Variability in Diagnostic Criteria for Eosinophilic Esophagitis: A Systematic Review
Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, North Carolina, United States The American Journal of Gastroenterology
(Impact Factor: 10.76).
11/2007; 102(10):2300-13. DOI: 10.1111/j.1572-0241.2007.01396.x
Eosinophilic esophagitis (EoE) is an emerging clinicopathologic entity defined by abnormal esophageal eosinophilic infiltration. Our understanding of this disease is hampered by the lack of a uniform diagnostic standard. The aim of this systematic review was to determine the range of diagnostic strategies and histologic criteria in the EoE literature.
The MEDLINE-indexed literature from 1950 through December 31, 2006 was independently searched by two investigators. To identify additional relevant studies, bibliographies were hand searched, as were the published proceedings of the 2000-2006 American College of Gastroenterology and American Gastroenterological Association national meetings. Data were extracted from all human EoE case reports, case series, cross-sectional and cohort studies, and clinical trials.
Of 318 publications initially identified, 116 original articles, 39 abstracts, and 69 reviews were included. We found 10 different histologic definitions of EoE, ranging from 5 to 30 eosinophils per high-powered field (hpf), though 41 (35%) of the original articles did not state their diagnostic criteria. In the 13 original articles (11%) reporting an hpf area, the eosinophil density per mm(2) varied 23-fold. There was also variation in esophageal biopsy protocols, but specific protocols were reported in just 45 (39%) original articles.
Significant variability in diagnostic criteria for eosinophilic esophagitis exists, and in a large proportion of studies, criteria are not reported. Because of this lack of a common disease definition, conclusions drawn from the cumulative EoE literature should be viewed with caution. A consensus research-quality standard for diagnosis of eosinophilic esophagitis is needed.
- "However, in 1993 Attwood et al.2 reported that EoE was distinct from reflux esophagitis and a separate clinical and pathological condition. EoE is known to be related to allergic conditions; although EoE is a rare disease, its incidence is increased in patients with certain allergic diseases.12,13 "
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ABSTRACT: BACKGROUNDAIMS: Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder of the esophagus. Similar to asthma, EoE can induce irreversible structural changes in the esophagus as a result of chronic and persistent eosinophilic inflammation. The aim of this study was to analyse changes in symptoms, eosinophil counts and endoscopic findings after treatment.
Nine patients with EoE (6 men and 3 women; mean age, 36.44 years) were diagnosed with EoE based on typical symptoms, endoscopic abnormalities and infiltration of the esophageal epithelium with ≥ 15 eosinophils/high-power field. The average endoscopic follow-up period was 10 months, ranging from 1 to 25 months. Symptoms and endoscopic and pathological findings at initial observation and follow-up were evaluated.
Seven of the 9 patients had dysphagia symptoms, which improved in 4 of 6 patients who were treated with proton pump inhibitor. Two patients were unresponsive to proton pump inhibitor and another 2 patients were treated with corticosteroid, which led to symptomatic relief. In 8 patients, esophageal eosinophilia was improved histologically at follow-up after treatment. Six of the 9 patients had typical endoscopic findings of EoE at initial examination. Despite treatment, these findings remained in 5 of the 6 patients at follow-up endoscopy.
After treatment, the symptoms and eosinophil counts were temporarily improved, but the endoscopic findings of EoE were generally not improved. This indicates that deformity of esophageal structure due to eosinophilic inflammation might be irreversible despite proper management.
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Eosinophilic esophagitis (EoE) represents a relatively new, rapidly increasing, chronic inflammatory disease of the esophagus.
To present a review of the recent literature, we performed a PubMed search for eosinophilic esophagitis, pathogenesis, and treatments.
EoE is defined clinicopathologically by esophagus- related symptoms in combination with a dense esophageal eosinophilia, both of which are refractory to treatment with proton pump inhibitors. EoE can affect patients at any age. In adult patients the leading symptom is dysphagia for solids, often leading to food impaction. Children with EoE present mainly with vomiting, thoracic and abdominal pain, and failure to grow. EoE can mimic symptoms and findings associated with gastroesophageal reflux disease. Studies to date suggest an allergy-triggered etiology with an overriding Th2 phenotype. Current treatments include topical and systemic corticosteroids, immunosuppressants, immunomodulators, dilation, and hypoallergic diets.
EoE represents a immune-mediated disease of undetermined pathogenesis. Natural history studies as well as prospective therapeutic trials will be critical to defining future treatment strategies.
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