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
Eosinophilic esophagitis in children and
adults: a systematic review and
consensus recommendations for
diagnosis and treatment.
FURUTA GT ET.AL; GASTROENTEROLOGY 2007 OCT;133(4):1342-63
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
Characteristics
Case
(n = 27)
Mean (std) 14.81(14.48)
Control
(n = 21)
p-value
9.14(4.69)
0.0716
Age
Median(Ran
12.00
9.00
ge)
(3.00-67.00) (1.00-19.00)
Male
17(62.96)
0.1223
10(47.62)
Sex
0.1642
Female
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
Characteristics
Acid Index
Case
(n = 27)
Control
(n = 21)
p-value
Mean (std) 5.55(6.61) 6.32(2.00)
0.0088
3.80
(0.8033.00)
0.0042
Median(Ra
nge)
>4
5.60
(4.2012.20)
13(48.15) 21(100.00)
Acid Index
<0.0001
<=4
14(51.85)
0(0.00)
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
Case
(n = 27)
Control
(n = 21)
p-value
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
>14.72
12(44.44)
21(100.00)
Characteristics
Demeester
Score
Demeester
Score
<0.0001
<=14.72
15(55.56)
0(0.00)
Other Characteristics
• Number of Reflux episodes
• Alkaline Reflux
• Bolus Transit Time
Case
(n = 27)
Control
(n = 21)
p-value
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
>50
9(34.62)
11(52.38)
Characteristics
Num of episode
Num of episode
0.2503
<=50
17(65.38)
10(47.62)
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
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
Alkaline reflux
Bolus transit
time
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