fluticasone and Esophagitis

People with eosinophilic esophagitis (EE) have clinical symptoms of esophageal disease, an elevated intraepithelial eosinophil count (15 in one or more high power field at endoscopy), consistent endoscopic findings and failure to respond to gastric acid suppressants. The cause of EE is unknown, however dietary, environmental and immunological factors may contribute. Current medical therapies include steroids, dietary manipulation, mast cell inhibitors, leukotriene receptor antagonists and immune modulators; however there is no universal approach to treatment.. To evaluate the benefits and harms of medical interventions for EE.. We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group trials register (The Cochrane Library Issue 1, 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2009), MEDLINE (1966 to February 2009) and EMBASE (1980 to February 2009).. Randomised controlled trials (RCTs) comparing a medical or dietary intervention for EE with a placebo or with another medical intervention.. Two reviewers independently screened the titles of abstracts.. Three RCTs fulfilled inclusion criteria, two in children and one in adults. In one trial, topical fluticasone decreased vomiting more than placebo (67% versus (vs) 27%, P<0.05) but did not improve dysphagia. Histological remission was reported in fluticasone group compared with placebo group (50% vs 9%, P=0.05; RR 5.5, 95%CI 0.81 to 37.49). One recipient of fluticasone developed oral candidiasis. In trial comparing fluticasone with oral prednisone, symptom resolution and improvement of esophagitis were similar. Majority of participants were symptom free at four weeks with no difference between groups (RR 1.03, 95%CI 0.95 to 1.11). Symptom relapse usually occurred within six weeks of stopping therapy and 45% had symptom relapse at six month follow-up with no difference between groups. With prednisone, 40% suffered adverse effects and three withdrew early from treatment with severe adverse effects (hyperphagia, weight gain, cushingoid features). With fluticasone, 15% developed esophageal candidiasis and 45% had relapse in symptoms at week 24. Histological improvement occurred in majority at four weeks with no difference between groups. In the third trial comparing mepolizumab to placebo, there was no difference in symptom response with mepolizumab compared to placebo, but decrease in esophageal eosinophil count was greater with mepolizumab than placebo (67% vs 25%).. As only three relevant RCTs were identified, we have limited capacity to compare the benefits and harms of medical interventions currently used for treating EE. Further RCTs on therapies for EE are required.

Topics: Adult; Androstadienes; Anti-Inflammatory Agents; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Child; Eosinophilia; Esophagitis; Fluticasone; Humans; Prednisone; Randomized Controlled Trials as Topic

Eosinophilic oesophagitis is a chronic inflammatory disease of the esophagus, frequently associated with allergic syndromes and increasingly diagnosed in patients presenting with episodic dysphagia. Topical steroid therapy and endoscopic dilation achieve control of symptoms and a good quality of life in most of patients.

Topics: Administration, Topical; Androstadienes; Anti-Inflammatory Agents; Diagnosis, Differential; Diet; Eosinophilia; Esophagitis; Esophagoscopy; Fluticasone; Humans; Immunologic Factors

Eosinophilic esophagitis (EE) and gastroesophageal reflux disease (GERD) have overlapping clinical, manometric, endoscopic and histopathologic features. The diagnosis of EE is nowadays based upon the presence of 15 or more eosinophils per high power field (eo/HPF) in esophageal biopsies. We report the cases of two young males suffering from dysphagia and recurrent food impaction with reflux esophagitis and more than 20 eo/HPF in upper-mid esophagus biopsies, both of which became asymptomatic on proton pump inhibitor (PPI) therapy. The first patient also achieved a histologic response, while EE remained in the other patient after effective PPI treatment, as shown by 24-h esophageal pH monitoring. Topical steroid therapy combined with PPI led to complete remission in this latter patient. GERD and EE may be undistinguishable, even by histology, so diagnosis of EE should only be established after a careful correlation of clinical, endoscopic and pathologic data obtained under vigorous acid suppression. These diagnostic difficulties are maximal when both diseases overlap. Limited data are available about this topic, and the interaction between EE and GERD is a matter of debate. In this setting, upper-mid esophagus step biopsies and esophageal pH monitoring of patients on PPI therapy are pivotal to evaluate the role of each disease. A PPI trial is mandatory in patients with a histopathologic diagnosis of EE; in those unresponsive to PPI treatment, EE should be suggested. However, a clinical response to PPI may not rule out quiescent EE, as shown in this report.

Topics: Adult; Androstadienes; Anti-Inflammatory Agents; Eosinophilia; Esophagitis; Esophagitis, Peptic; Esophagus; Fluticasone; Humans; Male; Proton Pump Inhibitors

To review recently published studies presenting novel and relevant information on some esophageal infectious, inflammatory and injurious diseases.. In the treatment of Candida esophagitis, fluconazole remains the treatment of choice, but clinical failures indicate new therapeutic opportunities, like two new echinocandins, micafungin and anidulafungin. Eosinophilic esophagitis is an increasingly recognized entity. New therapeutic insights come from a six-food elimination diet in children and from fluticasone propionate in adults; humanized monoclonal IgG antibody anti-interlukin-5, mepolizumab, has been shown to decrease eosinophilia and ameliorate symptoms. There has been some advance in microscopic characterization of lymphocytic esophagitis. Esophagitis is found to be present in 67% of patients with pemphigo vulgaris, in 32.3% of patients with systemic sclerosis and to be associated with thoracic neoplasias. In the case of caustic ingestion, endoscopic ultrasound with miniprobes has proven not to be better than videoendoscopy. Recent evidence shows that systemic steroids might even be harmful. Mitomycin C applied on fresh wounds is currently being evaluated. Stenting of the stricture has been proposed for contrasting esophageal remodeling.. These recent findings, together with a better understanding of diseases such as eosinophilic or lymphocytic esophagitis, allow new diagnostic and therapeutic approaches.

Topics: Androstadienes; Anti-Inflammatory Agents; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Antifungal Agents; Antineoplastic Agents; Biomarkers; Candidiasis; Caustics; Diet; Eosinophilia; Esophagitis; Esophagus; Fluticasone; Humans; Radiotherapy

Patients with eosinophilic oesophagitis (EO) present with difficulty swallowing, vomiting, regurgitation, chest and/or abdominal pain. People with EO frequently fail to respond to treatment with gastric acid suppressants or anti-reflux surgery.. To evaluate the benefits and harms of medical interventions for eosinophilic oesophagitis.. We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group trials register (The Cochrane Library Issue 1, 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to February 2004) and EMBASE (1980 to February 2004).. Randomised controlled trials were included if they compared a medical or dietary intervention for eosinophilic oesophagitis with a placebo or one medical intervention with another medical intervention.. Two reviewers independently screened the title of abstracts.. No completed RCTs were found in the published literature. We found one abstract reporting preliminary data from an RCT (not completed) comparing oral prednisolone with topical (swallowed metered dose) fluticasone in children. In this study (50 children enrolled to date) healing rates of oesophagitis and symptom resolution with fluticasone were similar to those with prednisolone. For another ongoing RCT, comparing the efficacy of swallowed fluticasone with placebo for eosinophilic oesophagitis in males and females aged 3 to 21 years no results are available.. The lack of completed RCT's makes it impossible to compare the relative benefits and harms of the wide range of medical interventions currently used for treating EO. Published case series suggest that an elemental diet, oral steroids and topical steroids all offer some benefits. However, lack of a comparison group in these studies makes it impossible to evaluate the effect of these interventions.

Topics: Androstadienes; Anti-Inflammatory Agents; Eosinophilia; Esophagitis; Fluticasone; Humans; Prednisone

Both gastroesophageal reflux disease and allergy/atopy have been implicated in the pathogenesis of eosinophilic esophagitis (EoE). There are no prospective studies comparing treatment of EoE with acid suppression versus topical corticosteroids.. To determine the outcome of adult eosinophilic esophagitis patients treated with esomeprazole versus topical fluticasone.. Prospective randomized controlled trial.. Academic medical center.. Adults (18-80) diagnosed with EoE by symptoms of dysphagia and esophageal biopsies with >or=15 eosinophils/hpf.. Subjects were randomized to esomeprazole (40 mg by mouth every morning) or aerosolized, swallowed fluticasone (440 mcg by mouth twice a day) for 8 weeks.. Improvement in dysphagia (8-point scale), esophageal eosinophil infiltration before and after treatment, prevalence of GERD measured by validated questionnaire and baseline pH study.. About 56% (14/25) had acid reflux by pH study. There was no difference between treatment groups in improvement in dysphagia scores [3/12 (25%) of the esomeprazole group versus 6/12 (50%) in the fluticasone group, P = 0.40]. Eosinophil infiltration decreased with treatment in both groups, and there was no difference in the amount of decrease between groups (P = 0.70).. Small sample size, unexpectedly high drop-out rate.. Gastroesophageal reflux disease is common in adult eosinophilic esophagitis patients. Dysphagia improves and esophageal eosinophilic infiltration decreases with either treatment. There was no difference in degree of improvement in dysphagia or eosinophil infiltration in patients treated with either topical fluticasone or oral esomeprazole. GERD may be important in the pathogenesis of adult EoE.

Topics: Administration, Oral; Adolescent; Adult; Aerosols; Aged; Androstadienes; Anti-Inflammatory Agents; Anti-Ulcer Agents; Eosinophilia; Esomeprazole; Esophagitis; Female; Fluticasone; Humans; Male; Middle Aged; Prospective Studies; Statistics, Nonparametric; Treatment Outcome

Although eosinophilic esophagitis is recognized increasingly, outcome data guiding therapy are limited. We conducted a prospective randomized trial comparing oral prednisone (P) and swallowed fluticasone (F) for histologic and clinical response.. Patients were randomized to receive P or F for 4 weeks, followed by an 8-week weaning protocol. Esophageal histology was evaluated at baseline and after 4 weeks of therapy. Clinical assessments were performed at weeks 0, 4, 12, 18, and 24.. Eighty patients with eosinophilic esophagitis were enrolled: 40 in the P arm and 40 in the F arm. Histologic improvement was seen in 30 of 32 P and 34 of 36 F patients, with a greater degree of histologic improvement in the P group. All P and 35 of 36 F patients were free of presenting symptom(s) at week 4. Symptom relapse was seen in 45% of patients by week 24. Kaplan-Meier analysis showed no difference between P and F with regard to relapse rate (P = .7399). No significant difference in time to relapse was found between groups (P = .2529). Systemic adverse effects were noted in 40% of the P arm, whereas esophageal candidal overgrowth was seen in 15% of the F arm.. Systemic and topical corticosteroids were effective in achieving initial histologic and clinical improvement. P resulted in a greater degree of histologic improvement, without evidence of an associated clinical advantage over F in terms of symptom resolution, relapse rates, or time to relapse. Symptom relapse was common to both groups upon therapy discontinuation, highlighting the need for maintenance treatment protocols.

Topics: Administration, Oral; Adolescent; Androstadienes; Child; Child, Preschool; Esophagitis; Esophagus; Female; Fluticasone; Humans; Infant; Male; Mycoses; Prednisone; Prospective Studies; Recurrence; Severity of Illness Index; Treatment Outcome

Eosinophilic esophagitis is an increasingly recognized disorder with distinctive endoscopic, histologic, and allergic features. Although several therapies are advocated, no placebo-controlled trials have been conducted. We aimed to determine the efficacy of swallowed fluticasone propionate (FP) in the treatment of eosinophilic esophagitis.. We conducted a randomized, double-blind, placebo-controlled trial of swallowed FP in pediatric patients with active eosinophilic esophagitis. Thirty-six patients were randomly assigned to receive either 880 mug of FP (21 patients) or placebo (15 patients) divided twice daily for 3 months. The primary end point was histologic remission, defined by a peak eosinophil count of

Topics: Adolescent; Age Factors; Androstadienes; Body Height; Body Weight; CD8-Positive T-Lymphocytes; Child; Child, Preschool; Double-Blind Method; Eosinophilia; Esophagitis; Female; Fluticasone; Humans; Hyperplasia; Infant; Male

Eosinophilic esophagitis (EoE) is a disorder characterized by a severe, isolated eosinophilic infiltration of the esophagus unresponsive to aggressive acid blockade but responsive to the removal of dietary antigens. We present information relating to our 10-year experience in children diagnosed with EoE.. We conducted a retrospective study between January 1, 1994, and January 1, 2004, to evaluate all patients diagnosed with EoE. Clinical symptoms, demographic data, endoscopic findings, and the results of various treatment regimens were collected and evaluated.. A total of 381 patients (66% male, age 9.1 +/- 3.1 years) were diagnosed with EoE: 312 presented with symptoms of gastroesophageal reflux; 69 presented with dysphagia. Endoscopically, 68% of patients had a visually abnormal esophagus; 32% had a normal-appearing esophagus despite a severe histologic esophageal eosinophilia. The average number of esophageal eosinophils (per 400 x high power field) proximally and distally were 23.3 +/- 10.5 and 38.7 +/- 13.3, respectively. Corticosteroids significantly improved clinical symptoms and esophageal histology; however, upon their withdrawal, the symptoms and esophageal eosinophilia recurred. Dietary restriction or complete dietary elimination using an amino acid-based formula significantly improved both the clinical symptoms and esophageal histology in 75 and 172 patients, respectively.. Medications such as corticosteroids are effective; however, upon withdrawal, EoE recurs. The removal of dietary antigens significantly improved clinical symptoms and esophageal histology in 98% of patients.

Topics: Administration, Oral; Androstadienes; Anti-Inflammatory Agents; Biopsy; Child; Cromolyn Sodium; Endoscopy, Gastrointestinal; Eosinophilia; Esophagitis; Female; Fluticasone; Follow-Up Studies; Humans; Male; Methylprednisolone; Retrospective Studies; Treatment Outcome

Sloughing esophagitis is an uncommon entity with an unclear pathogenesis characterized by desquamating sheets of squamous mucosa. It has been associated with bullous dermatologic disorders, other autoimmune diseases and has been most commonly reported in elderly, debilitated individuals on multiple medications.. We report sloughing esophagitis in a previously healthy 17 year-old girl. While the initial trigger of her esophagitis is unclear, she improved with proton pump inhibitor therapy and swallowed fluticasone, with complete resolution after 6 months.. Sloughing esophagitis can occur in the pediatric population. We discuss the presentation, differential diagnosis, and treatment of sloughing esophagitis in adolescents.

Topics: Adolescent; Anti-Inflammatory Agents; Esophagitis; Female; Fluticasone; Humans; Proton Pump Inhibitors

We report a case of a 43 year old male patient, who was admitted with recurring esophageal bolus impactions. Since his childhood he has been complaining about dysphagia and was unable to swallow medication. He also complained about heartburn. The last esophageal bolus impaction was some weeks ago. After elimination of the bolus impaction with a rigid endoscope we found a high grade stenosis in the proximal esophagus that could not even be passed with a children's endoscope. An initial treatment of eosinophil esophagitis would be the therapy with a local corticoid for 6-9 month. In patients with typical rings or stenosis a dilation therapy might be necessary.

Topics: Administration, Oral; Adult; Androstadienes; Catheterization; Combined Modality Therapy; Deglutition Disorders; Diagnosis, Differential; Endoscopy, Digestive System; Eosinophilia; Esophageal Stenosis; Esophagitis; Fluticasone; Heartburn; Humans; Male; Prednisolone; Recurrence

Eosinophilic esophagitis (EE) involves marked accumulation of eosinophils in the esophageal mucosa that responds to swallowed fluticasone propionate (FP) in a subset of patients.. We aimed to uncover the mechanism of action of swallowed FP in patients with EE by providing evidence for a topical effect in the esophagus by identifying a molecular signature for FP exposure in vivo.. Global microarray expression profiles, immunofluorescence microscopy, and cell signaling in esophageal tissue and cell lines were analyzed.. Thirty-two transcripts exhibited altered expression in patients who responded to swallowed FP treatment. Esophageal FK506-binding protein 5 (FKBP51) mRNA levels were increased (P < .05) in FP responders compared with those seen in control subjects and patients with untreated active EE. After FP treatment of esophageal epithelial cells, FKBP51 mRNA and protein levels were increased in a dose- and time-dependent manner by FP treatment in vitro. FP-induced FKBP51 was steroid receptor dependent because RU486 completely inhibited gene and protein induction. The half-life of FKBP51 mRNA was 16 to 18 hours independent of FP treatment. FKBP51 overexpression reduced FP action as assessed by FP inhibition of IL-13-induced eotaxin-3 promoter activity.. Our results suggest that swallowed glucocorticoid treatment directly affects esophageal gene expression in patients with EE. In particular, increased FKBP51 transcript levels identify glucocorticoid exposure in vivo and distinguish FP responders from untreated patients with active EE and patients without EE. In addition, FKBP51 reduces glucocorticoid-mediated inhibition of IL-13 signaling in epithelial cells in vitro, suggesting that FKBP51 might influence FP responsiveness. We propose that esophageal FKBP51 levels have diagnostic and prognostic significance in patients with EE.

Topics: Adolescent; Androstadienes; Cell Line; Cells, Cultured; Child; Child, Preschool; Eosinophilia; Epithelial Cells; Esophagitis; Esophagus; Female; Fluticasone; Gene Expression Profiling; Gene Expression Regulation; Glucocorticoids; Humans; Infant; Interleukin-13; Male; Oligonucleotide Array Sequence Analysis; Proteins; Tacrolimus Binding Proteins; Young Adult

Eosinophilic esophagitis (EE) is an emerging disorder with poorly understood pathogenesis.. Whereas prior studies have primarily focused on the role of eosinophils in disease diagnosis and pathogenesis, this study investigates the involvement of mast cells.. Total and degranulated mast cell counts were correlated to microarray and RT-PCR data to generate transcriptome expression profiles related to mast cell number and degranulation in patients with EE and healthy control subjects.. Esophageal mastocytosis and mast cell degranulation were readily apparent in patients with EE compared with control subjects (P < .01), as assessed by staining for total mast cells and the presence of extracellular mast cell tryptase (P < .01). Microarray analysis revealed that mast cell levels correlated with the dysregulation of 0.8% (301 genes) of the genome, which was partially distinct from the genes that correlated with tissue eosinophilia. The expression of transcripts for the mast cell proteases carboxypeptidase A3 and tryptase, but not chymase, correlated with mast cell levels and distinguished patients with EE from control subjects. Suprabasilar mast cell counts (P < .01) and degranulation (P < .01) were proportional with KIT ligand mRNA expression. Treatment of patients with EE with swallowed fluticasone propionate normalized levels of mast cells and the mast cell-related transcriptome in responder patients.. Herein we have identified local mastocytosis and mast cell degranulation in the esophagi of patients with EE; identified an esophageal mast cell-associated transcriptome that is significantly divergent from the eosinophil-associated transcriptome, with carboxypeptidase A3 mRNA levels serving as the best mast cell surrogate marker; and provided evidence for the involvement of KIT ligand in the pathogenesis of EE.

Topics: Adolescent; Adult; Androstadienes; Carboxypeptidases A; Cell Degranulation; Child; Child, Preschool; Eosinophilia; Esophagitis; Female; Fluticasone; Gene Expression Profiling; Humans; Infant; Male; Mast Cells; Stem Cell Factor

Eosinophilic esophagitis (EE) is a motility disorder of the esophagus that typically presents with dysphagia. The objective of the present study was to explore patient characteristics, clinical and endoscopic features, and response to treatment of patients with EE. Patients were selected retrospectively based on a review of biopsy results from previous endoscopies performed between 2004 and 2008. A total of 54 patients (41 men and 13 women) with biopsy-proven EE were included in the study. Further information regarding the patients' clinical and endoscopic features, and response to treatment were obtained through chart reviews and patient telephone interviews. The mean age of the patients at symptom onset was 30 years. All patients complained of dysphagia, 81% had a history of bolus obstruction, 43% had a history of asthma and 70% had a history of environmental allergies. Thirty-three per cent had a family history of asthma, while 52% had a family history of food or seasonal allergies. The most common endoscopic findings were rings and⁄or corrugations, which were found in 63% of patients. Swallowed fluticasone therapy resulted in symptom resolution in 74% of patients; however, 79% of these patients relapsed after discontinuing fluticasone therapy and required repeat treatments. Esophageal dilation was complication free and resulted in improvement in 80% of patients. However, 83% of those reporting improvement relapsed within one year. The clinical and endoscopic findings were similar to those found in the literature, with most patients requiring ongoing, repeated therapies. Further studies are needed to assess the safety and efficacy of treatment modalities ideally suited to patients with EE.

Topics: Adolescent; Adult; Aged; Androstadienes; Anti-Inflammatory Agents; Deglutition Disorders; Dilatation; Eosinophilia; Esophagitis; Esophagoscopy; Female; Fluticasone; Humans; Male; Middle Aged; Recurrence; Retrospective Studies; Treatment Outcome; Young Adult

A 17-year-old patient was transferred to the emergency room with an impacted food bolus by colleagues from the Department of Otorhinolaryngology. The examination of ear, nose and throat revealed significant amounts of saliva in both recessus piriformis, a radiologic examination of the esophagus showed a foreign body with a diameter of 1.6 cm in the region of the transitional zone of esophagus and stomach with a support level of the contrast medium. Clinical examination and laboratory tests showed no abnormalities. An emergency gastroscopy was performed. The foreign body, already evident in the barium swallow, was found in the distal esophagus. The foreign body was identified as a food bolus and gently advanced into the stomach with the aid of the gastroscope. In the stomach further food residues were detected and the examination was aborted because of increased risk of aspiration. On the next day, an elective gastroscopy was performed. Several biopsies were obtained from the esophagus because eosinophilic esophagitis (EE) was suspected due to clinical symptoms. Histological work-up showed a significant amount of eosinophilic granulocytes (> 15 eosinophils/HPF, 400 x) and reactive changes in the distal esophagus. Therefore, EE was diagnosed. Fluticasone therapy led to amelioration of symptoms and there was no evidence of recurring bolus impaction during follow-up.

Topics: Administration, Inhalation; Adolescent; Androstadienes; Anti-Inflammatory Agents; Biopsy; Bread; Diagnosis, Differential; Eosinophilia; Esophagitis; Esophagogastric Junction; Fluticasone; Foreign Bodies; Gastric Mucosa; Gastroscopy; Humans; Male; Recurrence; Respiratory Hypersensitivity

Eosinophilic esophagitis (EE) is a clinical entity that is recognized increasingly in children. The treatment of EE has been debated since its identification as a clinical entity separate from reflux esophagitis. We hypothesize that the treatment with a high-dose proton pump inhibitor (HDPPI) helps differentiate EE from noneosinophilic esophagitis (NEE).. Retrospective review of 2221 patients who underwent esophagogastroduodenoscopy (EGD) with biopsies was undertaken. Sixty-nine patients had more than or equal to 15 eosinophils/high-power field (eos/HPF) in 1 or more esophageal levels. Of those, 36 were initially treated with HDPPI for 3 months followed by repeat EGD. Patients who demonstrated histologic response were classified as NEE. Patients with no histologic response were diagnosed as having EE and treated with HDPPI+swallowed fluticasone for 3 months followed by repeat EGD.. Of the 36 patients, histologic response was seen in 14 (39%) after treatment with HDPPI; 95% confidence interval (0.23-0.54). Swallowed fluticasone was added to the treatment of the 22 patients who did not show histologic response to HDPPI alone. Of those, 15 patients underwent repeat endoscopies. Seven patients were lost to follow-up or did not have repeated EGDs. Histologic response was observed in 9 of 15 (60%) patients. Of the nonresponders (6 of 15), 5 of 6 (83%) self-reported noncompliance with the swallowed fluticasone. Patients with more than or equal to 15 eos/HPF at all 3 levels (25 of 36) were less likely to respond to HDPPI alone and more likely to be categorized as EE (18 of 25), P=or<0.043. Symptomatically, 28 of 36 patients reported resolution of symptoms after HDPPI therapy alone, P=or<0.0001, regardless of histology. Visual endoscopic findings during the first and second EGDs did not show any significance in differentiating EE from NEE, P=0.625 and P=0.2405, respectively.. The study demonstrates that HDPPI can be used to help differentiate EE from NEE histologically. Moreover, patients with more than or equal to 15 eos/HPF at all 3 levels are less likely to respond to HDPPI than patients with more than or equal to 15 eos/HPF at fewer than 3 levels. Therefore, having more than or equal to 15 eos/HPF at 1 or 2 biopsy levels does not necessarily establish the diagnosis of EE. Symptomatic response to HDPPI does not correlate with histologic findings. Clinical management guided by EGD with biopsy helps distinguish patients with EE from those with NEE.

Topics: Adolescent; Androstadienes; Anti-Inflammatory Agents; Biopsy; Child; Child, Preschool; Endoscopy, Digestive System; Eosinophilia; Eosinophils; Esophagitis; Female; Fluticasone; Humans; Male; Proton Pump Inhibitors; Retrospective Studies

Endoscopic findings of an 18-year old man with intermittent dysphagia showed widespread white exudations of the oesophagus. First misinterpreted as oesophageal candidiasis the mucosal biopsies revealed the histological features of a severe eosinophilic oesophagitis. Under treatment with topical steroids the symptoms dissolved. The control endoscopy showed a histological remission with absence of eosinophilic granulocytes, too. The eosinophilic oesophagitis is a rare allergy-like inflammation of the oesophagus especially seen in young men with increasing incidence. Without treatment the long-term risk of eosinophilic oesophagitis is the induction of severe oesophageal strictures.

Topics: Administration, Oral; Adolescent; Androstadienes; Anti-Allergic Agents; Antifungal Agents; Biopsy; Candidiasis; Deglutition Disorders; Diagnosis, Differential; Dose-Response Relationship, Drug; Eosinophilia; Esophagitis; Esophagoscopy; Esophagus; Fluticasone; Humans; Male; Miconazole

Eosinophilic esophagitis (EE) is a clinicopathologic syndrome comprising isolated eosinophilic inflammation of the esophagus, with symptoms of dysphagia, and possibly, reflux. It was initially described in children, and in recent years, there is a heightened awareness in adults. The etiology is not completely understood. The treatments include dietary manipulation, topical corticosteroids, systemic corticosteroids, Montelukast, and endoscopic dilation. In adults, there are no randomized trials demonstrating the efficacy of any particular treatment, and no prospective studies describing the natural history of the disease following treatment.. We performed an interval follow-up of patients treated with a swallowed corticosteroid inhaler. We contacted 51 adult patients who were diagnosed with EE and treated with a swallowed corticosteroid inhaler between September 1, 1999, and May 31, 2003. All patients had received 6 wk of treatment with fluticasone 220 mEq/puff, four puffs swallowed twice daily for 6 wk.. Thirty-two patients replied (63%) with a mean follow-up duration of 3.3 yr. Ninety-one percent of patients reported recurrent symptoms; a mean of 8.8 months after treatment was completed. Sixty-nine percent of patients repeated treatment with the steroid inhaler at least once.. It appears that EE is a chronic remitting disorder that requires more than one topical steroid treatment course.

Topics: Administration, Topical; Adult; Androstadienes; Anti-Inflammatory Agents; Deglutition Disorders; Eosinophilia; Esophagitis; Female; Fluticasone; Follow-Up Studies; Humans; Male; Nebulizers and Vaporizers; Recurrence; Treatment Outcome

A 19-year-old white woman presented with a 6-month history of progressively worsening dysphagia.. Esophagogastroduodenoscopy, esophageal biopsies followed by histological evaluation of biopsy samples including immunohistochemical staining for herpes simplex virus.. Herpes esophagitis with concurrent eosinophilic esophagitis.. Valaciclovir and fluconazole.

Topics: Androstadienes; Anti-Inflammatory Agents; Antiviral Agents; Eosinophilia; Esophagitis; Female; Fluticasone; Herpes Simplex; Humans; Young Adult

Our aim was to evaluate the changes induced by topical steroid treatment to the esophageal epithelial inflammatory eosinophilic and T-cell infiltrate and to IL-5, eotaxin-1/CCL11, and eotaxin-3/CCL26 esophageal gene expression levels in patients with eosinophilic esophagitis (EE).. Esophageal biopsies were taken from eight adult patients at the moment of diagnosis and after 3-month treatment with fluticasone propionate. Eosinophils, CD8, and CD4 T cells were examined by immunohistochemistry. IL-5, eotaxin-1/CCL11, and eotaxin-3/CCL26 gene expression levels were measured by real-time PCR. Eight control samples were also analyzed.. A significant decrease in the eosinophil infiltrate and in CD8(+) T-cell density was observed in the esophageal epithelium from the patients upon steroid treatment. IL-5 was not detected in control samples, and expression levels were variably downregulated after treatment in six of the patients. Gene expression of eotaxin-1/CCL11 showed relevant downregulation in four cases and a modest twofold decrease in three of the patients studied. Mean CCL11 expression values upon steroid treatment were similar to control samples (19.4 +/- 28.6 vs 8.42 +/- 5, P= 0.7). Eotaxin-3/CCL26 gene expression levels were significantly increased in EE. Although they were significantly downregulated upon steroid treatment, control expression levels were not reached in any of the cases analyzed (580.9 +/- 943.9 vs 1.45 +/- 1.0, P= 0.001).. Our results confirm that eotaxin-3/CCL26 is significantly increased in EE esophageal samples. However, the individual analysis of IL-5, CCL11, and CCL26 expression data suggests that several cytokines and chemokines could participate in the physiopathology of EE in humans.

Topics: Administration, Topical; Adult; Androstadienes; Anti-Inflammatory Agents; Biopsy; Case-Control Studies; Chemokine CCL11; Chemokine CCL26; Chemokines, CC; Down-Regulation; Eosinophilia; Esophagitis; Esophagus; Female; Fluticasone; Gene Expression; Humans; Interleukin-5; Linear Models; Lymphocyte Count; Male; Reverse Transcriptase Polymerase Chain Reaction

We describe the first detailed case of eosinophilic esophagitis associated with esophageal intramural pseudodiverticulosis and gastro-esophageal reflux disease in a 24-year-old man, who suffered from recurrent dysphagia since the age of 3 years. He presented with symptoms of dysphagia, food impaction and malnutrition. An esophagogram revealed a high-grade stenosis in the proximal part of the esophagus. Histological evaluation of esophageal mucosal biopsies demonstrated more than 20 eosinophil granulocytes per high power field, indicative of eosinophilic esophagitis. Additionally, esophago-gastro-duodenoscopy showed pseudodiverticulosis in the distal portion of the esophagus. A therapeutic regimen consisting of topical steroid intake, antihistamines, proton-pump-inhibition and specific food avoidance led to significant clinical improvement within 6 weeks.

Topics: Administration, Topical; Adult; Androstadienes; Anti-Allergic Agents; Catheterization; Deglutition Disorders; Diverticulum, Esophageal; Eosinophilia; Esophageal Stenosis; Esophagitis; Fluticasone; Gastroscopy; Humans; Male; Manometry

Topics: Adult; Androstadienes; Anti-Allergic Agents; Anti-Inflammatory Agents; Deglutition Disorders; Eosinophilia; Esophagitis; Fluticasone; Humans; Hypersensitivity; Male; Recurrence; Time Factors

To describe the manometric findings detected in adult patients with dysphagia that were diagnosed of eosinophilic oesophagitis, and to compare with the cases of eosinophilic infiltration of the oesophagus reported in the literature.. We present 12 adult patients diagnosed as suffering from this disorder in our department in a 1.5-year period, according to histological criteria and discarding any other cause of eosinophilic infiltration of the oesophagus. Stationary oesophageal manometry using a hydropneumocapillary perfusion system was performed in every case. The recommendations of the Spanish Group of Digestive Motility were followed for the interpretation of the results. In seven patients who presented motor disorder in manometric evaluation, treatment with steroid oesophageal lavage using fluticasone propionate was carried out and these patients were subsequently re-evaluated.. All patients were young predominantly men, and the first endoscopic examination showed regular concentric stenosis or a 'ring oesophagus'. Six patients had a severe nonspecific oesophageal motor disorder characterized by up to 80% of nontransmitted or very low-amplitude waves in the lower two-thirds of the organ. Three patients presented a manometric disturbance characterized by hyperkinetic peristaltic waves in distal oesophageal third. One patient had an alteration of the oesophageal motor dynamics characterized by 80% of deglutory complexes formed by a primary simultaneous wave in the two lower oesophageal thirds followed by a secondary peristaltic wave in 50% of cases that had a normal duration and amplitude. The remaining two patients had normal oesophageal motility. The upper oesophageal sphincter showed no alterations, and the manometric evaluation of the lower oesophageal sphincter tone proved normal in 10 patients, with slight hypotension in two cases. In seven of the nine patients who presented an oesophageal motor disorder, treatment with steroid oesophageal lavage using fluticasone propionate was administered and a new oesophageal manometry was performed afterwards, in which the motor disorder was clearly improved as soon as dysphagia, endoscopic lesions and histopathologic alteration disappeared.. In the literature, 61 cases of eosinophilic infiltration of the oesophageal mucosa subjected to oesophageal manometric study had been described, and 60.6% of them showed evidence of different types of manometric alterations, mainly with spastic or hypercontractility characteristics. Although six of our cases showed very deficient peristalsis with very low-amplitude or nontransmitted waves, and in another three high-amplitude peristaltic waves were recorded. Motor disorders improved parallel to the disappearance of the eosinophilic infiltration of the mucosa. These data suggest that motor disorders in eosinophilic oesophagitis are a consequence of eosinophil infiltration of the oesophagus and should be considered in the differential diagnosis of dysphagia. These manometric alterations could be considered as primary nonspecific disorders and included in the 'ineffective oesophageal motility' group.

Topics: Adolescent; Adult; Androstadienes; Anti-Inflammatory Agents; Deglutition Disorders; Eosinophilia; Esophageal Motility Disorders; Esophagitis; Esophagus; Female; Fluticasone; Humans; Male; Manometry; Middle Aged; Peristalsis

Eosinophilic esophagitis is an inflammatory condition of the esophagus characterized by eosinophilic infiltration. It is a condition mainly affecting children; the adult form has only recently gained recognition as a distinct entity. The major symptom among adults with eosinophilic esophagitis is dysphagia. It is often misdiagnosed as gastroesophageal reflux disease because of the similarity in symptoms. An endoscopic biopsy is required to distinguish between the conditions. The cause of eosinophilic esophagitis is poorly understood, but food allergy has been implicated. Topical steroids are the most effective and convenient method for the treatment of eosinophilic esophagitis in adults. The long-term prognosis of eosinophilic esophagitis is uncertain; however, data suggests a benign course. We herein present two eosinophilic esophagitis cases that were the first to be diagnosed in our clinic.

Topics: Adult; Androstadienes; Anti-Inflammatory Agents; Biopsy; Deglutition Disorders; Eosinophilia; Esophagitis; Esophagoscopy; Esophagus; Female; Fluticasone; Heartburn; Humans; Male

Eosinophilic esophagitis can be associated with a wide range of endoscopic patterns. The aim of the present case series report is to describe and classify endoscopic appearances before and after corticoid therapy in relation to histopathology and manometry.. In 30 patients (m : f, 27 : 3; mean age 36.2 years) with eosinophilic esophagitis, endoscopic findings were prospectively classified according to luminal diameter and mucosal pattern. Manometric and bioptic histopathologic findings were also recorded. Endoscopy was repeated following a 3-month course of steroid therapy.. In total, 20 % of patients showed a concentric esophageal stricture, and in 57 % simultaneous contraction rings were visible. Mucosal alterations consisted of granular mucosa (20 %), longitudinal furrows (33 %) and transversal undulations (3 %). Lower esophageal sphincter dysfunction and distal esophageal dysfunctional manometry were seen in 73 % and 57 % of cases, respectively. Following steroids, the esophagus showed a normal caliber in 97 % of patients, and 63 % of patients had normal mucosa.. The most frequent findings were narrowing of the esophageal lumen, which returned to normal following steroid treatment to a larger extent than mucosal alterations.

Topics: Administration, Topical; Adult; Androstadienes; Eosinophils; Esophagitis; Esophagoscopy; Female; Fluticasone; Glucocorticoids; Humans; Male; Manometry; Prospective Studies

Eosinophilic oesophagitis is an emerging disease, well known also in paediatric age, probably caused by both IgE and non-IgE mediated food allergies, diagnosed by upper endoscopy with biopsy. The most severe complication is oesophageal stenosis. The identification of the offending allergens is often difficult; therapy is focused to eliminate the supposed antigenic stimulus, to control the acute symptoms and to induce long-term remission.. We report the clinical outcome and the typical endoscopic findings of children and adolescents affected by eosinophilic oesophagitis, referring a proposal of diagnostic and treatment protocol.. Twelve patients, affected by eosinophilic oesophagitis with a histological diagnosis, underwent radiographic upper gastro-intestinal series, 24 h pH-probe and standardised allergic testing; they were treated with steroids (oral prednisone and swallowed aerosolised fluticasone) and elimination diet. Dilations were performed when eosinophilic oesophagitis was not yet diagnosed, or in patients resistant to conventional treatment.. Two patients were lost to follow up (mean follow up: 1 year 11 months); seven patients have no symptoms and normal histology, five of them on restricted diet (without cow's milk protein) and two patients on elemental diet (amino acid formula). In two patients (no allergens identified), mild dysphagia and eosinophilic infiltration persist; one patients underwent Nissen fundoplication for Barrett's oesophagus: he has no symptoms and normal oesophagus, on restricted diet (without cow's milk/eggs protein and wheat).. The recognition of typical endoscopic picture with careful biopsies extended to the whole oesophagus, even in emergency, could more quickly lead to the correct diagnosis and avoid severe complications of eosinophilic oesophagitis in children, as stricture and failure to growth. Elimination diet is the key of resolution when the allergens are identified. A great challenge remains the relation between gastro-oesophageal reflux disease and eosinophilic oesophagitis, which should however be explained.

Topics: Administration, Inhalation; Administration, Oral; Adolescent; Aerosols; Androstadienes; Anti-Inflammatory Agents; Biopsy; Catheterization; Child; Child, Preschool; Endoscopy, Digestive System; Eosinophilia; Esophageal pH Monitoring; Esophagitis; Female; Fluticasone; Food Hypersensitivity; Humans; Immunoglobulin E; Infant; Male; Prednisone; Prospective Studies; Retrospective Studies; Skin Tests; Upper Gastrointestinal Tract

Eosinophilic esophagitis is an increasingly recognized disorder characterized by intense eosinophilic infiltration of the esophageal mucosa. The aim of this study was to define the clinical syndrome, the endoscopic features, and the distribution of the eosinophil infiltrate in adults with eosinophilic esophagitis. We undertook a prospective evaluation of the symptomatic and histologic response to treatment with fluticasone propionate.. Twenty-six patients (18 men; mean age 36 years) had symptom assessment and barium studies, esophageal motility recordings, and 24-hour esophageal pH studies. Upper-GI endoscopy was performed with quantitative eosinophil counts of biopsy specimens from the proximal and distal esophagus, the gastric antrum, and the duodenum. Nineteen subjects received 4 weeks of swallowed fluticasone propionate. After treatment, symptom assessment and endoscopic biopsies were repeated.. All 26 patients had a history of dysphagia, and 11 presented acutely with food-bolus obstruction. Esophageal peristalsis was normal in most and gastroesophageal reflux coexisted in 10 patients. Characteristic endoscopic findings of furrows (20) and rings (18) were observed. All 19 treated patients had symptom improvement and a significant decrease in esophageal eosinophil counts.. Eosinophilic esophagitis is a distinct entity that may coexist with gastroesophageal reflux. Swallowed fluticasone propionate is an effective treatment.

Topics: Adrenal Cortex Hormones; Adult; Androstadienes; Deglutition Disorders; Duodenum; Endoscopy, Gastrointestinal; Eosinophils; Esophagitis; Esophagus; Fluticasone; Gastroesophageal Reflux; Humans; Leukocyte Count; Male; Mucous Membrane; Prospective Studies; Pyloric Antrum

A 40-year-old white male with atopy presented to our department in March 2004 with a history of chronic heartburn and solid-food dysphagia since 1994. The patient was taking on-demand salbutamol for asthma and ranitidine for mild heartburn, occurring less than once per week. Eight years previously, he had undergone esophageal dilatation for a Schatzki's ring.. Physical examination, laboratory investigations, video esophagram, upper endoscopy with mid-esophageal biopsies, and skin testing for a number of food and environmental allergens. Diagnosis Eosinophilic esophagitis.. Topical steroids with a fluticasone 220 microg multiple-dose inhaler, four puffs swallowed twice a day for 6 weeks.

Topics: Adult; Androstadienes; Anti-Inflammatory Agents; Chronic Disease; Deglutition Disorders; Diagnosis, Differential; Endoscopy, Gastrointestinal; Eosinophilia; Esophagitis; Fluticasone; Gastroesophageal Reflux; Humans; Male

Topics: Acetates; Adult; Androstadienes; Anti-Inflammatory Agents; Biopsy; Cyclopropanes; Diagnosis, Differential; Drug Therapy, Combination; Endoscopy, Gastrointestinal; Eosinophilia; Esophagitis; Fluticasone; Humans; Leukotriene Antagonists; Male; Quinolines; Sulfides

Eosinophilic esophagitis (EE) is a clinical-pathological disorder which is being increasingly diagnosed. It is etiologically associated with hypersensitivity to airborne allergens and/or dietary components. However, immediate hypersensitivity to foods has rarely been proven as the etiologic cause of the disorder. Two patients are presented with a history of rhinoconjunctivitis, allergic asthma, atopic dermatitis and food allergies which are currently under control and who show specific IgE to pulses and chicken respectively. These patients developed acute dysphagia and vomiting immediately after ingesting these foods and following appropriate examination were diagnosed as suffering from EE. The study also showed signs of blood hypereosinophilia while the esophageal manometry revealed a motor disorder characterized by aperistalsis and non-propulsive simultaneous waves affecting the lower two-thirds of the organ composed of smooth muscle. Topical treatment with fluticasone propionate was administered over a period of 3 months, in addition to a diet abstaining from the aforementioned foods and this led to remission of dysphagia and normalization of the endoscopic, histological and manometric studies of the esophagus. This situation remained stable for a considerable length of time after steroid treatment was discontinued, which showed that exposure to foods seemed to be the cause of the esophageal disorder. Similarly, allergies to inhalants and other digestive symptoms which appear upon immediate ingestion of the foods involved would not justify the sudden onset of dysphagia. We offer a pathophysiological explanation for the mechanisms of the disease based on the activation of eosinophils and mast cells by IgE and their ability to disturb the dynamic behavior of the neural and muscle components of the esophageal wall.

Topics: Adolescent; Androstadienes; Animals; Anti-Allergic Agents; Chickens; Deglutition Disorders; Eosinophilia; Esophagitis; Fabaceae; Female; Fluticasone; Food Hypersensitivity; Humans; Immunoglobulin E; Male

Three men, aged 20, 24 and 42 years, reported difficulties in passing food through the oesophagus. The diagnosis of eosinophilic oesophagitis was made after endoscopic investigation, laboratory tests and histological tests. In all three patients the symptoms disappeared: respectively spontaneously, during systemic treatment with corticosteroids due to a kidney complaint, and after topical corticosteroid treatment lasting 6 weeks. Eosinophilic oesophagitis occurs in particular in young men. There are complaints about the passage of food through the oesophagus, with frequent food impaction, also without any obvious stenosis. Endoscopic features are subtle and comprise a vulnerable oesophageal mucosa with a ringed appearance or small white spots on the oesophageal mucosa. Histopathology reveals an eosinophilic infection infiltrate in the oesophageal epithelium. Food allergies may play a causal role. With respect to the treatment, favourable results have been described for oral fluticasone, while endoscopic treatment may consist of dilation.

Topics: Adrenal Cortex Hormones; Adult; Androstadienes; Anti-Inflammatory Agents; Deglutition Disorders; Eosinophilia; Esophagitis; Fluticasone; Humans; Male; Treatment Outcome

Topics: Aged; Aged, 80 and over; Androstadienes; Anti-Inflammatory Agents; Deglutition Disorders; Eosinophilia; Esophagitis; Female; Fluticasone; Humans; Male; Middle Aged

Eosinophilic esophagitis (EE) is a recently recognized clinical disorder that is understood poorly. We aimed to determine the efficacy of swallowed fluticasone propionate on the immunopathologic features associated with EE.. A retrospective analysis was performed on 20 pediatric patients with EE. Inclusion criteria specified a peak eosinophil density of > or =24 cells per 400x field in the esophagus and treatment with swallowed fluticasone between 2 endoscopic assessments. Histologic specimens were examined for eosinophil and CD8(+) lymphocyte infiltration, papillary lengthening, and proliferation of the basal layer as determined by monoclonal anti-Ki-67 (MIB-1) antibody staining.. The mean time interval between endoscopic assessments was 4.8 months. The patients were divided equally between allergic and nonallergic groups based on the results of skin-prick testing. All of the nonallergic patients responded to fluticasone propionate. The endoscopic appearance of the mucosa improved and microscopic evaluation showed markedly reduced eosinophil infiltration, reduced basal layer hyperplasia documented by a reduced number of MIB-1(+) cells, and a reduced number of CD8(+) lymphocytes. However, allergic patients were relatively refractory to therapy; 20% had a partial response, whereas 20% had no detectable improvement. Esophageal eosinophil levels before and after therapy in all patients strongly correlated with the level of epithelial cell proliferation as measured by MIB-1 staining.. Collectively, these results suggest that patients treated with swallowed fluticasone have improved endoscopic, histologic, and immunologic parameters associated with EE. However, patients with identifiable allergies who fail dietary elimination may have a blunted response to treatment.

Topics: Administration, Oral; Adolescent; Androstadienes; Anti-Inflammatory Agents; Biopsy, Needle; Child; Child, Preschool; Cohort Studies; Eosinophilia; Esophagitis; Esophagoscopy; Female; Fluticasone; Follow-Up Studies; Humans; Immunohistochemistry; Male; Probability; Retrospective Studies; Risk Assessment; Severity of Illness Index; Treatment Outcome

Topics: Androstadienes; Anti-Inflammatory Agents; Dilatation; Endoscopy; Eosinophilia; Esophageal Perforation; Esophagitis; Fluticasone; Humans

Topics: Androstadienes; Antacids; Anti-Inflammatory Agents; Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Antirheumatic Agents; Aspirin; Barrett Esophagus; Child; Cross-Over Studies; Cyclooxygenase Inhibitors; Deglutition Disorders; Diagnosis, Differential; Double-Blind Method; Dyspepsia; Endoscopy; Eosinophilia; Esophagitis; Esophagitis, Peptic; Family Practice; Fluticasone; Gastroesophageal Reflux; Heartburn; Helicobacter Infections; Helicobacter pylori; Humans; Incidence; Middle Aged; Omeprazole; Prednisone; Proton Pump Inhibitors; Randomized Controlled Trials as Topic; Recurrence; Surveys and Questionnaires; Time Factors

Eosinophilic esophagitis (EE) shares symptoms with gastroesophageal reflux disease but has distinctive pathologic features and unknown immunopathology. Treatments with antigen restriction or systemic immunosuppression pose problems with compliance and side effects. Topically applied steroids offer an attractive alternative treatment. The aims of this study were to determine the immunopathologic features of EE and the effectiveness of antigen-specific diet restriction (DR) and topical immunosuppression.. A prospective trial was conducted examining the impact of DR and swallowed fluticasone propionate (FP) on pediatric patients with EE. Clinicopathologic features, including immunohistochemical analysis of the esophageal mucosa, were measured before and after treatment.. Immunohistochemical analysis of 11 prospectively identified children showed a significantly greater number of mucosal CD3 and CD8 lymphocytes, as well as CD1a antigen-presenting cells compared with normal controls. DR did not induce clinical improvement in any patients, whereas all children who completed treatment with FP had resolution of symptoms. Posttreatment analysis of proximal and distal esophageal mucosa showed a significant reduction in the number of eosinophils, as well as CD3(+) and CD8(+) lymphocytes compared with pretreatment sections.. EE is characterized by immunologically active esophageal mucosa. FP, not DR, effectively relieves symptoms. FP significantly reduces mucosal inflammation associated with EE.

Topics: Adolescent; Adult; Androstadienes; Anti-Inflammatory Agents; Antigens, CD1; Child; Child, Preschool; Diet; Eosinophilia; Esophagitis; Female; Fluticasone; Humans; Infant; Male; Prospective Studies; T-Lymphocytes

Topics: Administration, Inhalation; Administration, Topical; Adolescent; Adrenal Cortex Hormones; Androstadienes; Anti-Inflammatory Agents; Beclomethasone; Child; Eosinophilia; Esophagitis; Female; Fluticasone; Glucocorticoids; Humans; Male