1. 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

2. INTRODUCTION

3. Eosinophilc Esophagitis Allergic inflammatory condition of the esophagus. Similar in presentation to GERD. Symptoms include heart burn, swallowing difficulty, food impaction etc.

4. Diagnosis: Upper GI Endoscopy with Biopsy Histology: 15-20 Eosinophils/hpf Rx: Swallowed corticosteroids- Fluticasone and Budenoside

5. 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.

6. Histology: 4-5 Eosinophils per hpf Rx: PPI’s H2 Blockers

7. 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

8. CAN EE AND GERD COEXIST IN THE SAME PATIENT ?

9. BACKGROUND

10. 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

11. 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

12. 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.

13. 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.”

14. 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

15. Study Design Retrospective chart review Out-patient GI clinic

16. 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

17. 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

18. Case Selection contd… Advised to undergo routine evaluation for EE Including allergy testing 24 hr Esophageal pH monitoring was performed.

19. 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)

20. Control Selection Sex and age matched control group was obtained 21 controls identified Selected from pH impedance database

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. Characteristics Case (n = 27) Control (n = 21) p-value Age Mean (std)14.81(14.48)9.14(4.69)0.0716 Median(Ran ge) 12.00 (3.00-67.00) 9.00 (1.00-19.00) 0.1223 Sex Male17(62.96)10(47.62) 0.1642 Female10(37.03)11(52.38)

28. 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

29. Characteristics Case (n = 27) Control (n = 21) p-value Acid Index Mean (std)5.55(6.61)6.32(2.00)0.0088 Median(Ra nge) 3.80 (0.80- 33.00) 5.60 (4.20- 12.20) 0.0042 Acid Index >413(48.15)21(100.00) <0.0001 <=414(51.85)0(0.00)

30. 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

31. 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

32. Characteristics Case (n = 27) Control (n = 21) p-value Demeester Score Mean (std)19.27(21.50)22.15(7.39)0.0095 Median(Range) 13.24 (3.30-104.72) 19.38 (15.04-45.55) 0.0063 Demeester Score >14.7212(44.44)21(100.00) <0.0001 <=14.7215(55.56)0(0.00)

33. Other Characteristics Number of Reflux episodes Alkaline Reflux Bolus Transit Time

34. Characteristics Case (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 >509(34.62)11(52.38) 0.2503 <=5017(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

35. Correlation No correlation between the number of eosinophils per hpf and - Refulx Index - DeMeester score

37. 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.

38. 48%-44% However, approximately half of EE patients met the criteria for pathological reflux based on Reflux Index (48%) and DeMeester score (44%).

39. 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

40. Strengths Bigger sample size in comparison to other similar studies New direction to EE

41. Limitations Retrospective chart review. Need to increase sample size. Out-patient center.

42. Acknowlegements Dr. Maya Srivastava Dr. K. J. Qazi Dr. Michael Moore Dr. Mayur Virarkar Ms.Rameela Chandrashekhar Catholic Health System