Comparison of clinical features in patients with eosinophilic esophagitis living in an urban and rural environment

Abstract

Eosinophilic esophagitis (EoE) has been associated with exposure to aeroallergens. Living in different locations (urban vs. rural) could potentially expose individuals to different environmental factors. Currently, there is limited data on the matter, and all was based on small population studies that did not exclude proton pump inhibitor (PPI)-responsive esophageal eosinophilia in their cohort. The primary aim of this study was to determine the prevalence of EoE in an urban versus rural population and compare demographic and clinical characteristics in patients that had been treated with high-dose PPI prior to diagnosis. Esophageal biopsies were obtained from a cohort of patients who presented with symptoms of dysphagia, odynophagia, globus sensation, and heartburn during a 10-year period. Only patients who had biopsies from the mid and distal esophagus with ≥20 eosinophils per high-power field while on high-dose PPI treatment during endoscopy were included. Urban population was defined as >1000 people/square mile, and rural population was defined as ≤1000 people/square mile (U.S. Census Bureau). Demographic data from each group was analyzed for age, sex, body mass index, duration of symptoms, and tobacco use. Chi-square analysis was used for frequencies with statistical significance defined as P ≤ 0.05. A total of 20 718 patients were identified and their records evaluated. From this cohort, 57 (0.28%) symptomatic patients (male/female: 39/18, mean age = 29.5 years) had biopsy-proven EoE (≥20 eosinophils/hpf) while on PPI treatment. Of those EoE patients, 29 (50.9%) reported living in rural area versus 28 (49.1%) living in the urban area. The most common medical history components included asthma (12.3%), and the most common presenting symptoms included dysphagia (50.9%), heartburn (26.3%), and nausea/vomiting (22.8%). The average duration of symptoms, body mass index, and smoking habits did not differ between the groups. Dysphagia was significantly more prevalent in the urban population (37.9% vs. 64.3% P = 0.047), while heartburn and reflux were more prevalent in the rural population (37.9% vs. 14.3 P = 0.043). Asthma was prevalent in both populations without a significant difference (P = not significant). There is no residential variation in the incidence of EoE among patients with non-PPI-responsive esophageal eosinophilia. Dysphagia was more prevalent in the urban population, while heartburn and reflux symptoms were more prevalent in the rural environment. Further exploration of environmental factors and specific allergens may help explain the varying symptoms and causes of EoE.

Effects of allergen sensitization on response to therapy in children with eosinophilic esophagitis

“…Our population had similar clinical characteristics as reported in other regions, including a high rate of atopy and allergen sensitization, suggesting that patients may present similarly regardless of geographic location. 17,19,22–24 There were also no differences found between patients living in rural vs nonrural counties. The most common clinical symptoms included vomiting, abdominal pain, and heart-burn, with older patients having a higher incidence of dysphagia and food impaction.…”

Esophageal Eosinophilia is Increased in Rural Areas With Low Population Density: Results From a National Pathology Database

“…With the exception of one prior physician survey which found that cases of EoE were more common in some rural areas (6), a recent study detecting no difference in the frequency of EoE diagnosis in urban or rural settings using a 1,000 person/square mile cut-point for rural versus urban status (30), and an abstract from a single center showing more EoE cases from rural areas than urban areas (23), this association has not been previously described in the EoE literature. In some respects, this finding is counterintuitive.…”

The Role of Environmental Exposures in the Etiology of Eosinophilic Esophagitis

“…The second was a retrospective cohort that compared clinical features of EoE in urban and rural regions, based on 2010 US census data, using a population density cut off of 1000 people / square mile. 46 There was no statistically significant difference in prevalence between urban and rural areas, but some differences in clinical features. Urban patients, for example, were more likely to present with dysphagia, while rural patients were more likely to complain of heartburn and reflux.…”

“…A similar statement could be made for EoE being more common in areas with low population density. 36,37,46 This broad finding currently lacks a definitive explanation, and while multiple hypotheses are possible, further research is needed to explicate the underlying reasons for this trend. The studies on early life exposures, while intriguing and more granular, are still preliminary.…”