1 Literature Review Peter R. McNally, DO, FACP, FACG University Colorado at Denver School of Medicine Center for Human Simulation Aurora, Colorado 80045.

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Literature ReviewLiterature Review

Peter R. McNally, DO, FACP, FACGPeter R. McNally, DO, FACP, FACGUniversity Colorado at Denver University Colorado at Denver

School of MedicineSchool of MedicineCenter for Human SimulationCenter for Human Simulation

Aurora, Colorado 80045Aurora, Colorado 80045

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Roy-Ghanta S, Larosa DF, Katzka DA.Roy-Ghanta S, Larosa DF, Katzka DA.

Atopic Characteristics of Adult Patients with Atopic Characteristics of Adult Patients with Eosinophilic Esophagitis. Eosinophilic Esophagitis.

Clinical Gastroenterology and Hepatology. Clinical Gastroenterology and Hepatology.

2008;6:531-535.2008;6:531-535.

University of Pennsylvania, Philadelphia, Pennsylvania

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IntroductionIntroduction

• Eosinophilic esophagitis (EOE) is a Eosinophilic esophagitis (EOE) is a condition of increasing clinical condition of increasing clinical identification among pediatric and identification among pediatric and adult patientsadult patients

• Pediatric cases of EOE have commonly Pediatric cases of EOE have commonly been identified to have atopic been identified to have atopic conditions, environmental allergies conditions, environmental allergies and food allergiesand food allergies

Furuta GT, et al. FIGERS. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterol 2007;133;1342-1363.

Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:531-535.Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:531-535.

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AimAim

• To evaluate a cohort of adults with EOE for To evaluate a cohort of adults with EOE for prevalence of food associated and prevalence of food associated and environmental allergens.environmental allergens.

• Examine the value of in vitro techniques to Examine the value of in vitro techniques to diagnose food-associated allergensdiagnose food-associated allergens

• Examine the prevalence of other allergic Examine the prevalence of other allergic conditions among adults with EOE.conditions among adults with EOE.


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Study Design:Study Design:Study PopulationStudy Population

• Allergy Clinic charts of pts with Dx EOE were reviewed Allergy Clinic charts of pts with Dx EOE were reviewed for atopic history (allergic rhinitis, asthma, atopic for atopic history (allergic rhinitis, asthma, atopic dermatitis), testing of environmental/food allergy, & dermatitis), testing of environmental/food allergy, & laboratory results pertaining to the initial evaluation.laboratory results pertaining to the initial evaluation.

• Laboratory DataLaboratory Data– Eosinophil countEosinophil count– Total IgE kU/LTotal IgE kU/L– Allergic sensitization to food-associated allergens Allergic sensitization to food-associated allergens

by in vitro using AB ImmunoCAP system (Pharmacia by in vitro using AB ImmunoCAP system (Pharmacia Diagnostics, Uppsala, Sweden)Diagnostics, Uppsala, Sweden)

• Food History for 96 diverse foods Food History for 96 diverse foods


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Study Design: Definition of EOE:Study Design: Definition of EOE:

Clinical Criteria:Clinical Criteria: Symptoms of epigastric pain,Symptoms of epigastric pain,chest discomfort, dysphagia orchest discomfort, dysphagia orfood impaction poorlyfood impaction poorlyresponsive to PPI BID dosingresponsive to PPI BID dosingfor > 2 mo prior to biopsy.for > 2 mo prior to biopsy.

PlusPlus

Histologic CriteriaHistologic CriteriaI: Mean EO >15/HPF I: Mean EO >15/HPF

in in >> 2 HPF 2 HPF or or

II: Mean EO >25/HPF II: Mean EO >25/HPF in any fieldin any field

Example: >25 eosinophils/HPF


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Results: Demographics & Results: Demographics & Atopic CharacteristicsAtopic Characteristics

VariableVariable

Mean age + SD, yMean age + SD, y 35.2 + 1135.2 + 11

Age range, yAge range, y 18-5718-57

Sex: M/F (ratio)Sex: M/F (ratio) 14/9 (1.6 : 1)14/9 (1.6 : 1)

Atopy, no of patients (any)Atopy, no of patients (any) 18 (78%)18 (78%)

AsthmaAsthma 66

Allergic RhinitisAllergic Rhinitis 1818

Atopic dermatitisAtopic dermatitis 11


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Results: Demographics & Results: Demographics & Atopic CharacteristicsAtopic Characteristics

VariableVariable

Specific IgE for food allergensSpecific IgE for food allergens 19 (83%)19 (83%)

Specific IgE for Specific IgE for

environmental allergensenvironmental allergens

18/21 (86%)18/21 (86%)

Birch pollenBirch pollen 17/21 (81%)17/21 (81%)

Timothy & Ryegrass pollenTimothy & Ryegrass pollen 16/21 (76%)16/21 (76%)

Ragweed pollenRagweed pollen 16/21 (76%)16/21 (76%)

Dust mite allergenDust mite allergen 15/21 (71%)15/21 (71%)

Pet Dander (cat and dog)Pet Dander (cat and dog) 15/21 (71%)15/21 (71%)


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Results:Positive CAP Test to Food AllergensResults:Positive CAP Test to Food Allergens

FoodFood Number of PtsNumber of Pts FrequencyFrequencyWheatWheat 99 39%39%

CarrotCarrot 99 39%39%

TomatoTomato 88 35%35%

OnionOnion 88 35%35%

OnionOnion 88 35%35%

BananaBanana 77 30%30%

Sesame seedSesame seed 77 30%30%

Egg whiteEgg white 77 30%30%

Cow mildCow mild 77 30%30%

GarlicGarlic 66 26%26%

CornCorn 66 26%26%

PotatoPotato 66 26%26%

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Conclusions:Conclusions:

1.1. EOE in adults is commonly associated EOE in adults is commonly associated with other allergic phenomenonwith other allergic phenomenon

2.2. EOE is male gender dominant (EOE is male gender dominant (♂ to ♀ ♂ to ♀ ratio of 1.6:1)ratio of 1.6:1)

3.3. Both dietary and environmental Both dietary and environmental triggers of EOE are common (83 and triggers of EOE are common (83 and 88%, respectively) and should be 88%, respectively) and should be searched forsearched for


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Reviewer CommentsReviewer Comments

1.1. Dr. Roy-Ghanta and colleagues have shown that a Dr. Roy-Ghanta and colleagues have shown that a high degree of atopic diathesis exists among high degree of atopic diathesis exists among adults with EOE 18/23 (78%).adults with EOE 18/23 (78%).

2.2. Adult patients with EOE tend to be polysensitive Adult patients with EOE tend to be polysensitive to multiple environmental allergens.to multiple environmental allergens.

3.3. Food allergies confirmed by CAP testing was Food allergies confirmed by CAP testing was found in 19/23 (83%) of adult EOE pts.found in 19/23 (83%) of adult EOE pts.


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Roy-Ghanta, et al, do not answer the following questions?Roy-Ghanta, et al, do not answer the following questions?

1.1. What is the true prevalence of atopic diathesis, food and What is the true prevalence of atopic diathesis, food and environmental allergies among “all” EOE patients is not environmental allergies among “all” EOE patients is not established, because they examined only those patients established, because they examined only those patients seen by an allergist with a co-existing diagnosis of EOE. seen by an allergist with a co-existing diagnosis of EOE.

2.2. Why pts with EOE and atopic diathesis exhibit a lower male Why pts with EOE and atopic diathesis exhibit a lower male to female ration than others have reported (1.6:1 vs. 3:1)?to female ration than others have reported (1.6:1 vs. 3:1)?

3.3. Should all pts with EOE undergo formal allergy evaluation?Should all pts with EOE undergo formal allergy evaluation?

4.4. Can aggressive management of environmental allergies Can aggressive management of environmental allergies affect the course of EOE? affect the course of EOE?


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1.1. Dr. Roy-Ghanta and colleagues are commended Dr. Roy-Ghanta and colleagues are commended for demonstrating how common atopic diathesis, for demonstrating how common atopic diathesis, environmental and food allergies are among environmental and food allergies are among patients with EOE. patients with EOE.

2.2. Now it will be important for Dr. Roy-Ghanta and Now it will be important for Dr. Roy-Ghanta and others to systematically examine how common others to systematically examine how common allergic disorders are among ALL pts with EOE. allergic disorders are among ALL pts with EOE. Furthermore, we need to systematically examine Furthermore, we need to systematically examine the utility of aggressive management of the utility of aggressive management of environmental and dietary allergies on the clinical environmental and dietary allergies on the clinical course of this disorder. course of this disorder.


1 Literature Review Peter R. McNally, DO, FACP, FACG University Colorado at Denver School of Medicine Center for Human Simulation Aurora, Colorado 80045.

Documents

atopic conditions

prevalence of food

foodassociated allergens

dx eoe

definition of eoe

food impaction

allergic conditions

sweden food history