1 Literature Review Peter R. McNally, DO, FACP, FACG University Colorado at Denver School of Medicine Center for Human Simulation Aurora, Colorado 80045

2 Roy-Ghanta S, Larosa DF, Katzka DA. Atopic Characteristics of Adult Patients with Eosinophilic Esophagitis. Clinical Gastroenterology and Hepatology. 2008;6: University of Pennsylvania, Philadelphia, Pennsylvania

3 Introduction Eosinophilic esophagitis (EOE) is a condition of increasing clinical identification among pediatric and adult patients Eosinophilic esophagitis (EOE) is a condition of increasing clinical identification among pediatric and adult patients Pediatric cases of EOE have commonly been identified to have atopic conditions, environmental allergies and food allergies Pediatric cases of EOE have commonly been identified to have atopic conditions, environmental allergies and food allergies Furuta GT, et al. FIGERS. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterol 2007;133; Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:

4 Aim To evaluate a cohort of adults with EOE for prevalence of food associated and environmental allergens. To evaluate a cohort of adults with EOE for prevalence of food associated and environmental allergens. Examine the value of in vitro techniques to diagnose food-associated allergens Examine the value of in vitro techniques to diagnose food-associated allergens Examine the prevalence of other allergic conditions among adults with EOE. Examine the prevalence of other allergic conditions among adults with EOE. Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:

5 Study Design: Study Population Allergy Clinic charts of pts with Dx EOE were reviewed for atopic history (allergic rhinitis, asthma, atopic dermatitis), testing of environmental/food allergy, & laboratory results pertaining to the initial evaluation. Allergy Clinic charts of pts with Dx EOE were reviewed for atopic history (allergic rhinitis, asthma, atopic dermatitis), testing of environmental/food allergy, & laboratory results pertaining to the initial evaluation. Laboratory Data Laboratory Data – Eosinophil count – Total IgE kU/L – Allergic sensitization to food-associated allergens by in vitro using AB ImmunoCAP system (Pharmacia Diagnostics, Uppsala, Sweden) Food History for 96 diverse foods Food History for 96 diverse foods Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:

6 Study Design: Definition of EOE: Clinical Criteria: Symptoms of epigastric pain, chest discomfort, dysphagia or food impaction poorly responsive to PPI BID dosing for > 2 mo prior to biopsy. Plus Histologic Criteria I: Mean EO >15/HPF in > 2 HPF or or II: Mean EO >25/HPF in any field in any field Example: >25 eosinophils/HPF Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:

7 Results: Demographics & Atopic Characteristics Variable Mean age + SD, y Age range, y Sex: M/F (ratio) 14/9 (1.6 : 1) Atopy, no of patients (any) 18 (78%) Asthma Asthma6 Allergic Rhinitis Allergic Rhinitis18 Atopic dermatitis Atopic dermatitis1 Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:

8 Results: Demographics & Atopic Characteristics Variable Specific IgE for food allergens 19 (83%) Specific IgE for environmental allergens 18/21 (86%) Birch pollen Birch pollen 17/21 (81%) Timothy & Ryegrass pollen Timothy & Ryegrass pollen 16/21 (76%) Ragweed pollen Ragweed pollen 16/21 (76%) Dust mite allergen Dust mite allergen 15/21 (71%) Pet Dander (cat and dog) Pet Dander (cat and dog) 15/21 (71%) Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:

9 Results:Positive CAP Test to Food Allergens Food Number of Pts Frequency Wheat939% Carrot939% Tomato835% Onion835% Onion835% Banana730% Sesame seed 730% Egg white 730% Cow mild 730% Garlic626% Corn626% Potato626%

10 Conclusions: 1. EOE in adults is commonly associated with other allergic phenomenon 2. EOE is male gender dominant (♂ to ♀ ratio of 1.6:1) 3. Both dietary and environmental triggers of EOE are common (83 and 88%, respectively) and should be searched for Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:

11 Reviewer Comments 1. Dr. Roy-Ghanta and colleagues have shown that a high degree of atopic diathesis exists among adults with EOE 18/23 (78%). 2. Adult patients with EOE tend to be polysensitive to multiple environmental allergens. 3. Food allergies confirmed by CAP testing was found in 19/23 (83%) of adult EOE pts. Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:

12 Reviewer Comments Roy-Ghanta, et al, do not answer the following questions? 1. What is the true prevalence of atopic diathesis, food and environmental allergies among “all” EOE patients is not established, because they examined only those patients seen by an allergist with a co-existing diagnosis of EOE. 2. Why pts with EOE and atopic diathesis exhibit a lower male to female ration than others have reported (1.6:1 vs. 3:1)? 3. Should all pts with EOE undergo formal allergy evaluation? 4. Can aggressive management of environmental allergies affect the course of EOE? Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6:

13 Reviewer Comments 1. Dr. Roy-Ghanta and colleagues are commended for demonstrating how common atopic diathesis, environmental and food allergies are among patients with EOE. 2. Now it will be important for Dr. Roy-Ghanta and others to systematically examine how common allergic disorders are among ALL pts with EOE. Furthermore, we need to systematically examine the utility of aggressive management of environmental and dietary allergies on the clinical course of this disorder. Roy-Ghanta S, et al. Clin Gastro Hepatol. 2008;6: