Eosinophilic Esophagitis Presented by Sadudee boonmee, MD.

1. Eosinophilic Esophagitis : Diagnosis and Management Sadudee Boonmee Klakayan, MD

4. Pathogenesis Current Opinion in Allergy and Clinical Immunology 2010, 10:231–237

7. Eosinophil associated Esophagitis ( Rothenberg, J Allergy Clin Immunol 2004;113:11-28.)

8. LIACOURAS ET AL J Allergy Clin Immunol 2011;128:3-20.

9. Most common clinical manifestration Mirna Chehade and Seema S. Aceves Current Opinion in Allergy and Clinical Immunology 2010, 10:231–237 Age Clinical presentation Infant and Toddlers feeding difficulties,feeding refusal or intolerance, irritability, vomiting, failure to thrive School-aged children Abdominal pain, vomiting, GERD-like symptoms, difficulty swallowing, food aversion/self-limited diet, failure to thrive Adolescents Dysphagia, esophageal food impactions, nausea, GERD-like symptoms, self-limited diet Adult Dysphagia, esophageal food impactions

13. EoE vs GERD ( Rothenberg, J Allergy Clin Immunol 2004;113:11-28.)

14. LIACOURAS ET AL J Allergy Clin Immunol 2011;128:3-20. LIACOURAS ET AL J Allergy Clin Immunol 2011;128:3-20.

17. Normal Esophagous Esophageal furrowing White mucosal plaques

18. Esophageal ring trachealization Small-caliber esophagus with mucosal tearing after endoscopy

22. Normal esophagous EoE Superficial layering of surface Eo Microabcess

27. nejm 2004 351(9) 940-941

29. Studies Atopic disease Evidence of IgE to Aeroallergen Evidence of IgE to Food Aceves et al, J Clin Gastroenterol Vol 41, No 3, March 2007 Asthma 47% AR 40 % Eczema 4% + aeroallergen RAST 44% + food RAST 60% Collins et al, Clin Gastro and Hepato Vol. 6, No. 6 Asthma 52% AR 68 % Eczema 44% AC 56 % + SPT aeroallergen 71% + SPT food 76% ROY–GHANTA et al, Clin Gastro and Hepato Vol. 6, No. 5 Asthma 26% AR 78% AD 4% Specific IgE aeroallergen 86% ( Birch pollen ,Timothy ryegrass pollen Ragweed pollen , dust mite Pet dander ) Specific IgE for food 83%

30. Is There a Seasonal Variation in the Incidence or Intensity of Allergic Eosinophilic Esophagitis in Newly Diagnosed Children? Winter had significantly fewer newly diagnosed patients with AEE when compared with Spring, Summer, and Fall individually (P=0.0008, P=0.0001, P=0.0118,respectively) Flint Y. J Clin Gastroenterol 2007;41:451–453

31. Seasonal Distribution in Newly Diagnosed Cases of Eosinophilic Esophagitis in Adults signifi cant increase of EoE cases in spring and summer months ( n = 28) when compared with the fall and winter months ( n = 13) ( P = 0.019) Am J Gastroenterol 2009; 104:828 – 833;

34. Atopic disease Aeroallergen Specific IgE Food specific IgE Aceves et al J Clin Gastroenterol Vol 41, No 3, March 2007 Asthma 47% AR 40 % Eczema 4% + aeroallergen RAST 44% + food RAST 60% COLLINS ET AL Clin Gastro and Hepato Vol. 6, No. 6 Asthma 52% AR 68 % Eczema 44% AC 56 % + SPT aeroallergen 71% + SPT food 76% ROY–GHANTA ET AL Clin Gastro and Hepato Vol. 6, No. 5 Asthma 26% AR 78% AD 4% Specific IgE aeroallergen 86% ( Birch pollen ,Timothy ryegrass pollen Ragweed pollen , dust mite Pet dander ) Specific IgE for food 83%

35. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:531–535

41. esophageal eosinophils & No. of patients complaining of clinical symptoms before & 1 month after the initiation of dietary therapy Chris A. Liacouras et al. Clin Gastroentrol Hepato 2005;3:1198–1206

45. Predictive values for skin prick test and atopy patch test for eosinophilic esophagitis Jonathan M. Sperge, Letters to Editor Jaci.2006.11.016

46. Predictive values for skin prick test and atopy patch test for eosinophilic esophagitis Jonathan M. Sperge, Letters to Editor Jaci.2006.11.016

50. Study Design & No. of Pt Medication and Dosage Outcome Konikoff et al, 2006 RDBPC N = 36 Fluticasone propionate 2 puffs twice daily : All subjects received 220 mcg/puff( total 880mcg/d) * 3 mo (Ages 3–16 y) 1 o outcome : Prox EsoEo 65.9 + - 25.3 vs 1.4 + -1.1 eos/hpf [P =0.03] : Dist EsoEo 84.6 + -19.7 vs 19.6 + - 12.9 eos/hpf [P=0.04 ] 2 o outcome : Resolution of vomiting FP vs placebo  67% vs 27%; [ P =0 .04] :Improve endocopic finding (Furrow) [P=0.047] : reduce epithelial hyperplasia [ P= 0.01] :FP decreased the number of CD8 & mast cells in proximal and distal esophagus ( P=0 .05)

51. Study Design & No. of Pt Medication and Dosage Outcome Dohil et al,2010 RDBPC N = 24 Oral viscous budesonide * 3 mo Subjects <5 ft tall : 1 mg daily Subjects >5 ft tall : 2 mg daily (Age 1–17 y mean 7.8 yr) 1 o outcome In OVB gr 87.6%  responder Reduce peak EsoEo all esophageal Levels proximal (P=0.0024), mid (P =0 .0001), and distal (P=0 .0001) when compared to baseline 2 o outcome :Upper gastrointestinal endoscopy score reduced 4.6  1.5 [P=0.0005] :Symptom score decrease from 3.5  1.2 [p=0.0007] : Epithelial &Lamina propria Eosinophilia&Fibrosis reduced [P=0.0035]

52. Eosinophilic esophagitis: Updated consensus recommendations for children and adults (J Allergy Clin Immunol 2011;128:3-20.)

61. Why 15 Eos/HPF ? GASTROENTEROLOGY 2007;133:1342–1363 10 studies 15 eos/HPF based on peak count or mean number of fields 8 studies 20 eos/HPF based on Peak or mean number 2 studies 24 eos/HPF based on peak count or mean number 1 study 30 eos/HPF peak count

62. Elemental Diet Is an Effective Treatment for Eosinophilic Esophagitis in Children and Adolescents THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 98, No. 4, 2003