PPI Therapy in Eosinophilic Esophagitis
Background Current diagnostic guidelines recommend that eosinophilic oesophagitis (EoE) should be diagnosed only after GERD is excluded by a lack of response to a trial of acid suppression. There is limited information available providing outcome data about the effectiveness of this approach.
Aim To examine the impact of double-dose proton pump inhibitor (PPI) therapy on symptoms, endoscopic and histological features in patients with documented oesophageal eosinophilia consistent with EoE (≥15 eosinophils/high-power field).
Methods Sixty consecutive symptomatic patients with documented oesophageal eosinophilia received open-label omeprazole 20 mg orally twice daily before meals for 8 weeks. Clinical, endoscopic and histological (resolution: 0–5 eosinophils/HPF, partial improvement: 5–14 eosinophils/HPF), or no improvement: (≥15 eosinophils/HPF) evaluation was repeated at the end of this period. An expert GI pathologist, unaware of the study aims, reviewed all slides.
Results Clinical improvement occurred in 43 (71.6%), endoscopic signs were reduced in 34 (61.8%) and normalised in 12 (21.8%), and histologically, 34 (56.6%) improved, while 15 (25%) obtained complete resolution. Overall, 22 patients (36.7%) obtained both complete clinical and histological remission.
Conclusions More than 50% of patients with documented oesophageal eosinophilic infiltration in the EoE range improved when treated with a double-dose PPI trial for 8 weeks. These findings support the published guidelines recommending a PPI trial prior to diagnosing EoE, and confirm the existence of an eosinophilic oesophageal infiltrationPPI-responsive population.
Eosinophilic oesophagitis (EoE) is an emerging chronic disorder that is considered to be triggered by an aberrant immunological response to a yet-unidentified food or environmental antigen. The incidence and prevalence of EoE are on the increase. EoE is now a world health problem reported in every continent except Africa and has been shown to affect approximately 1 in 1000 subjects.
In 2007, published diagnostic criteria recommended that EoE should be diagnosed only after gastro-oesophageal reflux (GERD) is excluded as evidenced by a 'normal pH monitoring study of the distal oesophagus or lack of response to high-dose proton pump inhibitor (PPI) medication'. Two additional consensus guideline updates have shed further light to this approach, and emphasised that diagnostic testing (pH monitoring) might not adequately distinguish GERD and EoE. Thus, it was recommended that an acid suppressive trial be used to identify a PPI-responsive group of patients with eosinophilic oesophageal infiltration. Despite the publication of these papers, there is very limited information available providing outcome data about the effectiveness of this approach in adult patients in the United States. The actual proportion of patients with oesophageal eosinophilic infiltration that is PPI-responsive is not fully known. Thus, following the release of the 2007 recommendations, we adopted the proposed guidelines to offer a PPI therapeutic trial to all our patients with oesophageal symptoms and documented major eosinophilic infiltration [≥15 eosinophils/high-power field (HPF)]. The purpose of this study was to describe the outcome of this approach, specifically, the symptomatic, endoscopic and histological response rates in a cohort of consecutive adult patients at a tertiary centre.
Abstract and Introduction
Abstract
Background Current diagnostic guidelines recommend that eosinophilic oesophagitis (EoE) should be diagnosed only after GERD is excluded by a lack of response to a trial of acid suppression. There is limited information available providing outcome data about the effectiveness of this approach.
Aim To examine the impact of double-dose proton pump inhibitor (PPI) therapy on symptoms, endoscopic and histological features in patients with documented oesophageal eosinophilia consistent with EoE (≥15 eosinophils/high-power field).
Methods Sixty consecutive symptomatic patients with documented oesophageal eosinophilia received open-label omeprazole 20 mg orally twice daily before meals for 8 weeks. Clinical, endoscopic and histological (resolution: 0–5 eosinophils/HPF, partial improvement: 5–14 eosinophils/HPF), or no improvement: (≥15 eosinophils/HPF) evaluation was repeated at the end of this period. An expert GI pathologist, unaware of the study aims, reviewed all slides.
Results Clinical improvement occurred in 43 (71.6%), endoscopic signs were reduced in 34 (61.8%) and normalised in 12 (21.8%), and histologically, 34 (56.6%) improved, while 15 (25%) obtained complete resolution. Overall, 22 patients (36.7%) obtained both complete clinical and histological remission.
Conclusions More than 50% of patients with documented oesophageal eosinophilic infiltration in the EoE range improved when treated with a double-dose PPI trial for 8 weeks. These findings support the published guidelines recommending a PPI trial prior to diagnosing EoE, and confirm the existence of an eosinophilic oesophageal infiltrationPPI-responsive population.
Introduction
Eosinophilic oesophagitis (EoE) is an emerging chronic disorder that is considered to be triggered by an aberrant immunological response to a yet-unidentified food or environmental antigen. The incidence and prevalence of EoE are on the increase. EoE is now a world health problem reported in every continent except Africa and has been shown to affect approximately 1 in 1000 subjects.
In 2007, published diagnostic criteria recommended that EoE should be diagnosed only after gastro-oesophageal reflux (GERD) is excluded as evidenced by a 'normal pH monitoring study of the distal oesophagus or lack of response to high-dose proton pump inhibitor (PPI) medication'. Two additional consensus guideline updates have shed further light to this approach, and emphasised that diagnostic testing (pH monitoring) might not adequately distinguish GERD and EoE. Thus, it was recommended that an acid suppressive trial be used to identify a PPI-responsive group of patients with eosinophilic oesophageal infiltration. Despite the publication of these papers, there is very limited information available providing outcome data about the effectiveness of this approach in adult patients in the United States. The actual proportion of patients with oesophageal eosinophilic infiltration that is PPI-responsive is not fully known. Thus, following the release of the 2007 recommendations, we adopted the proposed guidelines to offer a PPI therapeutic trial to all our patients with oesophageal symptoms and documented major eosinophilic infiltration [≥15 eosinophils/high-power field (HPF)]. The purpose of this study was to describe the outcome of this approach, specifically, the symptomatic, endoscopic and histological response rates in a cohort of consecutive adult patients at a tertiary centre.