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
Disclosures Intellectual Property: Co Inventor oral viscous budesonide NIH: NIAID, NIDDK, NCATS grant Medical Advisory Committee: APFED
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
EoE is a Clinicopathologic Diagnosis Liacouras et al, 2011 Updated Consensus Recommendations, JACI
Liacouras et al, JACI 2011
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
Definition of Dysphagia Validated symptom questionnaires in adults Mayo Dysphagia Questionnaire EEsAI Validated symptom questionnaires in children PEES
EoE Symptoms in Allergic Subjects Aceves et al, Annals of Allergy 2010
Symptoms: Validated Indexes Schoepfer et al, Gastro 2014
Symptoms and Histology Pentiuk et al, JPGN 2009
Symptoms Food Impactions Dysphagia Vomiting Martin et al, JACI 2015
Endoscopy: Validated Indexes Hirano et al, Gut 2012
PPI REE What is it?
Multiple Case Series Molina Infante et al CGH 2010 Dranove et al J Peds 2009
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
Randomized Controlled Trial: Esomeprazole versus Fluticasone Peterson et al, Dig Dis Sci 2009
Clinical Distinctions? Over 200 adult patients No clear distinguishing features between EoE and PPI REE Dellon et al, Am J Gastro 2013
Histologic Distinctions? Dellon et al, CGH, 2014
PPI REE Can Be Transient and Turn into EoE Dohil, Newbury, Aceves Dig Dis Sci 2011
Transient PPI Response Schroeder et al, JPGN 2013
Transient PPI Response Schroeder et al, JPGN 2013
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
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
Histologic Distinctions Between PPI REE and EoE: Hard to Find Dellon et al, CGH, 2014
Molecular Expression Profile Wen et al, JACI 2014
Gene Profile Alignment Wen et al, JACI 2014
PPI REE as a Milder Molecular and Histologic Phenotype of EoE Wen et al, JACI 2014
PPI REE: Functionally Milder Phenotype of EoE Van Rhijn et al, CGH 2014
There are Spectrum Differences that May Help Us Decide on Treatment Wen et al, JACI 2014
Potential Treatment Algorithm Wen et al, JACI 2014
PPI Alleviates Proximal Eosinophilia Park et al, PLoS One 2015
Molecular and Clinical Identity Wen et al, JACI 2014
Post Therapy Fluticasone Still Has Abnormalities vanrhijn et al, Am J Gastro 2015
Relapse Related to PPI Metabolism Molina Infante. Dellon, AJG 2015
Consequences of EoE vs GERD
Esophageal Rigidity Eosinophilia and Rigidity Rigidity and Food Impactions Nicodeme et al, Clin Gastro Hepatol 2013
Consequences of GERD
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
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
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