Eosinophilic Esophagitis

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1 Eosinophilic Esophagitis Now, how do you say that? Presenters: Sean Jameson, BA Jennifer Jacob, RN, BSN Annette Ahrens, BA Cincinnati Center for Eosinophilic Disorders Division of Gastroenterology, Hepatology, and Nutrition and The Division of Allergy and Immunology

2 Objectives Define Eosinophilic Esophagitis (EE) Recognize the psycho-social aspects of Eosinophilic Esophagitis in the pediatric population. Discuss research findings related to EE.

3 Magnet Forces Force 6: Quality Care Force 7: Quality Improvement Force 8: Consultation & Resources Force 13: Interprofessional Relationships

4 The Cincinnati Center for Eosinophilic Disorders (CCED) The CCED is a: Fast Growing High Volume Multidisciplinary Care Center The mission of the CCED is to provide the best personal care for each patient and to learn from each patient through research.

5 Leadership Director Marc Rothenberg M.D., Ph.D Director, Division of Allergy and Immunology Director, Cincinnati Center for Eosinophilic Disorders Professor of Pediatrics Medical Director Philip Putnam, M.D. Associate Professor of Pediatrics Division of Gastroenterology, Hepatology and Nutrition

6 CCED Members Allergy/Immunology Marc Rothenberg, MD, PhD Pablo Abonia, MD Kimberly Risma, MD, PhD Sean Jameson, BA Barb Hanlon, RN Deborah Seider, RN Christine Steinmetz, RN Pathology Margaret Collins, MD ENT Alessandro D Alarcon, MD Gastroenterology James Franciosi, MD Philip Putnam, MD Jennifer Jacob, RN, BSN Aisha Williams Terryll Richardson, LPN Brandy Snyder, LPN Ann Weaver, RN Research Coordinators Bridget Buckmeier, BA, CCRP Annette Ahrens, BA Maggie Palazzolo, MS Nutrition Mandy Clemons, RD, LD Social Work Maleshia Neugebauer, MSW, LSW Speech Pathology Drew Gerwin, MA-CCC/SLP Psychology Wendi Lopez, PsyD

7 What We Do Diagnose the disorder Provide medical care Conduct significant research about Eosinophilic Gastrointestinal Disorder (EGID) Link patients to the latest treatments

8 How We Do It Coordinated care is critical to managing eosinophilic disorders. The C.C.E.D has members from eight divisions and has 35 clinical and research professionals. The center utilizes a number of ancillary services within the hospital during the process of treating patients. The C.C.E.D Model (Research Driven Patient Centered Care) GI Allergy Nutrition Pathology Social work Psychology ENT Speech Pathology

9 CCED New Patient Evaluation Week: Week Long Evaluation Monday Tuesday Wednesday Thursday Friday GI clinic visit X X Endoscopy /Colonoscopy Allergy skin prick test Allergy patch test Social work visit Education Class Treatment plan presented Dietary consult Patch test reading X Research X X X X X X X X X X

10 EE at CCHMC Over 40 new diagnoses of EE from Hamilton County presented to GI clinic last year Over 100 additional patients referred to the CCED per year nationally The CCED treats over 300 patients each year The CCED performs greater than 25% of endoscopies at CCHMC

11 Patient Distribution through the CCED 2004 to 2007

12 The CCED Impact The CCED was the first center in the country dedicated to research and treatment of eosinophilic disorders Three other Centers now exist since the CCED s conception following a similar model. ( CHOP, Denver Children s, San Diego Children s)

13 EE in the Literature Number of Articles

14 CCED Publications

15 FIGERS First International Gastrointestinal Eosinophil Research Symposium

16 Eosinophilic Esophagitis (EE)

17 Who has Eosinophilic Esophagitis? 70% are males Predominantly Caucasian Personal/family history of allergic conditions Familial tendency

18 What is an Eosinophil? Type of white blood cell produced in the bone Serves as a protection against infections Found in the GI tract, spleen, thymus and lymph nodes Within the GI tract eosinophils are found in the lining of the Stomach Small intestine Cecum Colon

19 Definition of Eosinophilic Esophagitis Clinico-pathologic disorder Histologic changes Clinical symptoms **Present with adequate proton pump inhibitor (PPI) treatment**

20 Esophagogastroduodenoscopy (EGD)

21 Histologic Changes Greater than 15 eos/hpf Basal cell hyperplasia Thickened epithelium Fibrotic lamina propria Long papillae Abnormal Normal

22 Degranulation White exudate Basal layer hyperplasia EE Eosinophilic infiltration

23 Endoscopic Appearance Normal Esophagus

24 Endoscopic Appearance Abnormal Esophagus Furrows Rings Exudate

25 Abnormal histology Normal But

26 Clinical Symptoms Pain Heartburn / reflux Substernal pressure Epigastric pain Vomiting Dysphagia Associated with specific foods Non-specific Feeding disorders Difficulty getting food down Food impaction

27 Clinical Symptoms Noel, et al, 2004

28 Associated Conditions Eczema Chronic rhinitis Food allergies Reactive airway problems Developmental delays Failure to thrive

29 So, what now?

30 Types of EE Allergic responds to elimination of foods reoccurs when offending foods are put back into diet. Non-allergic no response to food elimination

31 Treatment Allergic type Elemental diet amino acid-based, hypo-allergenic formula Elecare Neocate Elimination diet Directed Six Food ( Milk, egg, wheat, soy, seafood, peanut)

32 Food Trials If biopsy confirms resolution of esophagitis Reintroduce dietary antigens 1 new food every 2 weeks 1-4 new foods between EGDs EGD every 2-3 months Until there is a nutritionally adequate diet acceptable to the family and child **Recurrent esophagitis requires withdrawal of the recently added foods**

33 Non- Allergic Treatment Pharmacotherapy Steroids Topical Fluticasone (Flovent) Budesonide (Pulmicort) Systemic Prednisone Biologic Anti-IL5 ( Monoclonal antibody) Immodulators 6MP

34 Treatment flow chart

35 Complications of EE Food impactions Strictures

36 Psycho-Social Issues Foods Formula Financial Frequent surgeries Travel (hotel, meals, airfare) Work/ school absence Social Speech and feeding Poor adjustment Self image School interactions Meal times

37 Nursing Considerations EE is a REAL disease EE is a chronic disease Off label use of medications Children often have food restrictions Parents under stress Parents advocates for children

38 Support for Families The Eddy project Family education day Family Education and Enrichment for Eosinophilic Disorders

39 Support for Families The American Partnership for Eosinophilic Disorders (APFED) Campaign Urging Research for Eosinophilic Disorders (CURED) The Cincinnati Center for Eosinophilic Disorders

40 Research How it works What we find How it helps

41 Research Process Lab Personnel Clinical Visit Clinical Research Coordinator

42 Patient Participation in Research Patient Blood & Tissue Biopsy Questionnaires & Assessments Saliva DNA from Parents The quality of DNA extracted from saliva is comparable to DNA from blood!

43 Our Studies 19 Active Eosinophilic Studies Live sample Quality of Life and Treatment Adherence Longitudinal Sample Collection of blood, tissue, & saliva Drug Flovent Dosing Anti-IL 5 Data Anti-IL 13 (coming soon) EE Long Term Follow-up Prevalence and Incidence of EE EE and Celiac (coming soon)

44 Findings We have: Identified 500 specific genes increased in EE. (Biopsy) Identified Eotaxin 3, a key gene in EE. (Biopsy & Blood) Implemented Anti-IL 5 in patients with EGID Created several EE mouse models for experimentation.

45 The EE transcript signature EE EE Normal NL Eotaxin-3 is the number one gene over expressed

46 Real EE Patient Pedigree Eosinophilic Esophagitis (EE) Reflux Difficulty swallowing Difficulty swallowing & frequent dilatations

47 Recruitment Data of EE Patients From 2005-Current Adult Tissue & Blood (UC Affiliate) Clinical Symptom Score Pediatric Tissue & Blood DNA, Saliva Study

48 The Impact of Research Application of Flovent for treatment Positive outcome from utilization of Anti-IL 5 Understanding the difference in quality of life Familial inheritance identified, 1 in 1,000 individuals have EE

49 How we make it happen Research Staff (27) 11 Research Assistants 3 Clinical Research Coordinators 6 Post-Docs 5 Graduate Students 2 Visiting Research Fellows Representation of 11 Countries in our Lab Israel Chile Australia Egypt Japan India Croatia Spain France Kazekstan China

50

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