1 literature review peter r. mcnally, do, facp, facg university colorado denver school of medicine...

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Literature ReviewLiterature Review

Peter R. McNally, DO, FACP, FACGPeter R. McNally, DO, FACP, FACGUniversity Colorado Denver University Colorado Denver

School of MedicineSchool of MedicineCenter for Human SimulationCenter for Human Simulation

Aurora, Colorado 80045Aurora, Colorado 80045

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Kapel RCKapel RC11, Miller JK, Miller JK22, Torres C, Torres C33, Aksoy S, Aksoy S33, , Lash RLash R33 and Katzka DA and Katzka DA22..

Eosinophilic Esophagitis: A Prevalent Disease in Eosinophilic Esophagitis: A Prevalent Disease in the United States that Affects All Age Groups. the United States that Affects All Age Groups.

Gastroenterology. 2008;134:1316-1321Gastroenterology. 2008;134:1316-1321..

1Danbury Hospital, Danbury, Connecticut, 22University of Pennsylvania, Pennsylvania and

3Caris Diagnostics, Irving, Texas

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IntroductionIntroduction• Eosinophilic Esophagitis (EOE) is a condition of Eosinophilic Esophagitis (EOE) is a condition of

increasing recognition among both adults and children.increasing recognition among both adults and children.

• All physicians should consider EOE in the differential All physicians should consider EOE in the differential diagnosis among persons with Upper GI symptoms diagnosis among persons with Upper GI symptoms especially dysphagia, abdominal pain and especially dysphagia, abdominal pain and GERD/dyspepsia.GERD/dyspepsia.

• When endoscopy is performed in these patients, When endoscopy is performed in these patients, proximal esophageal biopsies should be obtained and proximal esophageal biopsies should be obtained and specifically examined for mucosal eosinophils. specifically examined for mucosal eosinophils.

Blanchard C, et al. Eosinophilic Esophagitis: pathogenesis, genetics, and therapy. J Allergy Clin Immunol. 2006;118:1054-1059

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AimAim

• The value of most current reports on EOE are limited by The value of most current reports on EOE are limited by sample bias (derived from tertiary or academic centers) and sample bias (derived from tertiary or academic centers) and small sample size.small sample size.

• The aim of this study was determine the clinical features of The aim of this study was determine the clinical features of EOE among a larger and broader population than EOE among a larger and broader population than previously reported from most academic centers.previously reported from most academic centers.

• This study used a very large computerized pathology This study used a very large computerized pathology database of patients seen at community level practices database of patients seen at community level practices from across the United States (34 states).from across the United States (34 states).

Kapel RC, et al. Gastroent. 2008;134:1316-1321.Kapel RC, et al. Gastroent. 2008;134:1316-1321.

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Study Design:Study Design:Study PopulationStudy Population

• Caris Diagnostic (Irving, Texas) provides GI Caris Diagnostic (Irving, Texas) provides GI pathology support for community based free pathology support for community based free standing endoscopy centers across US.standing endoscopy centers across US.– Case materials derived from 34 statesCase materials derived from 34 states– Majority of patients were adults (98.5% Majority of patients were adults (98.5% >> 18 yr) 18 yr)

• Database consisted of 414,598 patient casesDatabase consisted of 414,598 patient cases• Study Period: 2002-2006, all evaluable cases Study Period: 2002-2006, all evaluable cases

included esophageal biopsiesincluded esophageal biopsies


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Study Design:Study Design:Study PopulationStudy Population

• WinSURGE software used to search the Caris WinSURGE software used to search the Caris Database for the word “eosinophilic” Database for the word “eosinophilic”

• All identified cases reviewed by 3 pathologistsAll identified cases reviewed by 3 pathologists

• Esophageal specimens examined for # eosinophils Esophageal specimens examined for # eosinophils per 400X high-power field, selected from the 5 most per 400X high-power field, selected from the 5 most densely populateddensely populated


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Study Design:Study Design:

Definition of EOEDefinition of EOE

I: Mean EO I: Mean EO >>20/HPF 20/HPF

in 5 HPF in 5 HPF

or or

II: Mean EO II: Mean EO >>30/HPF 30/HPF when < 5 HPF when < 5 HPF availableavailable


Example: >25 eosinophils/HPF

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Study ResultsStudy Results

Esophageal Biopsy Specimens from 74,162 EGD’SEsophageal Biopsy Specimens from 74,162 EGD’S

98% adult (34 states)98% adult (34 states)

2% < 18 yoa (23 states) 2% < 18 yoa (23 states)

217 Referral Centers217 Referral Centers

Cases of Confirmed EOE Identified (total n=363):Cases of Confirmed EOE Identified (total n=363):

308 Criteria I308 Criteria I

55 Criteria II55 Criteria II


99


0

20

40

60

80

100

No

Pat

ien

ts

<18 18-29

30-39

40-49

50-59

60-69

>70

Age Group

Age Distribution of EOE


Total EE, N=363

1010


Demographics of EOE Cases (n=363)Demographics of EOE Cases (n=363)

• ♂ ♂ toto ♀ ♀ ratio of 3:1 (270 to 93) ratio of 3:1 (270 to 93)

• Age range: 1 to 98 yrs, mean 37.6 yrsAge range: 1 to 98 yrs, mean 37.6 yrs• Adult n = 321, Children n = 42Adult n = 321, Children n = 42• #1 Symptom#1 Symptom– Adult Dysphagia 70% Adult Dysphagia 70% – Children GERD 38%Children GERD 38%


1111


0

10

20

30

40

50

60

70

80

Dysphagia

GERD

Pain,N/V


Indication for EGD by gender, p = NS

1212



IndicationIndication ## FrequencyFrequency 95% CI95% CI

DysphagiaDysphagia 225225 70%70% 64.8-75.164.8-75.1

GERD/ GERD/ HeartburnHeartburn

8787 27%27% 22.3-32.322.3-32.3

Abd Pain/Abd Pain/

DyspepsiaDyspepsia

4242 13%13% 9.6-17.39.6-17.3

OdynophagiaOdynophagia 1717 5%5% 3.1-8.33.1-8.3

StrictureStricture 1313 4%4% 2.2-6.82.2-6.8

Indications for EGD in Adult EOE Cases

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IndicationIndication ## FrequencyFrequency 95% CI95% CI

GERD/ GERD/ HeartburnHeartburn

1616 3838 23.6-54.523.6-54.5

Abd Pain/Abd Pain/

DyspepsiaDyspepsia

1313 3131 17.7-47.117.7-47.1

DysphagiaDysphagia 1111 2626 13.9-42.013.9-42.0

Nausea/Nausea/

VomitingVomiting

66 1414 5.4-28.55.4-28.5

Chest PainChest Pain 22 4.84.8 0.6-16.20.6-16.2

Indications for EGD in EOE Cases Younger than 18 yrs

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• The indications for EGD among adults and The indications for EGD among adults and those < 18 yr were varied.those < 18 yr were varied.

– Adults: Dysphagia > GERD > Abd painAdults: Dysphagia > GERD > Abd pain– <18 yr: GERD > Abd pain > Dysphagia<18 yr: GERD > Abd pain > Dysphagia

• Indications for EGD by gender did not vary.Indications for EGD by gender did not vary.


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0

0.5

1

1.5

2

Pre

vale

nce

of

EO

E (

%)

2002 2003 2004 2005

Year

Prevalence of EOE in Pts Dysphagia


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Conclusions:Conclusions:

1.1. EOE is a disorder of increasing prevalenceEOE is a disorder of increasing prevalence

2.2. EOE is found across the nation, and is not confined EOE is found across the nation, and is not confined to tertiary referral or academic institutionsto tertiary referral or academic institutions

3.3. EOE is male gender dominant (EOE is male gender dominant (♂ to ♀ ratio of 3:1)♂ to ♀ ratio of 3:1)

4.4. Presenting Symptoms of EOE vary by Age Group Presenting Symptoms of EOE vary by Age Group Adults: Dysphagia (70%),GERD(27%),Abd pain (13%)Adults: Dysphagia (70%),GERD(27%),Abd pain (13%)<18 yr: GERD (38%), Abd pain(31%),Dysphagia (26%)<18 yr: GERD (38%), Abd pain(31%),Dysphagia (26%)


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Reviewer CommentsReviewer Comments

Kapel, et al, do not answer the following questions?Kapel, et al, do not answer the following questions?

1.1. Why is the diagnosis of EOE more common today?Why is the diagnosis of EOE more common today?a.a. Physician awareness?Physician awareness?b.b. Changes in allergic disorders or precipitating allergens?Changes in allergic disorders or precipitating allergens?

2.2. Why do the many pts present with EOE during middle age?Why do the many pts present with EOE during middle age?

3.3. Why do presenting clinical symptoms vary by age group?Why do presenting clinical symptoms vary by age group?

4.4. Why is EOE dramatically more common among men? Why is EOE dramatically more common among men?


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1.1. Dr. Kapel and colleagues are commended for demonstrating Dr. Kapel and colleagues are commended for demonstrating how a large computerized database from a community level how a large computerized database from a community level health care system of patients with GI disorders can provide health care system of patients with GI disorders can provide enlightening information.enlightening information.

2.2. Although EOE is a disorder more common among men (3:1), Although EOE is a disorder more common among men (3:1), both genders exhibit similar symptoms at presentation with both genders exhibit similar symptoms at presentation with dysphagia #1 among adults and GERD #1 among children.dysphagia #1 among adults and GERD #1 among children.

3.3. Kapel et al, findings emphasize the need for heightened Kapel et al, findings emphasize the need for heightened physician awareness of EOE among community practices physician awareness of EOE among community practices across the US and the need to consider EOE in the differential across the US and the need to consider EOE in the differential diagnosis of persons with a variety of Upper GI digestive diagnosis of persons with a variety of Upper GI digestive complaints.complaints.


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1.1. The clinician is urged to remember that The clinician is urged to remember that EOE may present with a multitude of EOE may present with a multitude of Upper GI complaints. Although Upper GI complaints. Although dysphagia is the most common symptom dysphagia is the most common symptom among adults, EOE should be among adults, EOE should be considered among all patients considered among all patients presenting with symptoms of GERD, presenting with symptoms of GERD, abdominal pain, dyspepsia, chest pain, & abdominal pain, dyspepsia, chest pain, & nausea/vomiting. nausea/vomiting.

2.2. Most endoscopists are in tuned to the Most endoscopists are in tuned to the endoscopic findings of multiple endoscopic findings of multiple esophageal rings and vertical groves, esophageal rings and vertical groves, but need to be vigilant and but need to be vigilant and biopsybiopsy from involved and uninvolved segments from involved and uninvolved segments even in the absence of endoscopic even in the absence of endoscopic findings.findings.


1 literature review peter r. mcnally, do, facp, facg university colorado denver school of medicine...

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