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Low Prevalence of Biopsy-Proven Eosinophilic Esophagitis in Patients with Esophageal Food Impaction in Mexican Population

Authors:
Diego García-Compeán at University Hospital. Autonomous University of Nuevo Leon
Diego García-Compeán
  • University Hospital. Autonomous University of Nuevo Leon
José Alberto González-González at Autonomous University of Nuevo León
José Alberto González-González
JJ Duran-Castro
JJ Duran-Castro
JJ Duran-Castro
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Gilberto Herrera Quiñones at Autonomous University of Nuevo León
Gilberto Herrera Quiñones
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Background Eosinophilic esophagitis (EoE) is the most common cause of dysphagia and esophageal food impaction (EFI) in the USA, Western Europe, and Australia. In Mexico, the uncomplicated form of this disease is infrequent, and prevalence in patients with EFI is unknown. Aims To determine the prevalence and causes of EFI, endoscopic and therapeutic aspects, and establish the prevalence of biopsy-proven EoE in patients with EFI. Methods Diagnostic upper gastrointestinal endoscopy reports from January 2011 to December 2016 were retrospectively reviewed. Patients with therapeutic procedures, gastrointestinal hemorrhage, or non-food foreign body impaction were excluded. The number of patients with EFI was determined. Additionally, patients with esophageal biopsy were retained for EoE prevalence calculation. The diagnosis of EoE was defined with the presence of eosinophil infiltration count ≥ 15/high-power field with or without typical endoscopic abnormalities. Results A total of 4700 reports of the same number of patients were selected; 2209 were males (47%) with a mean age of 57.6 ± 12.3 years (range 14–93). We identified 36 patients with EFI (0.76, 95% CI 0.51–1.01), 16 males (44.4%) with a mean age of 54.9 ± 19.7 (range 22–92). Esophageal biopsies were obtained in 17/36 (47.2%) cases. The diagnosis of EoE was confirmed in 2 patients (11.7%). Peptic stenosis was the most frequent cause of EFI. Conclusions EoE is an infrequent cause of EFI in the Mexican population (11.7%). EoE had the lowest prevalence compared to that reported in Caucasian populations. The prevalence of EFI was also low.
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... Moreover, a Mexican study that included adult patients with esophageal food impaction reported low prevalence (11.7%) of biopsy-proven EoE, whereas peptic stenosis was identified as the most common etiology. 104 These data, despite the several methodological concerns, which confine interpretability (among others retrospective design, various bias or inability to rule-out GERD), are in contrast to previous reports of increasing prevalence rates and might reflect a leveling off of EoE prevalence. ...
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Clinical Features and Treatment Response to Topical Steroids in Ethnic and Racial Minority Patients With Eosinophilic Esophagitis
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  • Oct 2023
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La Infección por Helicobacter pylori se Asocia con Disminución del Riesgo De Esofagitis Eosinofílica en Pacientes Mexicanos
Article
  • Mar 2023
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Incidence and evolution of foreign body impaction in the upper gastrointestinal tract and its relationship with eosionophilic oesophagitis
Article
  • Apr 2022
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Incidencia y evolución de las impactaciones por cuerpos extraños en el tracto digestivo superior y su relación con la esofagitis eosinofílica
Article
  • Dec 2021
Resumen Background: La impactación por cuerpos extraños es una indicación frecuente de endoscopia urgente. Una de las causas de impactación es la esofagitis eosinofílica (EE). Nuestro objetivo es analizar las características de las impactaciones por cuerpos extraños en el esófago y su relación con la esofagitis eosinofílica. Methods: En este estudio retrospectivo, se analizan todas las endoscopias urgentes realizadas por impactación de alimentos y cuerpos extraños en un hospital terciario entre el 1 de septiembre de 2018 y el 1 de septiembre de 2019. Se analizan características clínicas de los pacientes diagnosticados de esofagitis eosinofilica y se comparan con las impactaciones debidas a otros motivos. El seguimiento medio es de 18,7 meses. Results: Se realizaron 693 procedimientos de endoscopia urgentes, de ellos 239 (34%) fueron por impactación por cuerpos extraños. La edad media fue de 63 años y 135 (63%) eran hombres. 36 (17%) de todos los pacientes con impactación fueron diagnosticados de EE. Los factores asociados con la EE son la edad, ser menor de 50 años (OR, 7.3; 95% CI, 1.1-48.4; P=0.04), asma, rinitis y dermatitis atópica (OR, 8.9; 95% CI, 2.3-35.3; P= 0.002), hallazgos endoscópicos como traquealización (OR, 9.7; 95% CI, 1.3-70.9; P= 0.03) y el consumo de fármacos psicotrópicos o antagonistas del calcio (OR, 0.09; 95% CI, 0.009-0.9; P= 0.04). Fallecieron 15 (7%) pacientes, todos sin EE y en 6 fue relacionado con las impactaciones. Discussion: La impactación por cuerpos extraños en el tubo digestivo por EE es una patología frecuente en los servicios de endoscopia de urgencia. Tener menos de 50 años, asma, rinitis, dermatitis atópica, traquealización del esófago y no consumir fármacos psicotrópicos o antagonistas del calcio son factores asociados al diagnóstico de EE. La mortalidad en el seguimiento de los pacientes sin EE es importante.
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The Prevalence of Biopsy-Proven Eosinophilic Esophagitis in Hispanics Undergoing Endoscopy Is Infrequent Compared to Caucasians: A Cross-Sectional Study
Article
Full-text available
  • Dec 2017
  • DIGEST DIS SCI
Introduction: The prevalence of eosinophilic esophagitis (EoE), a chronic, immune-mediated, clinicopathologic, inflammatory disorder, has been well described in the pediatric and adult Caucasian population but not as well studied in the Hispanic population. The major aims of this study are to determine the prevalence and gene expression profile of EoE in these populations. Methods: This is a retrospective cohort study of patients from two institutions predominantly serving a Hispanic population. Patients included at Los Angeles County Hospital (LACH) had an esophagogastroduodenoscopy (EGD) and esophageal biopsies performed for evaluation of dysphagia and/or food impaction, while patients included from the University Hospital Medical Center of El Paso (UHMCEP) had an EGD and esophageal biopsies performed for any appropriate clinical indication. Gene expression analysis which has been shown to accurately diagnose EOE in Caucasians was performed for 9 patients at UHMCEP to determine its accuracy in Hispanics. Results: At LACH, 234 patients were included in the study of whom 155 (66.3%) were Hispanic and 22 (9.4%) were Caucasian. 3.2% of the Hispanic patients and 9.1% of the Caucasian patients were diagnosed with EOE with threefold difference. At UHMCEP 1700 patients were included of whom 1350 (79.4%) were Hispanic and 179 (10.5%) were Caucasian. 0.96% of the Hispanic patients and 7.26% of the Caucasian patients were diagnosed with EOE with a sevenfold difference. Gene expression accurately diagnosed EOE in a small number of both Hispanics and Caucasians who underwent analysis. Conclusions: Hispanic patients at LAC and UMHCEP had a significantly lower prevalence of EOE as compared to Caucasians at these two institutions and a lower prevalence as compared to Caucasians with EOE previously reported in the literature. Gene expression analysis, which has previously been shown to accurately diagnose EOE in Caucasian patients, accurately diagnosed EOE in a small sample of this Hispanic population. Based on this similar gene expression, other factors such as environmental, ethnic, and cultural causes should be investigated to explain the markedly lower prevalence of EOE in Hispanics.
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Eosinophilic esophagitis. The North against the South? A bio-economic-social mechanistic approach and clinical implications
Article
Full-text available
  • Aug 2017
Eosinophilic esophagitis is a chronic antigen-mediated disease characterized by esophageal symptoms, esophageal eosinophilia, and the absence of response to proton pump inhibitors. It is the most frequent cause of dysphagia and food impaction in adults. Its incidence and prevalence is very high in the developed countries (USA, Europe, Australia), where its connotation is that of an emerging epidemic. While studies have been published with large case series in the developed countries, those published in Latin America are small or consist of isolated case reports. The differences in the prevalence of the disease between the developed and developing regions are unknown. Genetic or racial causes have been cited. Nevertheless, the epidemic nature of the disease suggests that environmental causes are the most powerful. Based on the published hypotheses, as well as on epidemiologic studies, the present review discusses some of the possible causes of the disparity in the prevalence of eosinophilic esophagitis between the two types of countries. The ‘hygiene hypothesis’ is reviewed, together with the possible relation of Helicobacter pylori, intestinal parasites, and modifications of the esophageal microbiota in patients with eosinophilic esophagitis. In reference to studies conducted in the United States, the clinical behavior and progression of eosinophilic esophagitis in Hispanics is reviewed and a possible predominant phenotype in Mexican and other Latin American patients is discussed. Finally, based on the above, an algorithm for studying the disease in the Latin American countries is proposed.
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Collaborator in: Guidelines on eosinophilic esophagitis evidence-based statements and recommendations for diagnosis and management in children and adults
Article
Full-text available
  • Jan 2017
Introduction: Eosinophilic esophagitis (EoE) is one of the most prevalent esophageal diseases and the leading cause of dysphagia and food impaction in children and young adults. This underlines the importance of optimizing diagnosys and treatment of the condition, especially after the increasing amount of knowledge on EoE recently published. Therefore, the UEG, EAACI ESPGHAN, and EUREOS deemed it necessary to update the current guidelines regarding conceptual and epidemiological aspects, diagnosis, and treatment of EoE. Methods: General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used in order to comply with current standards of evidence assessment in formulation of recommendations. An extensive literature search was conducted up to August 2015 and periodically updated. The working group consisted of gastroenterologists, allergists, pediatricians, otolaryngologists, pathologists, and epidemiologists. Systematic evidence-based reviews were performed based upon relevant clinical questions with respect to patient-important outcomes. Results: The guidelines include updated concept of EoE, evaluated information on disease epidemiology, risk factors, associated conditions, and natural history of EoE in children and adults. Diagnostic conditions and criteria, the yield of diagnostic and disease monitoring procedures, and evidence-based statements and recommendation on the utility of the several treatment options for patients EoE are provided. Recommendations on how to choose and implement treatment and long-term management are provided based on expert opinion and best clinical practice. Conclusion: Evidence-based recommendations for EoE diagnosis, treatment modalities, and patients’ follow up are proposed in the guideline.
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Proton pump inhibitor-responsive esophageal eosinophilia: Still a valid diagnosis?
Article
Full-text available
  • Apr 2017
Purpose of review: To update rapidly evolving concepts regarding the controversial entity of 'proton pump inhibitor (PPI)-responsive esophageal eosinophilia,' referring to patients with clinical, endoscopic and histologic features of eosinophilic esophagitis (EoE) who achieve remission on PPI therapy. Recent findings: Up to half of pediatric and adult patients with typical EoE symptoms and histology achieve clinico-pathologic remission on PPI therapy, irrespective of whether esophageal pH monitoring demonstrates abnormal acid reflux. In patients with clinical and histologic features of EoE, genotypic and phenotypic features of PPI responders and nonresponders are virtually indistinguishable, and different from those of patients with gastroesophageal reflux disease. In PPI responders, PPIs effects on esophageal Th2 inflammation and gene expression are similar to those of topical steroids in PPI nonresponders. These therapies, along with diets, recently have been shown to be potentially interchangeable in two small series. Summary: Proton pump inhibitor-responsive esophageal eosinophilia is an inappropriate disease descriptor, arbitrarily based on a response to a single drug, and should be abandoned. Patients who have esophageal eosinophilia and esophageal symptoms that resolve with PPI therapy have phenotypic, molecular, mechanistic, and therapeutic features indistinguishable from similar patients who do not respond to PPIs. These patients with PPI responsiveness should be considered within the spectrum of EoE.
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Cómo mejorar el diagnóstico de esofagitis eosinofílica: experiencia de una serie de casos en México
Article
Full-text available
  • Oct 2016
Introducción: La esofagitis eosinofílica (EEo) es un padecimiento crónico e inmunológico mediado por antígenos habitualmente alimentarios. Comparte síntomas inespecíficos con la enfermedad por reflujo gastroesofágico (ERGE). En México es rara vez reportada, tal vez por las características raciales de la población o por una sospecha diagnóstica insuficiente. Objetivos: Describir una cohorte mexicana con EEo. Evaluar la utilidad de la historia clínica y de la endoscopia para diagnosticar EEo al compararla con ERGE. Material y métodos: Estudio retrospectivo de las características clínicas, hallazgos por endoscopia e histopatología de pacientes con EEo. Se realizó además un estudio de casos y controles con ERGE. Las imágenes obtenidas por endoscopia fueron interpretadas de forma ciega y aleatorizada por 4 gastroenterólogos, antes y después de otorgarles información sobre las alteraciones características de la EEo. Las biopsias esofágicas también fueron cegadas a 2 patólogos para evaluar su correlación diagnóstica. El análisis estadístico fue elaborado por pruebas exacta de Fisher y U de Mann-Whitney. Resultados: Se incluyeron 14 pacientes con EEo, 10 (71%) del sexo masculino de 35 años en promedio. En el grupo de EEo hubo más sujetos con historia personal de asma (p = 0.0023) e impactación alimentaria (p = 0.04). La evaluación inicial de los hallazgos endoscópicos mostró el 53% de interpretaciones acertadas para EEo incrementando al 96% en la segunda revisión (sensibilidad 100%, especificidad 71%, VPP 65%, VPN 100%). Conclusiones: Los pacientes con EEo en México tienen características similares a los de series occidentales. La sospecha clínica incrementa el diagnóstico por endoscopia hasta en un 40% cuando se mejora el conocimiento acerca de la enfermedad.
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Prevalence of Eosinophilic Esophagitis and Lymphocytic Esophagitis in Adults with Esophageal Food Bolus Impaction:
Article
Full-text available
  • Jul 2016
Background . The relation of esophageal food bolus impaction (FBI) to eosinophilic esophagitis (EoE) and lymphocytic esophagitis (LyE) is unclear. The aim of this study was to determine the prevalence of EoE and LyE among adults with FBI. Methods . In this retrospective study we analyzed data from all patients referred for gastroscopy during the past 5 years, because of a present or recent episode of FBI. Results . We found 238 patients with FBI (median age 51 (17–96), 71% males). Endoscopic therapy was required in 143 patients. Esophageal biopsies were obtained in 185 (78%) patients. All biopsies were assessed for numbers of eosinophils and lymphocytes. EoE was found in 18% of patients who underwent biopsy. We found 41 patients (22%) who fulfilled the criteria for both EoE and LyE (EoE/LyE). LyE was found in the 9% of patients with FBI. EoE together with EoE/LyE was the leading cause of FBI in patients ≤50 years (64%). GERD was the leading cause of FBI among patients older than 50 years (42%). Conclusions . Our study showed that EoE was the leading cause of FBI in particular among young adults. Our study highlights the need for esophageal biopsies in any patient with FBI.
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Pathophysiology of Eosinophilic Esophagitis
Article
  • Jul 2017
  • GASTROENTEROLOGY
Eosinophilic esophagitis (EoE) is an emerging disease that is distinguished from gastroesophageal reflux disease (GERD) by the expression of a unique esophageal transcriptome and the interplay of early life environmental factors with distinct genetic susceptibility elements at 5q22 (TSLP) and 2p23 (CAPN14). Rare genetic syndromes have uncovered the contribution of barrier disruption, mediated in part by defective desmosomes and dysregulated transforming factor beta (TGF-β) production and signaling, to EoE pathophysiology. Experimental modeling has defined a cooperative role of activated eosinophils, mast cells, and the cytokines IL-5 and IL-13, mediated by allergic sensitization to multiple foods. Understanding these processes is opening the way to better treatment based on disrupting allergic inflammatory and T helper type 2 cytokine–mediated responses including anti-cytokine therapeutics and dietary therapy.
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Oesophageal narrowing on barium oesophagram is more common in adult patients with eosinophilic oesophagitis than PPI-responsive oesophageal eosinophilia
Article
  • Mar 2016
  • ALIMENT PHARM THER
Background To date there have been no clear features that aid in differentiating patients with eosinophilic oesophagitis (EoE) from PPI-responsive oesophageal eosinophilia (PPI-REE). However, barium swallow roentgenography is a more sensitive and specific measure to detect subtle fibrostenotic remodeling changes present in EoE. We aim to characterise any clinical, endoscopic, histiological or barium roentgenographic differences between EoE and PPI-REE. AimTo characterise any clinical, endoscopic, histiological or barium roentgenographic differences between EoE and PPI-REE. Methods We performed a retrospective cohort analysis on data collected from a tertiary referral centre population from 2010 to 2015. Data from 66 patients with EoE and 28 patients with PPI-REE were analysed. Cases were adults who met consensus guidelines for EOE, and had a barium swallow study within 6 months of the index endoscopy. Clinical, endoscopic, histiological and barium swallow findings were collected. ResultsPatients with EoE reported similar characteristics as PPI-REE patients, except EoE patients were younger (35.6 vs. 46.6 years; P = 0.011), had earlier symptom onset (29.0 vs. 38.0 years; P = 0.026), and smaller oesophageal diameters on barium swallow (19.5 mm vs. 20; P = 0.042). Patients with EoE were more likely to have distal strictures (EoE 77% vs. 25%; P = 0.02) and, importantly, a greater likelihood of small calibre oesophagus (51.5% vs. 17.9%; P = 0.002). Moreover, EoE patients had a higher probability of developing small calibre oesophagus after 20 years of symptoms (72.3% vs. 30.2%; P = 0.074) compared to PPI-REE patients. Conclusions When compared with eosinophilic oesophagitis, PPI-REE patients demonstrate findings that suggest PPI-responsive oesophageal eosinophilia to be a later onset, less aggressive form of oesophageal stricturing disease than eosinophilic oesophagitis.
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Editorial: Eosinophilic Esophagitis Dilation in the Community—Try It—You will Like It—But Start Low and Go Slow
Article
  • Feb 2016
The saga of esophageal dilation for patients with eosinophilic esophagitis and strictures reads like a historical novel. Currently, data from over 500 eosinophilic esophagitis (EoE) patients now convincingly prove that esophageal dilation is effective for prolonged relief and safe. It can easily be performed in the gastroenterologists community but follow the basic tenets of starting low with small diameter bougies/balloons and progressing slowly as you gradually dilate these strictures to 16–18 mm. Table 1 outlines my approach.
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