Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters

Rank, Matthew A.; Sharaf, Rajiv N.; Furuta, Glenn T.; Aceves, Seema S.; Greenhawt, Matthew; Spergel, Jonathan M.; Falck‐Ytter, Yngve; Dellon, Evan S.; Chachu, Karen A.; Day, Lukejohn W.; Lebwohl, Benjamin; Muniraj, Thiruvengadam; Patel, Amit; Peery, Anne F.; Shah, Raj; Singh, Harminder; Singh, Siddharth; Spechler, Stuart J.; Sultan, Shahnaz; Su, Grace L.; Thrift, Aaron P.; Weiss, Jennifer M.; Weizman, Adam V.; Bernstein, Jonathan A.; Dinakar, Chitra; Golden, David B.K.; Khan, David A.; Lieberman, Jay; Oppenheimer, John; Shaker, Marcus; Stukus, David R.; Wallace, Dana; Wang, Julie

doi:10.1053/j.gastro.2020.02.039

Cited by 112 publications

(106 citation statements)

References 113 publications

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“…The relationship between the severity of duodenal inflammation and symptoms is unknown. While PPIs reduce eosinophilic infiltration in eosinophilic esophagitis, 43 the eosinophil count was not related to PPI use in FD. Further studies are necessary to clarify the contributions of duodenal mucosal inflammation to the pathogenesis of FD.…”

Section: Discussionmentioning

confidence: 81%

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Duodenal mucosal secretory disturbances in functional dyspepsia

Narayanan

Linden

Peters

et al. 2020

Neurogastroenterology Motil

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Although functional dyspepsia (FD) is mostly attributed to gastric sensorimotor dysfunctions, 1 intestinal, especially duodenal, disturbances have also been observed. A subset of patients have duodenal mucosal inflammation which is of variable, typically mild, severity and is perhaps a sequela of postinfectious FD. 2,3 Another study identified reduced expression of selected tight junction barrier proteins and increased ex vivo paracellular epithelial permeability. 4

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Section: Discussionmentioning

confidence: 81%

“…4,42 The relationship between the severity of duodenal inflammation and symptoms is unknown. While PPIs reduce eosinophilic infiltration in eosinophilic esophagitis, 43 the eosinophil count was not related to PPI use in FD.…”

Section: Discussionmentioning

confidence: 81%

Duodenal mucosal secretory disturbances in functional dyspepsia

Narayanan

Linden

Peters

et al. 2020

Neurogastroenterology Motil

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“…The American Gastroenterological Association Joint Task Force on Allergy and Immunology (AGA-JTF) guidelines for EoE recommend PPI therapy for esophageal eosinophilia, based on reports of reductions in histologic features of disease from 42% in observational studies, although there is heterogeneity in responses to PPIs. 5,24 Although response to PPIs is lower than reported with most corticosteroid studies, their safety and ease of administration can make them a good first-line treatment option-especially given the lack of FDA-approved formulations of swallowed topical corticosteroids that are optimized for esophageal delivery. Budesonide is available in a tablet formulation that was recently approved by the European Medicines Agency.…”

Section: Proton Pump Inhibitorsmentioning

confidence: 99%

“…5 Overall, about two-thirds of patients enrolled in placebo-controlled trials demonstrated a histologic response. 24 The AGA-JTF technical report identified heterogeneity in the histopathologic response rate to steroids in published clinical trials, demonstrating nonresponse to topical corticosteroids in proportion of patients ranging from 5% to 69%. 24 Current drawbacks to corticosteroids include the lack of an FDA-approved corticosteroid for EoE and absence of readily available formulations optimized for esophageal delivery in the United 20 Maximal symptoms are dysphagia with every meal, despite a modified, soft-solid diet, whereas minimal symptoms are complete absence of dysphagia without any dietary avoidance based on food texture.…”

Section: Swallowed Topical Corticosteroidsmentioning

confidence: 99%

Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis

Hirano

Furuta

2020

Gastroenterology

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Treatment of eosinophilic esophagitis has progressed from elemental formula for children and esophageal dilation for adults to selective exclusion of food triggers and swallowed topical corticosteroids. Management guidelines are available from the American Gastroenterological Association and the Joint Task Force on Allergy Immunology Practice Parameters. We cannot, however, evaluate the efficacy of treatments without a definition of response. We propose a treat-to-target approach, based on symptoms and findings from endoscopy and histology. This approach addresses dissociations between outcomes, such as symptom persistence despite normalization of histologic features and symptom resolution after esophageal dilation despite histologic features of active disease. Eosinophilic esophagitis can now be treated with biologic agents that target specific immune pathways, and findings from prospective trials have indicated that less-restrictive, empiric, elimination diets can be effective and reduce the need for repeated endoscopic assessment of disease activity during food reintroduction. We also discuss eosinophilic esophagitis subtypes, factors associated with disease, and advances in management.

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“…First line therapies for EoE are topical steroids, dietary elimination, and proton pump inhibitors, which are aimed at reducing inflammation and epithelial eosinophilia in the esophagus [1,9,10]. While pharmacologic and dietary therapies can decrease esophageal eosinophilia and microscopic evidence of fibrosis [11,12], they may not resolve overt strictures or narrowing.…”

Section: Introductionmentioning

confidence: 99%

Dilation-predominant approach versus routine care in patients with difficult-to-treat eosinophilic esophagitis: a retrospective comparison

et al. 2021

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Background & Aims: Little is known about esophageal dilation as a long-term treatment eosinophilic esophagitis (EoE). We examined the impact of a “dilate and wait” strategy on symptoms and safety of patients with EoE. Methods: This retrospective cohort study included two groups of EoE patients: those who underwent a dilation-predominant approach, defined as >3 dilations as EoE sole therapy or for histologically refractory disease (>15 eos/hpf); and those who had routine care, defined as <3 dilations or histologic response. Characteristics of the groups were compared and outcomes for the dilation-only group assessed. Results: Of 205 patients, 53 (26%) received the dilation-predominant strategy (n=408 dilations total), most commonly because of histologic treatment non-response (75%). These patients were younger (33 vs 41 yrs, p=0.003), had a narrower baseline esophageal diameter (9.8 vs 11.5mm, p=0.005), underwent more dilations (7.7 vs 3.4, p <0.001), but achieved a smaller final diameter (15.7 vs 16.7mm, p=0.01) compared to routine care. With this strategy, 30 patients (57%) had ongoing symptom improvement, with esophageal caliber change independently associated with symptom response (aOR 1.79; 95%CI 1.17-2.78); 26 (49%) used the strategy as a bridge to clinical trials. Over a median follow-up of 1001 days (IQR 581-1710), there were no deaths or dilation-related perforations, but there were 9 ER visits, including 1 for post-dilation bleeding and 4 for food impaction. Conclusions: A dilation-predominant long-term treatment strategy allows for symptom control or bridge to clinical trials for patients with difficult to treat EoE. Close follow-up and monitoring for complications is required.

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Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters

Cited by 112 publications

References 113 publications

Duodenal mucosal secretory disturbances in functional dyspepsia

Duodenal mucosal secretory disturbances in functional dyspepsia

Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis

Dilation-predominant approach versus routine care in patients with difficult-to-treat eosinophilic esophagitis: a retrospective comparison

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