What is Eosinophilic Esophagitis, how is it treated, and will it go away?

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2 Panelists

3 What is Eosinophilic Esophagitis, how is it treated, and will it go away? Bradley A. Becker, M.D. Professor of Pediatrics and Internal Medicine Division of Allergy and Immunology Saint Louis University School of Medicine SSM Cardinal Glennon Children s Medical Center

4 Age of Presenting Symptoms of Eosinophilic Esophagitis Noel RJ, Putnam PE, Rothenberg ME; Eosinophilic Esophagitis, N Engl J Med, 351:9, , 2004

5 Association of Allergy and Eosinophilic Esophagitis Noel RJ, Putnam PE, Rothenberg ME; Eosinophilic Esophagitis, N Engl J Med, 351:9, , 2004

6 Complications of EoE Greenhawt et al. The Management of Eosinophilic Esophagitis. J Allergy Clin Immunol: In Practice. July/August Not life threatening Reduced quality of life Major complications: Esophageal strictures and/or narrowing Food getting stuck Persistent or progressive difficulty swallowing Esophageal scarring and remodeling in up to 40% of patients

7 EoE: Often A Chronic Disorder DeBrosse et al. in 2011 Survey follow-up study of 4000 biopsies from patients consistent with EoE Compared biopsies with reoe vs. chronic esophagitis After 15 years: Reduced quality of life, increased difficulty swallowing, increased food impaction compared to CE or normal controls Self reported food impaction incidence of 40%

8 Pathogenesis of Eosinophilic Esophagitis Eosinophilic esophagitis: Pathogenesis, genetics, and therapy, CB Blanchard, N Wang, M Rothenberg, J Allergy Clin Immunol, 118:5, Strong family association Nearly 10% of patients have parents with EoE have a history of esophageal strictures 3-8% of have a parent or sibling with EoE 3 generations of affected relatives have been reported

9 Diagnosis of Eosinophilic Esophagitis Triggers J. Pablo et al. Annu Rev. Med : Immediate skin prick tests Blood Serum IgE allergy tests Food atopy patch skin tests Food diaries Only about 10-15% have food anaphylaxis No reports of fatalities Sensitization to many foods in most EoE patients

10 Food Allergy Prick Skin Testing Furuta et al., Consensus Report of Eosinophilic Esophagitis, Gastroenterology, 133:4, 2007 EoE in Pediatrics 2/3 of patients positive to at least one food Foods tested in clinical studies: Cow s milk, egg, wheat, soy, peanuts, fish, shellfish, tree nuts Also see other grains, meats, fruits, and vegetables

11 Avoidance Diets: Elemental Selected foods based on allergy testing Six food elimination diet Milk, egg, wheat, soy, all nuts and all seafood

12 Medications Trial of medication to reduce acid Swallowed steroids Flovent (fluticasone) Pulmicort (budesonide)

13 Suggested Food Reintroduction Strategy Greenhawt et al. The Management of Eosinophilic Esophagitis. J Allergy Clin Immunol: In Practice. July/August 2013.

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15 Nisha Mangalat, MD Assistant Professor of Pediatrics Saint Louis University School of Medicine Division of Pediatric Gastroenterology, Hepatology, & Nutrition Cardinal Glennon Children s Medical Center

16 Disclosures No financial or commercial interest disclosures

17 No Disclosures

18 Objectives Understand the diagnosis of Eosinophilic Esophagitis ( EoE ) is made by both clinical features and tissue findings Briefly discuss other conditions that lead to eosinophils in the esophagus (not EoE) Recognize typical GI clinical symptoms of EoE Review the endoscopic evaluation of EoE and common findings

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20 Eosinophilic Esophagitis Called EoE for short Inflammation of in the esophagus by a specific type of white blood cell, eosinophil It is an emerging disease related to food ingestion or perhaps aeroallergens

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22 Large amount of eosinophils in the esophagus Esophageal Eosinophilia, is usually, but not always, because of EoE

23 Other considerations for Eosophageal Eosinophilia GERD (Gastroesophageal reflux disease) PPI responsive esophageal eosinophilia PPI = Proton Pump Inhibitors, strong acid-blockers Examples of PPIs are Nexium, Prevacid, Prilosec Celiac disease Condition in genetically susceptible individuals resulting from abnormal immune response to gluten Crohn s Disease Chronic disease resulting in uncontrolled and dysregulated inflammation in the GI tract Infection Eosinophlic gastroenteritis

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33 How is EoE Diagnosed? Currently, the only way to accurately diagnosed EoE is by upper endoscopy and biopsy in the setting of a suggestive clinical history There are many visual features suggestive of EoE, but sometimes the tissue looks normal. Because the visual findings are not definitive, and the disease may be patchy, biopsies are required

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47 The Role of the Gastroenterologist Because of many possible GI symptoms, patients often present to a GI doctor first. When patients have a food impaction, an emergency scope is performed Otherwise, when EoE is suspected, patients are usually placed on a strong acid blocker in the category of Proton Pump Inhibitors (PPI), and subsequently undergo an upper endoscopy with biopsy.

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56 What GI follow up is needed? There are no hard and fast rules about number, and timing of repeat endoscopy To achieve treatment goals, team approach with GI, Allergy-Immunology, and Nutrition is needed To assure histologic, endoscopic remission, several endoscopies may be necessary andhelpful in the first few years after diagnosis to assure that the medication and dietary plan prescribed is effective.

57 Summary The diagnosis of Eosinophilic Esophagitis ( EoE ) is made by both clinical features and tissue findings Although Eosinophilic Esophagitis is the most common condition associated with large amount of esophageal eosinophilia, other conditions like Celiac Disease, Crohn s disease, infection can also results in eosinophils in the esophagus GI symptoms of EoE can vary based on age Common endoscopic findings in EoE are furrows, rings in the esophagus, white plaques in the esophagus Patients may require repeat endoscopies to assure endoscopic and histologic remission of EoE at intervals determined by collaboration between Allergist and GI

58 Nisha Mangalat, MD Assistant Professor of Pediatrics Saint Louis University School of Medicine Division of Pediatric Gastroenterology, Hepatology, & Nutrition Cardinal Glennon Children s Medical Center

59 Nutrition and Eosinophilic Esophagitis Kathryn Helling, MS, RD, LD September 17, 2014

60 Objectives Understand nutrition therapy options Understand specific nutrients of concern Understand role of a pediatric dietitian on the EoE team

61 EoE Nutrition Therapy Options Elimination Diet Individualized Six Food Elimination Diet Avoid milk, egg, wheat, soy, nuts, and fish Elemental Diet Primary source of nutrition is an elemental formula such as Elecare or Neocate

62 Potential Nutrient Deficiencies Food Nutrients Other Food Sources Milk Soy Wheat Protein, calcium, vitamin D, phosphorus, potassium, etc. Protein, iron, zinc, magnesium, folate Iron, B vitamins such as folic acid Meats, legumes, whole grains, nuts, and fortified foods/beverages such as soymilk. Meats, grains, fortified foods/beverages Other enriched grains, fruits, vegetables, legumes Egg Protein, selenium, choline Meat, legumes, whole grains, fish, seafood Nuts Fish source: Gastroenterol Clin N Am 43 (2014) Vitamin E, B vitamins, zinc, selenium, phosphorus Protein, omega 3 fatty acids, zinc, phosphorus, selenium, B12 Legumes, whole grains, vegetable oils, fish Whole grains, meats, milk, nuts, soy, flaxseed, nuts, oils

63 ary-reference-intakes-for-calciumand-vitamin-d/dri-values.aspx

64 Potential Nutrient Deficiencies Each 8 ounce glass of milk contains 300 mg calcium and 100 IU vitamin D. If drinking a milk alternative beverage such as rice milk or soy milk, make sure it is enriched. Age Calcium Needs (RDA) 1-3 years 700 mg = 20 ounces milk 4-8 years 1,000 mg = 28 ounces milk 9-18 years 1,300 mg = 35 ounces milk

65 Making an appointment with a Registered Dietitian what to expect A pediatric dietitian with experience in EoE and food allergies can help parents come up with an individualized meal plan for their child. Topics discussed in an appointment include: your child s growth, age appropriate nutrient needs, label reading, recipes/websites/resources, cross-contamination, and a list of foods to avoid and foods to include in the diet. Consider a multivitamin Encourage the entire family to embrace the new diet. Keep mealtime enjoyable

66 QUESTIONS

67 Staff Contact Information Wendy Chromoga Asthma Coach Jessica Dunsmore Director of Public Awareness Joy Krieger Executive Director Andrea Lebb Program Outcome & Information Manager Reagan Nelson Program Director Alyssa Smith Office Manager Amy Trapp Development Director