fluticasone and Gastroesophageal-Reflux

Esophagitis is the end result of a variety of insults to epithelial homeostasis. Eosinophilic esophagitis is a manifestation of non-IgE-mediated food allergy that most commonly affects the esophagus of males who have other atopic phenomena. Reflux esophagitis reflects repeated exposure to acidic gastric contents because of failure of the normal protections afforded by the LES. Because certain histologic features can be present in either condition, endoscopic biopsy alone does not distinguish them. Their symptoms overlap, but the treatment options are very different, such that making a formal diagnosis by following consensus guidelines is essential. A treatment protocol designed to manage the inflammation by controlling the provocative factors (acid for GERD and food antigens for EoE) or suppressing the inflammation (ie, topical steroids for EoE) should result in normalization of the mucosa and resolution of symptoms. Eosinophilic esophagitis is a chronic condition that rarely remits spontaneously, so any therapeutic modality will need to be continued indefinitely.

Topics: Adolescent; Budesonide; Diet Therapy; Eosinophilic Esophagitis; Esophageal pH Monitoring; Esophagitis, Peptic; Fluticasone; Fundoplication; Gastroesophageal Reflux; Glucocorticoids; Histamine H2 Antagonists; Humans; Proton Pump Inhibitors

Eosinophilic esophagitis (EoE) has been reported to be more prevalent in patients with esophageal atresia/tracheoesophageal fistula (EA-TEF). To date, there is limited data on the management of EoE in this group of patients. The aim of this study is to evaluate the treatment outcomes of EoE in children with EA-TEF. A retrospective chart review was performed on all EA-TEF children who were diagnosed with and treated for EoE between January 2000 and September 2013 at the Sydney Children's Hospital. Data collected included details of the patient's treatment, post-treatment endoscopy, symptoms and nutrition. Twenty patients were included in the study. Median age at diagnosis was 26 months (8-103 months), and median time from diagnosis to last follow-up was 23 months (2-132 months). Patients were treated with budesonide slurry, swallowed fluticasone, elimination diet alone or in combination. All patients were on proton pump inhibitors at time of diagnosis of EoE which was continued. Six out of seven patients who had furrowing/exudate in endoscopy at diagnosis had complete resolution at a median follow-up period of 26 months (P = 0.031). Median peak intraepithelial eosinophil count reduced significantly from 30/high-powered field (HPF) (19-80/HPF) to 8/HPF (0-85/HPF) (median time for improvement = 24 months) (P = 0.015). There was a significant reduction in symptoms of dysphagia and reflux post-treatment (P < 0.001). Prevalence of strictures significantly decreased (P = 0.016), as did need for dilatations (P = 0.004). In four out of six patients with gastrostomies at baseline, the feeding improved on treatment of EoE and the gastrostomy could be closed. There was also a nonsignificant trend towards improvement in weight and height 'z scores' of the patients. Treatment of EoE in children with EA-TEF was found to significantly reduce intraepithelial eosinophil count, symptoms, strictures and need for dilatations.

Topics: Administration, Oral; Administration, Topical; Budesonide; Child; Child, Preschool; Deglutition Disorders; Diet Therapy; Eosinophilic Esophagitis; Esophageal Atresia; Esophageal Stenosis; Esophagoscopy; Female; Fluticasone; Gastroesophageal Reflux; Glucocorticoids; Humans; Infant; Male; Retrospective Studies; Tracheoesophageal Fistula; Treatment Outcome

Noninvasive biomarkers would be valuable for diagnosis and monitoring of eosinophilic esophagitis (EoE). The aim of this study was to determine the utility of a panel of serum biomarkers for the diagnosis and management of EoE.. We conducted a prospective cohort study of consecutive adults undergoing outpatient esophagogastroduodenoscopy. Incident cases of EoE were diagnosed per consensus guidelines; controls had gastroesophageal reflux disease (GERD) or dysphagia and did not meet the EoE criteria. EoE cases were treated with topical steroids and had repeat endoscopy. Pre- and post-treatment serum samples were analyzed in a blinded manner for interleukin (IL)-4, IL-5, IL-6, IL-9, IL-13, transforming growth factor (TGF)-α, TGF-β, tumor necrosis factor-α, eotaxin-1, -2, and -3, thymic stromal lymphopoietin (TSLP), major basic protein, and eosinophil-derived neurotoxin. Cases and controls were compared at baseline, and pre- and post-treatment assays were compared in cases.. A total of 61 incident EoE cases and 87 controls were enrolled; 51 EoE cases had post-treatment serum analyzed. There were no significant differences in any of the biomarkers between EoE cases and controls at baseline. IL-13 and eotaxin-3 for cases and controls were 85 ± 160 vs. 43 ± 161 pg/ml (P=0.12) and 41 ± 159 vs. 21 ± 73 (P=0.30). There were no significant differences in assay values among cases before and after treatment. There were also no differences after stratification by atopic status or treatment response.. A panel of inflammatory factors known to be associated with EoE pathogenesis were not increased in the serum, nor were they responsive to therapy. None of these biomarkers are likely candidates for a serum test for EoE. Histologic analysis for diagnosis and management of EoE continues to be necessary, and novel, less invasive, biomarkers are needed.

Topics: Adult; Aged; Androstadienes; Biomarkers; Budesonide; Case-Control Studies; Cohort Studies; Cytokines; Deglutition Disorders; Endoscopy, Digestive System; Eosinophil Major Basic Protein; Eosinophil-Derived Neurotoxin; Eosinophilic Esophagitis; Esophagus; Female; Fluticasone; Gastroesophageal Reflux; Glucocorticoids; Humans; Male; Middle Aged; Prospective Studies; Transforming Growth Factors

Esophageal eosinophilia and eosinophilic esophagitis (EoE) are increasingly recognized and prevalent conditions, which now represent common clinical problems encountered by gastroenterologists, pathologists, and allergists. The study of EoE has become a dynamic field with an evolving understanding of the pathogenesis, diagnosis, and treatment. Although there are limited data supporting management decisions, clinical parameters are needed to guide the care of patients with eosinophilic-esophageal disorders. In this evidence-based review, recommendations developed by adult and pediatric gastroenterologists are provided for the evaluation and management of these patients. New terminology is emphasized, particularly the concepts of esophageal eosinophilia and proton-pump inhibitor-responsive esophageal eosinophilia (PPI-REE) as entities distinct from EoE.

Topics: Adult; Algorithms; Androstadienes; Anti-Inflammatory Agents; Biopsy; Clinical Trials as Topic; Diagnosis, Differential; Endpoint Determination; Eosinophilia; Eosinophilic Esophagitis; Esophagoscopy; Esophagus; Evidence-Based Medicine; Fluticasone; Gastroesophageal Reflux; Humans; Prednisone; Proton Pump Inhibitors

Symptoms of vomiting and dysphagia in children with eosinophilic esophagitis may be related to the development of mucosal fibrosis.. Our aims were to (1) investigate esophageal fibrosis in children with EoE compared to patients with gastroesophageal reflux disease and normal individuals, and (2) to assess the degree of mucosal fibrosis in patients with EoE before and after medical treatment.. A retrospective analysis of esophageal biopsies from patients with EoE, GERD, and normal mucosa was performed. Demographic data, clinical information, eosinophil number, and sub-epithelial fibrosis was compared among the groups. A similar comparison was performed in EoE patients, before and after therapy.. Esophageal biopsies from 53 children were included, of which 17 with EoE, 17 GERD, and 19 were normal. A significantly higher number of eosinophils and greater fibrosis was found in EoE patients vs. GERD and normal (fibrosis grade 2: 13 patients in the EoE group vs. one patient for each control group; p=0.0001). After therapy, a significant decrease in fibrosis and eosinophils number was noted in EoE patients [fibrosis grade 2: 10 (71.5%) patients vs. one (7.1%) patient, and eosinophil count was 35.5/HPF vs. 13.4/HPF, pre- and post-therapy, respectively; p<0.05]. The decrease in esophageal fibrosis paralleled the improvement in the related clinical symptoms.. A higher degree of esophageal fibrosis was found in patients with EoE compared to GERD or normal esophagus. Conventional therapy in EoE improved obstructive symptoms, decreased eosinophils count, and reversed the degree of fibrosis. We suggest that appropriate therapy in patients with EoE will improve clinical symptoms and histology.

Topics: Adolescent; Allergens; Androstadienes; Anti-Inflammatory Agents; Biopsy; Case-Control Studies; Child; Child, Preschool; Eosinophilic Esophagitis; Eosinophils; Esophagus; Female; Fibrosis; Fluticasone; Food Hypersensitivity; Gastroesophageal Reflux; Humans; Infant; Male; Mucous Membrane; Retrospective Studies; Treatment Outcome

The population prevalence of eosinophilic esophagitis (EoE) is ~7% in adults. Current American Gastroenterology Association guidelines recommend endoscopic biopsy (Bx) in patients with symptoms of dysphagia. We conducted a cost-effectiveness model to determine if endoscopic Bx is cost effective in patients with refractory gastroesophageal reflux disease (GERD) without dysphagia.. We designed a 5-year Markov model to compare costs and quality-adjusted life years for a cohort of 35-year-old patients with GERD refractory to proton pump inhibitor (PPI) therapy. We compared upper endoscopy (EGD) with and without Bx for EoE. We modeled that patients with EoE who did not undergo initial biopsy would wait 5 years until the diagnosis would be established via a second endoscopy with biopsy.. In patients with refractory GERD without dysphagia, endoscopic Bx for EoE was associated with an incremental cost-effectiveness ratio (ICER) of $51,420 per quality of life year (QALY). The upper endoscopy with biopsy arm cost $12,490 per patient and was associated with 4.080 QALYs, compared with EGD without Bx arm that cost $12,280 and was associated with 4.076 QALYs. The ICER was <$50,000 per QALY when the prevalence of EoE exceeded 8%, or the time of missed diagnosis was 6 years or greater. The biopsy arm was also cost effective if the QALY associated with symptomatic GERD was ≤0.93, cost of 3-month course of PPI therapy ≥$770 cost of fluticasone <$650, probability of EoE resolved on PPI ≤25%, symptom resolution on fluticasone ≥70%, cost endoscopy with biopsy ≤$520, or the cost of endoscopy without biopsy exceeded $300.. Upper endoscopy with Bx for EoE appears to be a cost-effective approach in patients when the prevalence of EoE is 8% or greater.

Topics: Adult; Androstadienes; Anti-Inflammatory Agents; Biopsy; Cohort Studies; Cost-Benefit Analysis; Decision Support Techniques; Decision Trees; Deglutition Disorders; Eosinophilic Esophagitis; Esophagoscopy; Female; Fluticasone; Gastroesophageal Reflux; Humans; Male; Markov Chains; Middle Aged; Proton Pump Inhibitors; Quality of Life; Quality-Adjusted Life Years; Sensitivity and Specificity; Software; Time Factors; United States

In pediatric intractable asthma, there is occasionally an association with GERD (gastroesophageal reflux disease). It is not clear in which cases GERD should be suspected or how effective the GERD therapy is in treating the asthma.. Twenty-seven preschool children (<6 years of age) suffering from recurrent asthma attack in spite of asthma therapy underwent 24-hour esophageal pH monitoring. We examined retrospectively the incidence of GERD and the effectiveness of famotidine in GERD positive patients.. 18 of the 27 patients (66.7%) had positive results (GERD positive group). In 12 of the 15 patients (80%) who underwent GERD therapy (famotidine), respiratory symptoms were decreased. In the GERD positive group, the incidence of acid reflux during waking hours was more frequent than during sleeping hours. In 8 of 12 patients (66.7%) in whom famotidine was effective, cough and wheeze often occurred during the daytime and corresponded with the time when acid reflux must commonly occurred.. We conclude that children suffering from recurrent asthma attack in spite of asthma therapy must be examined for the presence of GERD.

Topics: Androstadienes; Asthma; Child, Preschool; Diagnosis, Differential; Esophageal pH Monitoring; Famotidine; Fluticasone; Gastroesophageal Reflux; Histamine H2 Antagonists; Humans; Infant; Recurrence; Retrospective Studies

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

We studied 223 outpatients who presented between October 2001 and June 2003 with persistent cough of more than 3 weeks' duration. Eosinophilic airway disorders (EAD), including atopic cough and cough variant asthma, were clinically diagnosed in 119 patients, on the basis of the following factors: history of atopic disease, duration of cough, history of previous prolonged cough, or presence of forced expiration wheeze. Since eosinophils are frequently found in the sputum of patients with EAD, a positive test strongly suggests the presence of EAD. In this study, the test was positive in 86% of the patients with EAD. The patients with clinically diagnosed EAD, including those with no eosinophils in the sputum, were treated with inhaled fluticasone 400 or 800 microg/day. Fluticasone was effective in 97% of the patients with EAD and was more effective than bronchodilators or antiallergic drugs. When we compared the results of fluticasone 400 microg/day with those of 800 microg/day doses, the cough disappeared within 1 week in 28% of the patients who received 400 microg/day, whereas in 76% with 800 microg/day. Among the patients with diagnosed EAD, bronchial asthma developed in 6 patients during the observation period. Most of these patients had forced expiration wheeze and lower FEV 1 at the initial visit. This study showed that EAD could be diagnosed in the early stage on the basis of thorough history-taking, the presence of forced expiration wheeze and detection of eosinophils in the sputum. It is important to diagnose and treat EAD as early as possible since inhaled steroid is highly effective.

Topics: Administration, Inhalation; Adult; Androstadienes; Anti-Inflammatory Agents; Asthma; Bronchitis; Cough; Eosinophilia; Female; Fluticasone; Gastroesophageal Reflux; Humans; Male; Retrospective Studies

Topics: 2-Pyridinylmethylsulfinylbenzimidazoles; Adolescent; Albuterol; Amoxicillin; Androstadienes; Anti-Bacterial Agents; Anti-Infective Agents; Anti-Ulcer Agents; Asthma; Benzimidazoles; Bronchi; Bronchodilator Agents; Bronchoscopy; Carcinoid Tumor; Diagnosis, Differential; Drug Therapy, Combination; Fluticasone; Forced Expiratory Flow Rates; Forced Expiratory Volume; Gastroesophageal Reflux; Humans; Immunoglobulin E; Lung Neoplasms; Male; Metronidazole; Omeprazole; Pantoprazole; Radioallergosorbent Test; Respiratory Sounds; Sulfoxides; Syndrome; Tomography, X-Ray Computed; Tuberculin Test; Vital Capacity

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