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

INTRODUCTION

Eosinophilc Esophagitis

• Allergic inflammatory condition of the esophagus.

• Similar in presentation to GERD.

• Symptoms include heart burn, swallowing difficulty, food impaction etc.

• Diagnosis: • Upper GI Endoscopy with Biopsy

• Histology:• 15-20 Eosinophils/hpf• Rx: • Swallowed corticosteroids- Fluticasone and

Budenoside

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.

• Histology:• 4-5 Eosinophils per hpf

• Rx:

• PPI’s• H2 Blockers

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

CAN EE AND GERD COEXIST IN THE SAME PATIENT ?

BACKGROUND

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

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

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.

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.”

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

Study Design

• Retrospective chart review

• Out-patient GI clinic

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

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

Case Selection contd…

• Advised to undergo routine evaluation for EE

• Including allergy testing

• 24 hr Esophageal pH monitoring was performed.

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)

Control Selection

• Sex and age matched control group was obtained

• 21 controls identified

• Selected from pH impedance database

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

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

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.

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

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

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

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)

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

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

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

Other Characteristics

• Number of Reflux episodes

• Alkaline Reflux

• Bolus Transit Time

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

Correlation

• No correlation between the number of eosinophils per hpf and

- Refulx Index

- DeMeester score

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.

48%-44%

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

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

Strengths

• Bigger sample size in comparison to other similar studies

• New direction to EE

Limitations

• Retrospective chart review.

• Need to increase sample size.

• Out-patient center.

Acknowlegements

• Dr. Maya Srivastava

• Dr. K. J. Qazi

• Dr. Michael Moore

• Dr. Mayur Virarkar

• Ms.Rameela Chandrashekhar

• Catholic Health System