Eosinophilic esophagitis—established facts and new horizons

Despite dramatic advances in our understanding of the pathogenesis and course of disease in the relatively short timeframe since the discovery and first description of eosinophilic esophagitis (EoE) less than three decades ago, many open questions remain to be elucidated. For instance, we will need to better characterize atypical clinical presentations of EoE and other forms of esophageal inflammatory conditions with often similar clinical presentations, nut fulfilling current diagnostic criteria for EoE and to determine their significance and interrelationship with genuine EoE. In addition, the interrelationship of EoE with other immune-mediated diseases remains to be clarified. Hopefully, a closer look at the role of environmental factors and their interaction with genetic susceptibility often in context of atopic predisposition may enable identifying the candidate substances/agents/allergens and potentially earlier (childhood) events to trigger the condition. It appears plausible to assume that in the end—comparable to current concepts in other immune-mediated chronic diseases, such as for instance inflammatory bowel disease or asthma bronchiale—we will not be rewarded with the identification of a “one-and-only” underlying pathogenetic trigger factor, with causal responsibility for the disease in each and every EoE patient. Rather, the relative contribution and importance of intrinsic susceptibility, i.e., patient-driven factors (genetics, aberrant immune response) and external trigger factors, such as food (or aero-) allergens as well as early childhood events (e.g., infection and exposure to antibiotics and other drugs) may substantially differ among given individuals with EoE. Accordingly, selection and treatment duration of medical therapy, success rates and extent of required restriction in dietary treatment, and the need for mechanical treatment to address strictures and stenosis require an individualized approach, tailored to each patient. With the advances of emerging treatment options, the importance of such an individualized and patient-centered assessment will increase even further

Widely differing screening and treatment practice for osteoporosis in patients with inflammatory bowel diseases in the Swiss IBD cohort study.

Low bone mineral density (BMD) and osteoporosis remain frequent problems in patients with inflammatory bowel diseases (IBDs). Several guidelines with nonidentical recommendations exist and there is no general agreement regarding the optimal approach for osteoporosis screening in IBD patients. Clinical practice of osteoporosis screening and treatment remains insufficiently investigated.In the year 2014, a chart review of 877 patients included in the Swiss IBD Cohort study was performed to assess details of osteoporosis diagnostics and treatment. BMD measurements, osteoporosis treatment, and IBD medication were recorded.Our chart review revealed 253 dual-energy x-ray absorptiometry (DXA) scans in 877 IBD patients; osteoporosis was prevalent in 20% of tested patients. We identified widely differing osteoporosis screening rates among centers (11%-62%). A multivariate logistic regression analysis identified predictive factors for screening including steroid usage, long disease duration, and perianal disease; even after correction for all risk factors, the study center remained a strong independent predictor (odds ratio 2.3-21 compared to the center with the lowest screening rate). Treatment rates for patients with osteoporosis were suboptimal (55% for calcium, 65% for vitamin D) at the time of chart review. Similarly, a significant fraction of patients with current steroid medication were not treated with vitamin D or calcium (treatment rates 53% for calcium, 58% for vitamin D). For only 29% of patients with osteoporosis bisphosphonate treatment was started. Treatment rates also differed among centers, generally following screening rates. In patients with longitudinal DXA scans, calcium and vitamin D usage was significantly associated with improvement of BMD over time.Our analysis identified inconsistent usage of osteoporosis screening and underuse of osteoporosis treatment in IBD patients. Increasing awareness of osteoporosis as a significant clinical problem in IBD patients might improve patient care

Is There a Role for Topical Swallowed Steroids upon Emergency Room Admission for Suspected Food Bolus Obstruction in Eosinophilic Esophagitis?

Since most pharmacological treatments in case of esophageal food impaction (EFI) are unsuccessful, an endoscopy is usually required to resolve EFI. We present the first results of a budesonide orodispersible tablet (BOT) as a medical treatment option before endoscopy. We evaluated all patients with a suspected EFI to receive BOT before emergent endoscopy at a tertiary hospital between March 2019 and June 2020. A total of eight patients received BOT before endoscopy. Mean age was 50.1 years and 87.5% were male. In 38% (3/8) of patients the EFI resolved without endoscopic intervention. No adverse events occurred. After endoscopy, a diagnosis of EoE was established in 75%. This case series demonstrate the potential of BOT as medical rescue therapy in case of EFI

Close follow-up is associated with fewer stricture formation and results in earlier detection of histological relapse in the long-term management of eosinophilic esophagitis.

BACKGROUND AND AIMS No recommendations exist regarding optimal follow-up schedule in patients with eosinophilic esophagitis (EoE) under maintenance treatment. METHODS We retrospectively evaluated a long-term surveillance concept at the Swiss EoE clinic, where clinical, endoscopic and histological disease activity is assessed annually regardless of EoE symptoms. Data on 159 adult patients under maintenance steroid treatment with available follow-up were analyzed. Patients were classified as having close (duration between visits <18 months) or non-close follow-up (≥18 months). RESULTS We analyzed a total of 309 follow-up visits of 159 patients (123 males, age at diagnosis 38.9 ± 15.4 years). 157 (51%) visits were within a close follow-up schedule (median duration between visits of 1.0 years (interquartile range (IQR) 0.9-1.2)), while 152 visits (49%) were not (median duration between visits 2.9 years (IQR 2.0-4.1)). There was no difference regarding ongoing clinical, endoscopic, and histological disease activity, and adherence to prescribed steroid treatment between the two groups. However, stricture formation was significantly less frequently observed at visits within a close follow-up schedule (22.9 vs. 33.6%, p = 0.038). Absence of close follow-up was a significant risk factor for stricture development in a multivariate regression model. Patients who achieved histological remission and were followed within a close-follow-up schedule had significantly earlier detection of histological relapse compared to patients not within such close follow-up. CONCLUSION Close follow-up is associated with fewer stricture formation and appears to result in earlier detection of histological relapse in patients with eosinophilic esophagitis. We advocate for regular assessment of disease activity (every 12-18 months) in order to detect relapsing disease as early as possible, and therefore potentially minimize the risk for EoE complications

The impact of colectomy on the course of extraintestinal manifestations in Swiss inflammatory bowel disease cohort study patients.

BACKGROUND AND AIMS Extraintestinal manifestations are reported to occur in up to 45% of inflammatory bowel disease (IBD) patients during the course of disease. It is unknown whether colectomy reduces the rate of de novo extraintestinal manifestations (EIMs) or impacts on severity of EIMs following a parallel versus independent disease course from underlying IBD. METHODS Using data from the Swiss Inflammatory Bowel Disease Cohort Study we aimed to analyse the course of EIMs in ulcerative colitis (UC) and Crohn's disease (CD) patients undergoing colectomy during the cohort's prospective follow-up. RESULTS One hundred and twenty-one IBD patients (33 CD, 81 UC and seven unclassified) underwent colectomy during prospective follow-up in the Swiss Inflammatory Bowel Disease Cohort Study. Within the 114 patients with UC or CD any EIM was reported in 40 (nine CD and 31 UC) patients. Activity of EIMs ceased entirely after colectomy in 21 patients (52.5%). Complete cessation of EIM after colectomy was higher in patients with UC versus CD with 58.1% versus 33.3%. After colectomy, 29 out of the 114 patients (25.4%) experienced any EIM. Two thirds of these (19 patients) represented persisting EIMs, while in one third (10 patients) EIM represented a de-novo event after colectomy. Overall, 13.5% of IBD patients developed a de-novo EIM after colectomy. CONCLUSIONS In IBD patients undergoing colectomy, EIMs present prior to surgery will persist in about half of patients. Complete cessation of EIM after colectomy may be less common in CD than in UC. In patients who never experienced EIMs prior to colectomy de-novo manifestations thereafter should be expected in up to one in seven patients

Evaluating a calcium-aware kernel for CT CAC scoring with varying surrounding materials and heart rates:a dynamic phantom study

OBJECTIVES: The purpose of this study was twofold. First, the influence of a novel calcium-aware (Ca-aware) computed tomography (CT) reconstruction technique on coronary artery calcium (CAC) scores surrounded by a variety of tissues was assessed. Second, the performance of the Ca-aware reconstruction technique on moving CAC was evaluated with a dynamic phantom. METHODS: An artificial coronary artery, containing two CAC of equal size and different densities (196 ± 3, 380 ± 2 mg hydroxyapatite cm-3), was moved in the center compartment of an anthropomorphic thorax phantom at different heart rates. The center compartment was filled with mixtures, which resembled fat, water, and soft tissue equivalent CT numbers. Raw data was acquired with a routine clinical CAC protocol, at 120 peak kilovolt (kVp). Subsequently, reduced tube voltage (100 kVp) and tin-filtration (150Sn kVp) acquisitions were performed. Raw data was reconstructed with a standard and a novel Ca-aware reconstruction technique. Agatston scores of all reconstructions were compared with the reference (120 kVp) and standard reconstruction technique, with relevant deviations defined as > 10%. RESULTS: For all heart rates, Agatston scores for CAC submerged in fat were comparable to the reference, for the reduced-kVp acquisition with Ca-aware reconstruction kernel. For water and soft tissue, medium-density Agatston scores were again comparable to the reference for all heart rates. Low-density Agatston scores showed relevant deviations, up to 15% and 23% for water and soft tissue, respectively. CONCLUSION: CT CAC scoring with varying surrounding materials and heart rates is feasible at patient-specific tube voltages with the novel Ca-aware reconstruction technique. KEY POINTS: • A dedicated calcium-aware reconstruction kernel results in similar Agatston scores for CAC surrounded by fatty materials regardless of CAC density and heart rate. • Application of a dedicated calcium-aware reconstruction kernel allows for radiation dose reduction. • Mass scores determined with CT underestimated physical mass

Coronary calcium mass scores measured by identical 64-slice MDCT scanners are comparable: a cardiac phantom study

To assess whether absolute mass scores are comparable or differ between identical 64-slice MDCT scanners of the same manufacturer and to compare absolute mass scores to the physical mass and between scan modes using a calcified phantom. A non-moving anthropomorphic phantom with nine calcifications of three sizes and three densities was scanned 30 times on three 64-slice MDCT scanners of manufacturer A and on three 64-slice MDCT scanners of manufacturer B in both sequential and spiral scan mode. The mean mass scores and mass score variabilities of seven calcifications were determined for all scanners; two non-detectable calcifications were omitted. It was analyzed whether identical scanners yielded similar or significantly different mass scores. Furthermore mass scores were compared to the physical mass and mass scores were compared between scan modes. The mass score calibration factor was determined for all scanners. Mass scores obtained on identical scanners were similar for almost all calcifications. Overall, mass score differences between the scanners were small ranging from 1.5 to 3.4% for the total mass scores, and most differences between scanners were observed for high density calcifications. Mass scores were significantly different from the physical mass for almost all calcifications and all scanners. In sequential mode the total physical mass (167.8 mg) was significantly overestimated (+2.3%) for 4 out of 6 scanners. In spiral mode a significant overestimation (+2.5%) was found for system B and a significant underestimation (−1.8%) for two scanners of system A. Mass scores were dependent on the scan mode, for manufacturer A scores were higher in sequential mode and for manufacturer B in spiral mode. For system A using spiral scan mode no differences were found between identical scanners, whereas a few differences were found using sequential mode. For system B the scan mode did not affect the number of different mass scores between identical scanners. Mass scores obtained in the same scan mode are comparable between identical 64-slice CT scanners and identical 64-slice CT scanners on different sites can be used in follow-up studies. Furthermore, for all systems significant differences were found between mass scores and the physical calcium mass; however, the differences were relatively small and consistent