E' possibile trattare con inibitori di pompa protonica pazienti affetti da esofagite eosinofila precedentemente non-responsivi? Dati preliminari da una piccola coorte di pazienti con EoE

SCOPO Valutare un numero di soggetti con EoE che non avevano avuto risposta alla I linea di trattamento con PPI e avevano iniziato gli steroidi, come II linea. A causa della comparsa di eventi avversi, in un gruppo di pazienti è stato proposto di tornare ad una terapia con PPI per poi valutarne l’esito. MATERIALI E METODI Alla diagnosi, il campione di pazienti è stato interrogato su sintomi, abitudini, comorbidità ed elementi endoscopici-istologici. In tutti i pazienti è stata intrapresa una terapia con steroidi che ha portato a remissione la malattia, ma la comparsa di eventi avversi ha fatto sì che si tornasse ai PPI. RISULTATI Il campione è stato suddiviso in responder (<15 eos/HPF) e non responder alla EGDS a 12 settimane. I pazienti non responder hanno mostrato: maggiore consumo di alcol (p<0.05), maggior numero di episodi di bolus impaction (p=0.022), maggiore ricorrenza di poliposi nasale (p=0.004), un numero maggiore di eosinofili sul tessuto nelle fasi di mancata risposta e in quelle di risposta a steroidi (p<0.005) e maggiore numerosità di eosinofili sistemici (p<0.05). CONCLUSIONI I risultati hanno evidenziato che la terapia con PPI può essere riconsiderata solo in caso di raggiungimento di una risposta con steroidi e di comparsa di effetti avversi steroide-correlati. Questo può essere considerato uno studio pilota che propone il ritorno ai PPI nei pazienti con EoE inizialmente non responder solo in caso di impossibilità a proseguire la terapia con steroidi

Eosinophilic esophagitis: novel concepts regarding pathogenesis and clinical manifestations

Eosinophilic esophagitis is a chronic disease whose incidence and prevalence are increasing, based on a genetic-driven interaction between environment and immune system. Several gene loci involved in the development of the disease have been identified. A two-step mechanism has been hypothesized: a TSLP-induced allergic sensitization followed by upregulation of CAPNA14-related esophageal-specific pathways. Environment seems to have a larger effect than genetic variants. Factors that could play a role are allergens, drugs, colonizing bacteria and possibly Helicobacter Pylori infection. Acting on these modifiable risk factors may be a tool to prevent the disease. EoE is characterized by a typical eosinophilic infiltrate limited to the esophageal epithelium, supported by a Th2-mediated immune response, found in other atopic conditions. The key of the pathogenesis is the disfunction of the epithelial barrier which allow the interaction between allergens and inflammatory cells. Eosinophilic-predominant inflammation leads to the typical wall remodeling, histologically characterized by epithelial and smooth muscle hyperplasia, lamina propria fibrosis and neo-angiogenesis. These alterations find their clinical expression in the pattern of symptoms: dysphagia, food impaction, chest pain, heartburn

Dietary Management of Eosinophilic Esophagitis: Tailoring the Approach

Eosinophilic esophagitis (EoE) is a unique form of non\u2010immunoglobulin E\u2010mediated food allergy, restricted to the esophagus, characterized by esophageal eosinophil\u2010predominant inflammation and dysfunction. The diagnosis requires an esophago\u2010gastroduodenoscopy with esopha-geal biopsies demonstrating active eosinophilic inflammation with 15 or more eosino-phils/high\u2010power field, following the exclusion of alternative causes of eosinophilia. Food allergens trigger the disease, withdairy/milk, wheat/gluten, egg, soy/legumes, and seafood the most com-mon. Therapeutic strategies comprise dietary restrictions, proton pump inhibitors, topical cortico-steroids, biologic agents, and esophageal dilation when strictures are present. However, avoidance of trigger foods remains the only option targeting the cause, and not the effect, of the disease. Be-cause EoE relapses when treatment is withdrawn, dietary therapy offers a long\u2010term, drug\u2010free alternative to patients who wish to remain off drugs and still be in remission. There are currently multiple dietary management strategies to choose from, each having its specific efficacy, ad-vantages, and disadvantages that both clinicians and patients should acknowledge. In addition, dietary regimens should be tailored around each individual patient to increase the chance of tol-erability and long\u2010term adherence. In general, liquid elemental diets devoid of antigens and elimination diets restricting causative foods are valuable options. Designing diets on the basis of food allergy skin tests results is not reliable and should be avoided. This review summarizes the most recent knowledge regarding the clinical use of dietary measures in EoE. We discussed endpoints, rationale, advantages and disadvantages, and tailoring of diets, as well as currently available dietary regimens for EoE

Eosinophilic esophagitis: clinical, endoscopic, histologic and therapeutic differences and similarities between children and adults

In the absence of secondary causes, eosinophilic esophagitis (EoE) is a chronic, local, progressive, T-helper type 2 immune-mediated disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. In the last 20 years, the incidence and prevalence of EoE have risen sharply, and the chances of encountering affected patients in clinics and endoscopy rooms have increased. Nevertheless, it is estimated that the mean diagnostic delay of EoE is 4-6 years in both children and adults. Unfortunately, the longer the disease stays unrecognized, the likelier it is for the patient to have persistent or increased esophageal eosinophilic inflammation, to complain of non-resolving symptoms, and to develop fibrotic complications. Early detection depends on the recognition of initial clinical manifestations that vary from childhood to adulthood and even among patients of the same age. The disease phenotype also influences therapeutic approaches that include drugs, dietary interventions, and esophageal dilation. We have herein reviewed epidemiologic, clinical, endoscopic, and histologic features and therapeutic options of EoE focusing on differences and similarities between children and adults that may certainly serve in daily clinical practice