Co-occurrence of eosinophilic esophagitis and potential/probable celiac disease in an adult cohort: a possible association with implications for clinical practice

Abstract

We describe an adult cohort with eosinophilic esophagitis (EoE) and evidence of celiac disease (CD), propose a change in diagnostic practice to better characterize these conditions, and hypothesize new directions for research. Pediatric studies postulate association between gluten sensitivity and EoE. However, few publications describe the prevalence, detection, or therapeutic and pathophysiologic implications of such association in adults. Retrospective chart review was done on patients diagnosed with EoE from 2009 to 2010 at University of Utah Hospitals and Clinics. Data included sex, age, presentation, duodenal pathology, tissue transglutaminase immunoglobulin A antibody (TTG) positivity, human leukocyte antigen (HLA) type (when indicated), and gross and microscopic Esophagogastroduodenoscopy (EGD) findings. Duodenal biopsy, TTG results, and HLA type were correlated. Endoscopy was repeated after gluten-free diet. Forty-four of 75 patients were followed in EoE specialty clinic with duodenal biopsy and TTG testing per protocol. Six EoE patients had potential or probable CD. No sex or age differences were noted between those with findings of CD and EoE and those with EoE alone. Six patients with findings of CD and EoE followed gluten-free diet. Five underwent repeat endoscopy. Three had resolution of esophageal eosinophilia. Potential or probable CD was commonly found in adults with EoE. Diagnosis of CD may be challenging due to nonspecific symptoms and insufficient duodenal biopsy and serologic testing. Furthermore, gluten-free diet resolved EoE findings in some patients, suggesting possible shared pathophysiology in some cases of EoE and CD. TTG testing and adequate duodenal biopsy may further direct clinical care for EoE patients, and studies are needed to elucidate mechanisms linking EoE and CD.

Discovery and characterization of a novel humanized anti-IL-15 antibody and its relevance for the treatment of refractory celiac disease and eosinophilic esophagitis

“…57 Whereas it is still unclear why such variable results are observed, it could be due to the age of patients, with an association being more prominent in adults. 58 Indeed, EoE has different features between children in adults, with higher rates of asthma and positive allergic reactivity to food antigens in children. 59 There is also a clear, still unexplained, gender-bias for both diseases since EoE is more prominent in men, whereas CeD is more prominent in women.…”

Genetics of eosinophilic esophagitis

“…In one study of adult patients with both EoE and celiac disease, a gluten-free diet resolved patients’ esophageal eosinophilia, which raises the possibility of shared pathophysiology in those subjects. 76 In another study, gluten removal successfully treated the celiac component but not the EoE component of patients with concurrent disease. 78 Altogether, additional studies are required to elucidate the pathoetiological and genetic links between EoE and celiac disease.…”

“…Celiac disease is linked with EoE; 76–80 in fact, a diagnosis of celiac disease increases risk for EoE by at least 25%. 78 EoE and celiac disease share common features including that both are food antigen-driven, although there is limited evidence that gluten is a causal food in EoE, 81 both involve a pathophysiology that places epithelial cells in the center stage, and both resolve upon removal of causal foods.…”

Utility of gastric and duodenal biopsy sampling in adult eosinophilic esophagitis patients to rule out other gastrointestinal disorders

“…However, evidence is lacking on the diagnostic value of these additional biopsies to rule out other relevant generalized or eosinophilic gastrointestinal (GI) disorders (e.g., celiac disease, parasitic infection, non-EoE eosinophilic gastrointestinal disorders (EGIDs). More importantly, these characterized alternate symptom etiologies or causes of esophageal eosinophilia such as non-EoE EGIDS are mostly rare, or its true relationship remains controversial as illustrated by the previous suggested association between celiac disease and EoE in adults [11][12][13][14][15]. For that reason, the diagnostic value of biopsy specimens sampled from the stomach and duodenum needs to be determined within a large cohort of adult EoE patients, so future evidence-based statements on its utility in daily practice may be established.…”