Eosinophilic Esophagitis

CoverPage_978-1-60761-514-9......Page 1
front-matter......Page 2
Eosinophilic Esophagitis......Page 4
Preface......Page 6
Contents......Page 8
Contributors......Page 12
Introduction......Page 18
History of Esophageal Eosinophilia......Page 19
Eosinophilic Gastroenteritis and Colitis......Page 21
Eosinophilic Esophagitis......Page 22
FIGERS......Page 23
Future......Page 24
References......Page 25
Esophageal Mucosal Eosinophilia in Pediatric Patients......Page 28
Geographic Distribution of EoE......Page 29
Presenting Symptoms......Page 30
Racial Distribution......Page 32
Airborne Allergens and Seasonal Variation in EoE......Page 33
Frequency Metrics......Page 34
EoE is Part of an Allergy Epidemic in the Context of the Hygiene Hypothesis......Page 35
Disruption of the Esophageal Epithelial Barrier Contributes to EoE......Page 36
References......Page 37
Introduction......Page 42
Prevalence of Esophageal Eosinophilia......Page 43
Incidence and Prevalence of Eosinophilic Esophagitis......Page 44
Age Distribution, Age at Diagnosis, Age at Onset, Diagnostic Delay......Page 47
Social Status and Education......Page 48
Positive Family History......Page 49
Relevant Questions and Outlook......Page 50
Eosinophilic Esophagitis: A Truly New or Only Newly Recognized Disease?......Page 51
Eosinophilic Esophagitis: A Seasonal or a Perennial Disease?......Page 52
Eosinophilic Esophagitis: An Industrialized or a Westernized Disease?......Page 53
References......Page 54
Introduction......Page 56
The Granule Cationic Proteins......Page 58
Cytokines and Growth Factors......Page 59
Lipid Mediators Expressed By Eosinophils......Page 62
Monitoring of Eosinophil Activity in Disease......Page 63
Eosinophilopoiesis in the Bone Marrow......Page 64
Transcriptional Regulation of Eosinophil Lineage Commitment and Differentiation......Page 65
Eosinophil Mobilization, Trafficking, Survival, and Death at Sites of Tissue Inflammation......Page 67
Activation of Eosinophil Secretion and Degranulation......Page 70
Eosinophil Induction and Regulation of Tissue Remodeling and Fibrosis......Page 72
Pathogenic Mechanisms of Eosinophil-Mediated Tissue Fibrosis......Page 73
References......Page 75
Introduction......Page 88
Lymphocytes and Mast Cells Are Present in the Normal Esophagus......Page 89
Lymphocytes May Play a Role in the Induction of EoE......Page 90
T Lymphocytes in Patients with EoE Carry an Allergic Phenotype......Page 91
Mast Cells Are Increased in Number in the EoE Esophagus......Page 92
Possible Role of Mast Cells in the Pathogenesis of EoE......Page 93
Conclusion......Page 95
References......Page 96
Introduction......Page 100
Esophageal Fibrosis and Remodeling in EoE......Page 101
Transforming Growth Factor beta-1 (TGFβ1)\r......Page 103
Interleukin-5......Page 104
Inflammatory Cells......Page 105
Fibroblasts......Page 106
Correlation of Remodeling with Symptoms and Endoscopy......Page 107
Corticosteroids......Page 108
Anti-IL5......Page 109
IL-13......Page 110
Summary......Page 111
References......Page 112
Introduction......Page 114
The EoE Transcriptome......Page 115
Genetic Risk Variants in EE......Page 117
Conclusion......Page 121
References......Page 122
Introduction......Page 124
Historical Perspective......Page 125
Enumeration of Eosinophils......Page 126
Pathophysiological Mechanisms Associated with Mucosal Eosinophilia......Page 127
Esophageal Eosinophilia......Page 128
Differences Between EoE and Other EGIDs......Page 129
Similarities Between EoE and EGID......Page 130
Summary......Page 131
References......Page 132
Introduction......Page 136
Symptoms......Page 137
Dysphagia......Page 138
Evaluation of Dysphagia......Page 140
Vomiting......Page 141
Other Symptoms......Page 142
The Impact of Chronic Disease......Page 143
References......Page 144
Epidemiology......Page 146
Clinical Features......Page 147
Natural History......Page 148
References......Page 149
Introduction......Page 152
GERD, Through Epithelial Injury or Stimulation, Causes the Production of Cytokines and Other Molecules that Attract Small Numbers of Eosinophils to the Esophagus......Page 153
EoE Contributes to or Causes GERD......Page 154
Anti-inflammatory Effects of PPIs......Page 155
Effects on Inflammatory Cells......Page 156
Clinical Implications of Anti-inflammatory Effects of PPI’s for Esophageal Eosinophilia......Page 157
Potential Role for PPIs in the Pathogenesis of EoE......Page 158
References......Page 159
Introduction......Page 164
Technique for Performing Barium Esophagography......Page 165
Strictures......Page 166
Ringed Esophagus......Page 167
Small-Caliber Esophagus......Page 170
Other Findings......Page 173
Other Radiologic Modalities......Page 174
Esophagography for Suspected Esophageal Perforation......Page 176
Conclusion......Page 179
References......Page 180
Introduction......Page 182
Endoscopy of the Normal Esophagus......Page 183
Concentric Rings......Page 184
Diminished Mucosal Vascularity......Page 186
Crepe-Paper Esophagus......Page 188
Endosonographic Findings......Page 189
Conclusions and Future Directions......Page 190
References......Page 191
Introduction......Page 194
Differential Diagnosis......Page 198
Gastroesophageal Reflux Disease......Page 200
Eosinophils......Page 201
Epithelial Reactivity......Page 202
Dendritic Cells......Page 204
Mast Cells......Page 206
Lymphocytes......Page 208
Lamina Propria......Page 210
References......Page 213
Introduction......Page 218
Approach to Child with Suspected Esophageal Narrowing and EoE......Page 219
Adults......Page 221
Food Impaction......Page 224
Maladaptive Eating Behaviours......Page 225
Psychological Impacts......Page 226
Perforation......Page 227
Esophageal Muscular Inflammation......Page 229
References......Page 230
Introduction......Page 236
Pathophysiology......Page 237
Epidemiology......Page 238
IgE-Mediated Disorders......Page 239
Non-IgE-Mediated (Cell Mediated) Disorders......Page 241
“Mixed” IgE/Non-IgE-Mediated Disorders......Page 244
Diagnosis......Page 245
Management......Page 249
References......Page 250
Atopy and Allergy......Page 256
Prevalence of Atopic Diseases in Eosinophilic Esophagitis Patients......Page 257
Presence of Atopic Family History in Eosinophilic Esophagitis Patients......Page 258
Food Allergy and Eosinophilic Esophagitis......Page 260
Aeroallergens and Eosinophilic Esophagitis......Page 261
Increase in Eosinophilic Esophagitis and Other Atopic Diseases in the General Population......Page 262
Similar Pathophysiology in Eosinophilic Esophagitis and Other Atopic Diseases......Page 266
Summary......Page 267
References......Page 268
Introduction......Page 270
Background......Page 271
Family History......Page 272
Food Allergens......Page 274
Food Skin Prick Testing......Page 276
Food Specific IgE Testing......Page 278
Environmental Allergens......Page 279
Environmental Skin Prick Testing......Page 280
Role of Allergen Avoidance and Implications for Treatment......Page 281
Summary......Page 283
References......Page 284
Introduction: Allergy Testing......Page 286
EoE and Food Allergens......Page 287
EoE and Aeroallergens......Page 288
Skin Prick Testing for Antigen Sensitization......Page 289
Atopy Patch Testing in EoE......Page 290
Assessment of Atopy by Analysis of Blood Samples......Page 293
Food-Specific IgG......Page 294
Conclusion......Page 295
References......Page 296
Introduction......Page 300
Pathophysiology......Page 301
Current Case Series......Page 302
Safety and Potential Complications......Page 309
Conclusion......Page 311
References......Page 312
Introduction......Page 314
Corticosteroids......Page 315
Conclusion......Page 316
References......Page 317
Introduction......Page 318
Swallowed Steroid Therapies......Page 319
Additional Therapies......Page 321
References......Page 322
Case Presentation......Page 324
Systemic Corticosteroids......Page 325
Topical Corticosteroids......Page 326
Conclusion......Page 328
References......Page 329
Introduction......Page 330
Elemental Diet......Page 332
Directed Elimination Diets Based on Results of Allergy Testing......Page 333
Standard Elimination Diet......Page 334
Food Substitutions and Cross-Contamination in Elimination Diets......Page 335
Nutritional Assessment......Page 336
Potential Nutritional and Other Consequences of Elimination Diets......Page 337
References......Page 338
Introduction......Page 340
Estimating Nutritional Requirements......Page 341
Nutritional Concerns with an Elimination Diet......Page 342
Milk Avoidance......Page 343
Soy Avoidance......Page 344
Other Nutrients/Vitamins/Protein/Fat......Page 346
Enteral Tube Feedings......Page 347
Financial Considerations......Page 349
Food Reintroduction......Page 350
Label Reading......Page 351
Patient/Family Education......Page 352
References......Page 353
Introduction......Page 355
Mucosal Immunology and Fundamentals of Oral Tolerance......Page 356
Antigen Processing in the Gastrointestinal Tract......Page 358
Mechanisms of Oral Tolerance......Page 359
Factors Influencing Development of Tolerance......Page 362
References......Page 364
Introduction......Page 368
Neutralization of IgE by Omalizumab......Page 369
Treatment of EoE with Monoclonal Antibodies to IL-5......Page 370
Future Directions......Page 372
References......Page 374
Introduction......Page 378
Clinical Presentations......Page 379
Growth and Nutritional Concerns......Page 380
Behavioral Presentation......Page 381
Conditioned Aversion......Page 384
Management......Page 385
Nutrition......Page 386
Behavioral......Page 387
Implications for Future Study......Page 388
References......Page 389
Introduction......Page 392
Demographics and Illness Characteristics of EoE in Children and Adolescents......Page 393
Impact of EoE on Quality of Life......Page 395
Psychological Adjustment Among Children and Adolescents with Chronic Illness......Page 399
Feeding Disorders......Page 401
Tube Feeding......Page 402
Abdominal Pain......Page 403
Social Stigma and Adherence......Page 404
Coping in Families of Children and Adolescents with EoE......Page 405
Implications for Psychological Care of Children and Adolescents with EoE......Page 406
References......Page 408
Goals of Therapy......Page 412
Evaluation Prior to Initiation of Therapy......Page 414
Initial Therapy for EoE: Drugs, Diet, or Dilation?......Page 416
Patients Refractory to Therapy......Page 421
Treatment of Asymptomatic Patients......Page 422
References......Page 423
Introduction......Page 426
Diagnosis......Page 427
Initial Management......Page 428
Corticosteroids......Page 429
Elemental Diet......Page 430
Dietary Restriction......Page 431
Suggested Approach to the Pediatric Patient with Eosinophilic Esophagitis......Page 432
References......Page 434
INDEX......Page 436