Alimentary Tract
Prevalence of eosinophilic esophagitis in patients with refractory gastroesophageal reflux disease symptoms: A prospective study

https://doi.org/10.1016/j.dld.2010.08.002Get rights and content

Abstract

Background

Eosinophilic esophagitis (EoE) is not routinely considered in the differential diagnosis of refractory gastroesophageal reflux disease (GERD).

Aims

To prospectively evaluate the prevalence of EoE and describe the clinical features and predictors of EoE in patients with refractory symptoms of GERD.

Methods

Esophageal biopsies were obtained in patients with symptoms of GERD refractory to 8 weeks of conventional antisecretory therapy. Diagnosis of EoE was defined as at least 20 eosinophils × high power field and clinical unresponsiveness to proton pump inhibitors. Clinical and manometric features were compared. Independent risk factors predicting EoE were identified.

Results

Six out of 150 included patients (4%) met the diagnostic criteria for EoE. Patients with EoE were significantly younger, had significantly more dysphagia, atopy, ineffective esophageal peristalsis, esophageal rings and esophageal strictures than patients without EoE. Independent predictors of EoE were: age under 45 years (OR 4.8, 95% CI 2.4–8.6), dysphagia (OR 12.2, 95% CI 4.3–19.4), and atopy (OR 3.4, 95% CI 1.5–7.4).

Conclusions

EoE is an uncommon condition (4%) in patients with refractory symptoms of GERD. Age under 45 years, atopy or dysphagia may warrant suspicion of EoE in this subset of patients.

Introduction

Eosinophilic esophagitis (EoE) is defined as the presence of an abundant eosinophil infiltrate of the esophageal mucosa observed at biopsy [1]. While it is true that there is still controversy about the number of eosinophils that must be observed per high power field (HPF) for the diagnostic standard of EoE, most authors have used a number equal or greater than 20 cells [2]. This disease was first described in children and recently in adults [3]. An increased prevalence has been observed in recent years, which may be partially explained by the more diligent search for the disease or etiology-related changing mechanisms [4], [5], [6]. The prevalence of EoE is highly variable and appears to depend on the characteristics of the study population. Recent prospective studies indicated a low prevalence (0.05–0.4%) in general population [4], [7]. However, it may be up to 15% in patients with dysphagia [8], [9] or as high as 48% in patients with food bolus impaction [10].

The clinical features of EoE are not completely known due to the fact that few prospective studies have been conducted. However, EoE is frequently associated with dysphagia, esophageal food impaction, allergic processes (aeroallergens, food, asthma) and some endoscopic abnormalities (concentric rings, longitudinal furrows, mucosal white plaques, strictures and narrowing of the esophageal lumen) [11], [12]. EoE may also be associated with clinical symptoms suggestive of gastroesophageal reflux disease (GERD) such as heartburn and regurgitation in about 30% of cases [11]. Also cases with non-specific symptoms and normal endoscopy have been reported from 8% to 28% of cases [12], [13].

For some time, the existence of a pathophysiological relationship between GERD and EoE has been speculated, as eosinophilic infiltrates have been observed in the esophageal mucosa of patients with GERD. It has also been suggested that EoE may cause secondary GERD [14], [15]. Some authors have reported more than 20 eosinophils × HPF in patients with GERD, which disappeared after treatment with gastric acid inhibitors [16]. Recently it was observed that patients with EoE are hypersensitive to acid perfused in the oesophagus, thus acid may play a role in the symptoms [17]. Although there may be overlapping of the two diseases, it is currently accepted that the EoE is a pathological entity different from GERD, whose etiology seems to be related to allergic and genetic factors [18], [19], [20]. Consequently, EoE symptoms respond well to topical steroid administration, while the response to gastric acid inhibitors is very limited.

We hypothesized that some patients with GERD symptoms who do not respond to conventional treatment may have EoE. Currently this disease is not routinely considered in the differential diagnosis of refractory GERD. For this reason, we proposed as main objective to prospectively evaluate the prevalence of EoE in a consecutive population of patients with GERD who were refractory to conventional therapy, and as secondary objective to describe the clinical features and predictors of EoE in this subset of patients.

Section snippets

Patients and study design

This study was approved by the Ethics and Research Committee of the Faculty of Medicine of the Universidad Autónoma de Nuevo León. From July 2007 to December 2009, we prospectively studied patients who were treated at the outpatient clinic of the Gastroenterology Department and the Service of Allergy and Immunology, University Hospital of the Universidad Autónoma de Nuevo León.

Patients older than 18 years of age with esophageal and extra-esophageal clinical symtoms suggestive of GERD according

Features of the study population

In total 150 patients were included, and all completed the protocol assessments. The median age was 46 years (range 18–92). Moreover, 59 (39.3%) were under 45 years and 66 (44%) were male. The most frequent symptoms were: heartburn and regurgitation in 114 (76%) and 84 (56%) patients respectively and only 30 (20%) had dysphagia. The median duration of symptoms was 48 months (range 20–60). The diagnosis of GERD was established by clinical criteria in 121 (80.6%), by endoscopy in 19 (12.6%), by

Discussion

As far as we know this is presently the first prospective study with the largest sample size aimed to establish the prevalence of EoE in patients with refractory GERD. We found a low prevalence (4%) of EoE in these selected patients. This prevalence is higher than the one found in a general population [4], [7], it is lower than the one reported in patients with dysphagia and food impaction [8], [9], [10] and it is similar to the one seen in patients in whom endoscopy was performed for different

Conflict of interest statement

All the authors declare that they have not conflict of interest in regards with this research.

References (32)

  • B.M. Yan et al.

    Eosinophilic esophagitis. A newly established cause of disphagia

    World J Gastroneterol

    (2006)
  • S.N. Sgouros et al.

    Eosinophilic esophagitis in adults: a systematic review

    Eur J Gastroenterol Hepatol

    (2006)
  • F.J. Moawad et al.

    Eosinophilic esophagitis

    Dig Dis Sci

    (2009)
  • C.L. Whitney-Miller et al.

    Eosinophilic esophagitis: a retrospective review of esophageal biopsy specimens from 1992 to 2004 at an adult academic medical center

    Am J Clin Pathol

    (2009)
  • J. Ronkainen et al.

    Prevalence of oesophageal eosinophils and eosinophilic oesophagitis in adults: the population-based Kalixanda study

    Gut

    (2007)
  • G.A. Prasad et al.

    Prevalence and predictive factors of eosinophilic esophagitis in patients presenting with dysphagia: a prospective study

    Am J Gastroenterol

    (2007)
  • Cited by (0)

    View full text