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The Co-existence and Severity of Acid and Alkaline Reflux in Pediatric and Adult
Patients with Eosinophilic Esophagitis
Asif Shah
University at Buffalo - Catholic Health System
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INTRODUCTION
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Eosinophilc Esophagitis
• Allergic inflammatory condition of the esophagus.
• Similar in presentation to GERD.
• Symptoms include heart burn, swallowing difficulty, food impaction etc.
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• Diagnosis: • Upper GI Endoscopy with Biopsy
• Histology:• 15-20 Eosinophils/hpf• Rx: • Swallowed corticosteroids- Fluticasone and
Budenoside
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GERD
• Inflammation of esophagus secondary to reflux of acidic gastric contents into the esophagus.
• Clinical presentation similar to EE.
• Diagnosis:
• 24-hr esophageal pH monitoring.
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• Histology:• 4-5 Eosinophils per hpf
• Rx:
• PPI’s• H2 Blockers
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Distinguishing features
Eosinophilic Esophagitis
• Heart burn, food impaction
• Upper GI endoscopy
• 15-20 Eosinophils/hpf
• Corticosteroids
• ?? PPI
GERD
• Heart burn,food impaction
• Upper GI endoscopy
• 4-5 Eosinophils/hpf
• 24 hr esophageal monitoring
• NO CORTICOSTEROIDS
• PPI’s
• H2 Anatgonists
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CAN EE AND GERD COEXIST IN THE SAME PATIENT ?
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BACKGROUND
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Background
• There is a continuous controversy regarding the coexistence and clinical significance of EE and GERD in the same patient.
• Most studies from tertiary centers.• Increased expression of eotaxin-3
distinguishes between EE and GERD Bhattacharya, Carlsten et al
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Background contd…..
• The recent translational study by Blanchard et al and Bhattacharya et al brings molecular clarity to clinical suspicions that GERD and EE are distinct. Review article: the pathogenesis and management of eosinophilic esophagitis G. T. FURUTA* & A. STRAUMANN
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FURUTA GT ET.AL; GASTROENTEROLOGY 2007 OCT;133(4):1342-63
Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for
diagnosis and treatment.
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Background ..Contd…
• “PPI therapy should not be considered as a primary treatment for patients with EE. It may be considered as co-therapy because it sometimes alleviates symptoms in part (Grade C).”
• “It is interesting to speculate that the esophagus of EE patients may have enhanced sensitivity to acid, even in the absence of pathologic reflux.”
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Aim of the study
• To determine the frequency of pathologic acid and alkaline reflux in patients seen in a private practice setting with biopsy proven EE
• Compare reflux severity to control patients with only GERD
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Study Design
• Retrospective chart review
• Out-patient GI clinic
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Study Design contd….
• Comparison of the frequency and severity of pathologic reflux in patients with EE
• Vs
• Patients with pathologic reflux only based on 24 hr esophageal pH monitoring
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Case Selection
• Identified using ICD-9 Diagnostic code for EE
• Time frame : Jan 2006-July 2009
• 41 cases identified
• EGD and Biopsy proven EE
• Fulfilling the following criteria:
• i) ≥ 20 Eosinophils per hpf on histology
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Case Selection contd…
• Advised to undergo routine evaluation for EE
• Including allergy testing
• 24 hr Esophageal pH monitoring was performed.
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Case Selection contd..
• 27 patients were included in the study
• 4 patients did not complete the 24 hr pH probe
• 10 patients diagnosed with other GI disease (eosinophilc colitis)
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Control Selection
• Sex and age matched control group was obtained
• 21 controls identified
• Selected from pH impedance database
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41 patients identified using diagnostic code for EE
14 patients did not complete probe / Dx with other disease
27 patients included in the study
13 cases had acid index >4
14 cases had acid index < 4
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Control Selection contd…
• Inclusion criteria:
• EGD documenting absence of eosinophilia
• Diagnosis of pathological GERD was based on:
• i) Reflux index > 4%
• ii) DeMeester Score 14.72
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Statistical Methods
• Univariate statistical analysis was used to compare variables within different groups
• Statistical Analysis was performed using SAS Statistical analysis software version 9.2 (SAS Institute Inc, Cary, NC, USA).
•
• A nominal significance level of 0.05 was used.
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Results
• 41 cases were identified
• 14 were excluded from the study secondary to refusal to complete pH probe or diagnosis of other disease
• 27 cases included in the study
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Case Characteristics: age & sex
• Mean Age of cases 14.81 yrs
• All the cases were more than 1 year of age
• 17 were males
• 10 were females
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Control Characteristics: age & sex
• Mean age of controls was 9.14 years.
• 10 were males
• 11 were females
• None was less then 1 yr of age.
• There was no statistical significance between the cases and contols in these variables
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CharacteristicsCase
(n = 27)Control(n = 21)
p-value
Age
Mean (std) 14.81(14.48) 9.14(4.69) 0.0716
Median(Range)
12.00 (3.00-67.00)
9.00(1.00-19.00)
0.1223
SexMale 17(62.96) 10(47.62)
0.1642Female 10(37.03) 11(52.38)
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Reflux Index and DeMeester Scores
• Mean Acid Index (cases) 5.55
• Mean Acid Index (controls) 6.32
• Statistically significant with p-value 0.008
• Median Acid Index (cases) 3.80
• Median Acid Index (controls) 5.60
• Statistically significant p-value 0.0042
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Reflux Index and DeMeester Scores
• 13 cases had acid index >4
• 14 cases had acid index <4
• All the controls had acid Index >4
• Statistically significant p-value <0.0001
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Reflux Index and DeMeester Scores
• Mean DeMeester score (cases) 19.27
• Mean DeMeester score (controls) 22.15
• Statistically significant with p-value 0.0095
• Median DeMeester score (cases) 13.24
• Median DeMeester score (controls) 19.38
• Statistically significant with p-value 0.0063
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Other Characteristics
• Number of Reflux episodes
• Alkaline Reflux
• Bolus Transit Time
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CharacteristicsCase
(n = 27)Control(n = 21)
p-value
Num of episode
Mean (std) 56.43(63.06) 50.87(25.55) 0.7878
Median(Range)44.20
(13.10-342.80)50.70
(14.10-106.40)0.5137
Num of episode>50 9(34.62) 11(52.38)
0.2503<=50 17(65.38) 10(47.62)
Alkaline reflux
Mean (std) 15.20(17.82) 9.48(11.91) 0.1719
Median(Range)6.75
(0.10-59.00)3.10
(0.00-37.90)0.1813
Bolus transit time
Mean (std) 26.69(41.18) 34.19(64.72) 0.4871
Median(Range)16.20
(3.90-210.00)19.80
(2.70-313.00)0.3109
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Correlation
• No correlation between the number of eosinophils per hpf and
- Refulx Index
- DeMeester score
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Conclusions
• In EE patients the mean and median acid index (mean = 5.55 vs. 6.32) and DeMeester score (mean = 19.27 vs 22.15) were statistically significantly less than in the patients with GERD.
• Alkaline reflux, bolus transit, and number of reflux episodes were similar.
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48%-44%
• However, approximately half of EE patients met the criteria for pathological reflux based on Reflux Index (48%) and DeMeester score (44%).
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Conclusions…
• EE and GERD frequently co-exist, but the reflux is less severe than in patients treated solely for GERD in the private practice setting.
• Both EE, GERD should be tested for and treated simultaneously for maximal benefit to the patient
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Strengths
• Bigger sample size in comparison to other similar studies
• New direction to EE
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Limitations
• Retrospective chart review.
• Need to increase sample size.
• Out-patient center.
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Acknowlegements
• Dr. Maya Srivastava
• Dr. K. J. Qazi
• Dr. Michael Moore
• Dr. Mayur Virarkar
• Ms.Rameela Chandrashekhar
• Catholic Health System