Dysphagia What Else Should Allergists Consider?

Transcription

1 Dysphagia What Else Should Allergists Consider? Seema Aceves MD, PhD Associate Professor, Pediatrics and Medicine Director, EGID Clinic University of California, San Diego Rady Children s Hospital, San Diego

2 Disclosures Intellectual Property: Co Inventor oral viscous budesonide NIH: NIAID, NIDDK, NCATS grant Medical Advisory Committee: APFED

3 Learning Objectives Understand and be able to evaluate the clinical symptoms in EoE Understand the clinical, histologic, and endoscopic consequences of EoE Describe and know the allergic and gastroenterological differential diagnoses for common presenting clinical complaints of EoE including dysphagia

4 EoE is a Clinicopathologic Diagnosis Liacouras et al, 2011 Updated Consensus Recommendations, JACI

5 Liacouras et al, JACI 2011

6 Differential Diagnosis of Swallowing Disorders Infants Prematurity GI anomilies Duodenal atresia Cleft Palate/Lip Craniofacial abnormalities Tracheoesophageal fistula Neurological Conditions Cardiac Conditions Children GERD Aspiration Anatomical Neurologic Guillain Barre Eosinophilic Esophagitis IBD Adults Stroke Cancer Post ICU syndrome Eosinophilic Esophagitis Psychogenic Guillain Barre Sjogren Parkinson Disease Poor dentition

7 Definition of Dysphagia Validated symptom questionnaires in adults Mayo Dysphagia Questionnaire EEsAI Validated symptom questionnaires in children PEES

8 EoE Symptoms in Allergic Subjects Aceves et al, Annals of Allergy 2010

9 Symptoms: Validated Indexes Schoepfer et al, Gastro 2014

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11 Symptoms and Histology Pentiuk et al, JPGN 2009

12 Symptoms Food Impactions Dysphagia Vomiting Martin et al, JACI 2015

13 Endoscopy: Validated Indexes Hirano et al, Gut 2012

14 PPI REE What is it?

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16 Multiple Case Series Molina Infante et al CGH 2010 Dranove et al J Peds 2009

17 51 Children 1 month 15 yo Symptoms >15 eos in at least one biopsy 82% had symptom improvement on PPI Partial Responders (>5 <15 eos/hpf) 22% Complete Responders (<5 eos/hpf) 47% EoE (>15 eos/hpf) 31% EoE: FH of atopy Food Impactions Less Abdominal Pain Higher baseline mean eos/hpf Guiterrez Junquera et al JPGN 2015

18 Randomized Controlled Trial: Esomeprazole versus Fluticasone Peterson et al, Dig Dis Sci 2009

19 Clinical Distinctions? Over 200 adult patients No clear distinguishing features between EoE and PPI REE Dellon et al, Am J Gastro 2013

20 Histologic Distinctions? Dellon et al, CGH, 2014

21 PPI REE Can Be Transient and Turn into EoE Dohil, Newbury, Aceves Dig Dis Sci 2011

22 Transient PPI Response Schroeder et al, JPGN 2013

23 Transient PPI Response Schroeder et al, JPGN 2013

24 If PPIR EE was GERD Wouldn t It Track with GERD Associated Infections? Infections that track with GERD like H. pylori are inversely related to EoE Dellon et al, Gastro 2011

25 Clinical Distinctions Between EoE and PPI REE: Hard to Find Over 200 adult patients No clear distinguishing features between EoE and PPI REE Dellon et al, Am J Gastro 2013

26 Histologic Distinctions Between PPI REE and EoE: Hard to Find Dellon et al, CGH, 2014

27 Molecular Expression Profile Wen et al, JACI 2014

28 Gene Profile Alignment Wen et al, JACI 2014

29 PPI REE as a Milder Molecular and Histologic Phenotype of EoE Wen et al, JACI 2014

30 PPI REE: Functionally Milder Phenotype of EoE Van Rhijn et al, CGH 2014

31 There are Spectrum Differences that May Help Us Decide on Treatment Wen et al, JACI 2014

32 Potential Treatment Algorithm Wen et al, JACI 2014

33 PPI Alleviates Proximal Eosinophilia Park et al, PLoS One 2015

34 Molecular and Clinical Identity Wen et al, JACI 2014

35 Post Therapy Fluticasone Still Has Abnormalities vanrhijn et al, Am J Gastro 2015

36 Relapse Related to PPI Metabolism Molina Infante. Dellon, AJG 2015

37 Consequences of EoE vs GERD

38 Esophageal Rigidity Eosinophilia and Rigidity Rigidity and Food Impactions Nicodeme et al, Clin Gastro Hepatol 2013

39 Consequences of GERD

40 Conclusions Dysphagia is not a common symptoms among allergic patients Dysphagia has to be solicited Validated scoring tools exist for dysphagia The most common other causes for dysphagia are GERD and PPIREE Important to distinguish EoE from these diseases

41 Question 1 The most common causes of dysphagia likely seen by the allergist are: A. Crohn s disease B. Allergic Rhinitis C. Gastroesophageal Reflux Disease D. PPI responsive esophageal eosinophilia

42 Question 2 For people with dysphagia and esophageal eosinophilia A. No follow up is required B. A trial of PPI is warranted C. The consequence will be esophageal stricture D. All of the above E. None of the above