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Severity of esophageal eosinophilia predicts response to conventional gastroesophageal reflux therapy
E Ruchelli1, W Wenner, T Voytek
1Department of Pathology, Children's Hospital of Philadelphia, PA, USA.
Insights
Severe eosinophilic esophagitis in children may not respond to reflux treatment. A high eosinophil count in biopsies predicts poor treatment outcomes, suggesting different causes and alternative therapies may be needed.
Area of Science:
- Gastroenterology
- Pediatric Medicine
- Immunology
Background:
- Pediatric gastroesophageal reflux (GER) can present with severe eosinophilic esophagitis (EoE).
- Some pediatric patients with GER and severe EoE are unresponsive to standard anti-reflux medical therapy.
- The role of eosinophil counts in predicting treatment response and differentiating etiologies in pediatric EoE is not fully understood.
Purpose of the Study:
- To determine if the degree of eosinophilia in esophageal biopsies predicts treatment response in pediatric patients with GER and EoE.
- To investigate if eosinophil counts can help distinguish different underlying causes of EoE.
- To establish a clinical threshold for eosinophil counts to guide treatment decisions.
Main Methods:
- A retrospective review of initial esophageal biopsies from 102 pediatric patients with at least 1 intraepithelial eosinophil per high power field was conducted.
- Patients presented with symptoms of reflux and underwent initial endoscopy.
- All patients received H2 blockers and prokinetic agents, with treatment response categorized as improvement, relapse, or failure.
Main Results:
- Significant differences in mean eosinophil counts (MEC) were observed between groups: improved (1.1 ± 0.3 SEM), relapsed (6.4 ± 2.4 SEM), and failed treatment (24.5 ± 6.1 SEM).
- A MEC threshold of ≥7 eosinophils per high power field demonstrated 61.3% sensitivity, 95.7% specificity, and an 86.1% predictive value for treatment failure.
- A MEC <7 predicted successful therapy in 85% of cases.
Conclusions:
- Eosinophil counts in esophageal biopsies are predictive of response to conventional anti-reflux therapy in pediatric patients.
- A threshold of ≥7 eosinophils per high power field serves as a valuable clinical indicator for predicting treatment outcomes.
- Variable responses to treatment may indicate different etiologies of EoE, suggesting that alternative medical treatments might be more appropriate for patients with severe eosinophilia before considering surgery.
Abstract:
Pediatric patients who present with symptoms of gastroesophageal reflux and severe eosinophilic esophagitis may be unresponsive to aggressive anti-reflux medical therapy. In order to determine whether the degree of eosinophilia predicts anti-reflux treatment response and possibly distinguishes different etiologies, we reviewed the initial biopsies of patients with esophageal eosinophilia and compared the number of eosinophils with the response to anti-reflux treatment. Over a 1-year period, 102 patients with a biopsy demonstrating at least 1 intraepithelial eosinophil were identified among patients undergoing initial endoscopy for symptoms of reflux. All patients were treated with H2 blockers and prokinetic agents. Treatment response was classified into three categories: improvement, relapse, and failure. There were significant differences between the group who improved (mean eosinophil count [MEC] 1.1 +/- 0.3 SEM) and those who failed (24.5 +/- 6.1 SEM, P < 0.0025) or relapsed 6.4 +/- 2.4 SEM, P < 0.05). A threshold MEC value of > or = 7 provided a sensitivity of 61.3%, a specificity of 95.7%, and a predictive value for treatment failure of 86.1. A MEC value of < 7 provided an 85% predictive value of successful therapy. From these data we made the following conclusions: (1) The number of eosinophils has a predictive value of treatment response with > or = 7 per high power field offering a valuable clinical threshold for predicting outcome of conventional therapy. (2) The variable response to conventional reflux treatment may reflect different etiologies. (3) Alternate medical treatment modalities may be appropriate in the presence of severe eosinophilia, before considering surgical intervention.