapy. This mounting evidence supports the concept that PPI-REE represents a continuum of the same immunologic mechanisms that underlie EoE. Accordingly, it seems counterintuitive to differentiate PPI-REE from EoE based on a differential response to PPI therapy when their phenotypic, molecular, mechanistic, and therapeutic features cannot be reliably distinguished. For patients with symptoms and histologic features of EoE, it is reasonable to consider PPI therapy not as a diagnostic test, but as a therapeutic agent. Due to its safety profile, ease of administration and high response rates (up to 50%), PPI can be considered a first-line treatment, before diet and topical steroids. The reasons why some EoE patients respond to PPI, while others do not, remain to be elucidated.

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Section: Differences and Similarities Between Gord Ppi-ree And Eoementioning

confidence: 99%

Section: Differences and Similarities Between Gord Ppi-ree And Eoementioning

confidence: 99%

Section: Differences and Similarities Between Gord Ppi-ree And Eoementioning

confidence: 99%

Section: Differences and Similarities Between Gord Ppi-ree And Eoementioning

confidence: 99%

See 2 more Smart Citations

Proton pump inhibitor-responsive oesophageal eosinophilia: an entity challenging current diagnostic criteria for eosinophilic oesophagitis

Molina–Infante

Bredenoord

Cheng

et al. 2015

Gut

288

216

View full text Add to dashboard Cite

show abstract

“…This novel phenotype was recognized in the updated 2011 consensus recommendations on EoE [1] and has been endorsed in all subsequent guidelines [58,59]. However, cumulative evidence to date largely supports the idea that PPI-REE constitutes a subphenotype of EoE rather than a distinct disease entity [60], especially since PPI-REE and EoE remain indistinguishable based not only on clinical, endoscopic [61,62], and histological findings [63], but also on pH monitoring [55], the measurement of biological tissue markers [64][65][66] including cytokines related to eosinophilic inflammation, and esophageal gene transcripts. In addition, monotherapy with PPIs completely reverses cytokine and gene transcript levels in patients with PPI-REE, much in the same way as topical corticosteroids in EoE [67].…”

Section: Drug Therapy Proton Pump Inhibitors: a First-line Therapy Thmentioning

confidence: 99%

Eosinophilic Esophagitis: An Evidence-Based Approach to Therapy

González‐Cervera¹,

Aj²

2016

J Investig Allergol Clin Immunol

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In recent years, several randomized controlled trials and meta-analyses have evaluated the efficacy of the various therapeutic options available for treating patients with eosinophilic esophagitis, including dietary modifications, proton pump inhibitors, topical corticosteroids, and endoscopic esophageal dilation. Proton pump inhibitors are currently considered the first-line treatment for eosinophilic esophagitis, achieving histological remission and improvement of symptoms in 50.5% and 60.8% of patients, respectively. The efficacy of topical corticosteroids in eosinophilic esophagitis has been assessed in several trials. Meta-analyses summarizing results indicate that budesonide and fluticasone propionate are significantly superior to placebo, both in decreasing eosinophil densities in the esophageal mucosa and in relieving symptoms. However, owing to differences in drug delivery, viscous budesonide seems to be the best pharmacological therapy for eosinophilic esophagitis. Results for dietary modifications have been mixed depending on the type of diet prescribed. Thus, while exclusive amino acid-based elemental diets are the most effective in inducing histological remission of eosinophilic esophagitis (90.8%), their severe drawbacks limit their implementation in clinical practice. Allergy testing-based food elimination provides a suboptimal remission rate of 45.5%, although this is lower in adults than in children (32.2% vs 47.9%, respectively). In addition, the various available studies are highly heterogeneous. Empirical 6-food elimination diets were shown to be the best diet-based therapy, with a homogeneous remission rate of 72%. Simpler, more convenient empirical schemes have also been evaluated. The aim of this review is to provide an evidence-based overview on the efficacy of the options available for treatment of eosinophilic esophagitis along with a practical management algorithm.

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Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)

Amil‐Dias,

Oliva,

Papadopoulou

et al. 2024

J. pediatr. gastroenterol. nutr.

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IntroductionEosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus characterized by symptoms of esophageal dysfunction and histologically by predominantly eosinophilic infiltration of the squamous epithelium. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published a guideline in 2014; however, the rapid evolution of knowledge about pathophysiology, diagnostic criteria, and therapeutic options have made an update necessary.MethodsA consensus group of pediatric gastroenterologists from the ESPGHAN Working Group on Eosinophilic Gastrointestinal Diseases (ESPGHAN EGID WG) reviewed the recent literature and proposed statements and recommendations on 28 relevant questions about EoE. A comprehensive electronic literature search was performed in MEDLINE, EMBASE, and Cochrane databases from 2014 to 2022. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of evidence and formulate recommendations.ResultsA total of 52 statements based on the available evidence and 44 consensus‐based recommendations are available. A revision of the diagnostic protocol, options for initial drug treatment, and the new concept of simplified empiric elimination diets are now available. Biologics are becoming a part of the potential armamentarium for refractory EoE, and systemic steroids may be considered as the initial treatment for esophageal strictures before esophageal dilation. The importance and assessment of quality of life and a planned transition to adult medical care are new areas addressed in this guideline.ConclusionResearch in recent years has led to a better understanding of childhood EoE. This guideline incorporates the new findings and provides a practical guide for clinicians treating children diagnosed with EoE.

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PPI-responsive esophageal eosinophilia cannot be distinguished from eosinophilic esophagitis by endoscopic signs

Abstract: Endoscopic signs at baseline endoscopy cannot distinguish EoE from PPI-REE before a PPI trial; the demographic and clinical characteristics in both groups are similar. Endoscopic features do not enable differentiation between PPI-REE and EoE.

Cited by 39 publications

References 28 publications

Proton pump inhibitor-responsive oesophageal eosinophilia: an entity challenging current diagnostic criteria for eosinophilic oesophagitis

Proton pump inhibitor-responsive oesophageal eosinophilia: an entity challenging current diagnostic criteria for eosinophilic oesophagitis

Eosinophilic Esophagitis: An Evidence-Based Approach to Therapy

Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)

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