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Celiac.com 03/23/2022 - There's not much solid data, and no clear consensus, on the connection between eosinophilic esophagitis and celiac disease. There seems to be no clear pattern to the conditions in which they occur together in patients. A team of researchers recently set out to investigate rates of esophageal eosinophilia and eosinophilic esophagitis in a large group of children with celiac disease, and to prospectively follow the group over an eleven year period. The research team included Fernanda Cristofori; Fulvio Salvatore D’Abramo; Vincenzo Rutigliano; Vanessa Nadia Dargenio; Stefania Castellaneta; Domenico Piscitelli; Davide De Benedittis; Flavia Indrio; Lidia Celeste Raguseo; Michele Barone; and Ruggiero Francavilla. They are variously affiliated with the Interdisciplinary Department of Medicine, Pediatric Section “B. Trambusti”, University of Bari “Aldo Moro” in Bari, Italy; the Department of Emergency and Organ Transplantation, Section of Gastroenterology, University of Bari “Aldo Moro” in Bari, Italy; the Department of Emergency and Organ Transplantation, Section of Pathology, University of Bari “Aldo Moro” in Bari, Italy; the Department of Information Engineering, University of Pisa, Largo L. Lazzarino in Pisa, Italy; and the Department of Medical and Surgical Science, University of Foggia, Viale L. Pinto, 71122 Foggia, Italy. The team used data from a prospective observational study performed between 2008 and 2019. They used ESPGHAN criteria to make celiac disease diagnosis. They sampled at least four esophageal biopsies in patients who underwent endoscopy. The team defined esophageal eosinophilia as at least 15 eosinophils/HPF seen on esophageal biopsy. They diagnosed eosinophilic esophagitis using the International Consensus Diagnostic Criteria for Eosinophilic Esophagitis. The team diagnosed a total of 465 children with celiac disease. A total of three hundred and seventy patients underwent endoscopy, while the team found esophageal biopsies for 313 of those. The rate of esophageal eosinophilia in children with celiac disease was 1.6%. Just a single child was diagnosed with eosinophilic esophagitis, for which the team calculated a prevalence rate of 0.3%. Overall, the team saw eosinophilic esophagitis in celiac patients at a rate at least 6.5 times higher than in the general population. According to the team, eosinophils over 15/HPF do not have a clinical implication or warrant intervention in celiac patients, so they do not recommend esophageal biopsies beyond what may be clinically indicated. This is one of the first studies to put some hard numbers on the connection between eosinophilic esophagitis and celiac disease. The idea that people with celiac disease don't generally need to worry about eosinophilic esophagitis is one less thing to deal with in the often confusing world of living with celiac disease. Read more: Nutrients 2021, 13(11), 3755

Celiac.com 09/09/2015 - Some researchers and clinicians suspect a connection between eosinophilic esophagitis (EoE) and celiac disease, but prior studies have shown conflicting results A team of researchers recently set out to determine the relationship between EoE and celiac disease among patients with concomitant esophageal and duodenal biopsies. The research team included Elizabeth T. Jensena, Swathi Eluria, Benjamin Lebwohl, Robert M. Gentab, and Evan S. Dellon. For their cross-sectional study, they team used data covering the period from January 2009 through June 2012 from a U.S. national pathology database. They defined esophageal eosinophilia as the presence of ≥15 eosinophils per high-power field. The crude and age and sex adjusted odds of esophageal eosinophilia for patients with active celiac disease were compared with those without celiac disease. Sensitivity analyses were performed by using more stringent case definitions and by estimating the associations between celiac disease and reflux esophagitis and celiac disease and Barrett’s esophagus. Out of 292,621 patients in the source population, the team looked at data from 88,517 patients with both esophageal and duodenal biopsies. Four thousand one hundred one (4.6%) met criteria for EoE, and 1203 (1.4%) met criteria for celiac disease. Patients with celiac disease had 26% higher odds of EoE than patients without celiac disease (adjusted odds ratio, 1.26; 95% confidence interval [CI], 0.98–1.60). The strength of the connection varied according to EoE case definition, but all definitions showed a weak positive association between the two conditions. Interestingly, this study showed no connection between celiac disease and reflux esophagitis (adjusted odds ratio 0.95; 95% CI, 0.85–1.07) or between celiac disease and Barrett’s esophagus (adjusted odds ratio 0.89; 95% CI, 0.69–1.14). Overall, this study showed only a weak increase in EoE in patients with celiac disease. The connection strengthened in direct relation to the strength of definitions of EoE, and was not seen with other esophageal conditions. Doctors should consider concomitant EoE in patients with celiac disease where clinical indications support it. Disclosures: Dellon reports receiving research funds from Meritage Pharma, consulting for Aptalis, Novartis, Receptos and Regeneron, and receiving an educational grant from Diagnovus. Source: Clinical Gastroenterology and Hepatology. doi:10.1016/j.cgh.2015.02.018.

What is eosinophilic esophagitis (EoE)? Let's break it down: The esophagus is the long tube that connects your mouth to your stomach. What goes through your esophagus? Food and drink. Eosinophils are a type of white blood cell that increases in the case of allergy. EoE is a condition where eosinophils have infiltrated the lining of the esophagus causing inflammation and discomfort. It affects both children and adults, more males than females, and can manifest in failure to thrive and feed in infants, as well as heartburn and difficulty swallowing solid food in older patients. EoE results in a stiffening of the esophagus with strictures, making it quite difficult and uncomfortable to swallow. It seems fairly clear that if white blood cells associated with food allergy increase in an area of the body that food passes through, the obvious conclusion to form is that the individual is eating something they are having a negative reaction to—right? Yet standard treatment for this condition, which is rising in incidence, is drugs (specifically proton pump inhibitors) and mechanical dilation of the restricted esophagus when these other medications fail to work. I do find it interesting that we are seeing more and more of this condition over the last 20 years, during which time the American diet has continued to worsen. Diagnosis is made from an endoscopy that evaluates swallowing and includes a biopsy of the esophagus that reveals a high eosinophil count. Causes of EoE include acid reflux, which affects the lining of the esophagus, often causing ulcers, while less common causes are viruses (herpes simplex) and fungal medications that become stuck in the esophagus, creating the inflammation seen with the condition. Due to the acid reflux component and the tendency in our country to treat with drugs first, proton pump inhibitors that lessen acid production and therefore lessen the symptoms of acid reflux, are recommended as the first order of treatment—even in children. The protocol is 4 to 8 weeks of the drug, after which time the symptoms are re-evaluated to see if they have improved or remain the same. If they remain, a diagnosis of EoE is made. I'm not saying that short-term use of proton pump inhibitors has no value. If someone has a bacterial infection of the stomach (H. pylori) that can result in ulcers, or an active ulcer, this drug is effective. It can also provide symptomatic relief for someone who is miserable with the symptoms of EoE. But it's not the root cause ‘answer' for the condition and it particularly upsets me when very young children come in who are already on the drug. Why? The problem with the protocol that uses proton pump inhibitors is two-fold: It's typically not addressing the root cause, which is a food reaction. It's likely making the real root cause worse. This is interesting. If the problem is actually a food reaction or allergy, a proton pump inhibitor that lessens acid production actually compromises the ability of the body to digest food. This compromised digestion makes it MORE likely that an allergy or food reaction will develop. Fortunately, a new study sheds light on how effective dietary treatment can be. On February 14, 2014, the journal Gastroenterology published an article entitled "Efficacy of Dietary Interventions in Inducing Histologic Remission in Patients with Eosinophilic Esophagitis: a Systematic Review and Meta-analysis. The researchers evaluated 581 references and data from 1317 patients, both children and adults who received different dietary treatments. The treatments included amino acid-based elemental formulas (basically a liquid diet that is completely allergen free), elimination diets based on allergy testing and 6-food elimination diets that include the removal of wheat, milk, soy, eggs, peanuts, tree nuts, fish, and shellfish. What the researchers looked for was the ability to reduce infiltration of the eosinophils in follow-up biopsies. This would mean that the body's immune system was no longer mounting an inflammatory response. Their findings were as follows: Elemental diets (liquid and allergy-free) were effective in 91% of cases. The Six food elimination diet was effective in 72% of the cases. Foods removed based on the result of allergy tests were effective in 46% of the cases. Both adults and children seemed to respond equally. What can we learn from this study? Eliminating common allergens, including gluten, a known inflammatory agent, is a great place to start when trying to improve this condition. A full 91% and 72% improved when common allergic foods were removed. Those are some pretty impressive percentages. I have found an interesting trend in our country. If doctors have the option of giving a prescription or asking a patient to make a dietary change, they will opt for the prescription. It's certainly easier to swallow a pill rather than make a dietary and lifestyle change. I'll grant you that. But is it right? When you appreciate that the pill is a mere band-aid and a highly temporary one at that, what really is a doctor doing for someone in NOT insisting that they change their diet? The truth of the matter is that taking the ‘easy' way out is not only cowardly, it is irresponsible. After the drug stops working, then what? Realize that throughout the period of time that the patient was on the drug, they were continuing to eat whatever was actually creating the problem and therefore their esophagus became more and more inflamed. While the human body's ability to heal is quite miraculous, once sufficient hardening and strictures have occurred in the esophagus, a full return to normalcy might not be possible. It is important that we intervene with the correct therapy quickly. Another facet to the ‘drug over food' decision on the part of most doctors is that they themselves don't change their own diets. I have often spoken with doctors who are themselves unhealthy yet they refuse to change their diets and are therefore convinced that they won't get their patients to make lifestyle changes either. Thus, they don't tend to recommend it because they are already convinced it won't occur. Is it fair to the patient to take the easy way out while they continue to worsen? I don't think so. Personally, I can tell you that here at HealthNOW Medical Center we have seen many cases of EoE and each one of them was associated with a food reaction, often gluten and dairy. And, because we practice what we preach, we have no trouble with our patients following our dietary and lifestyle change recommendations. If you know any youngster, adolescent or adult suffering with this condition, show them (or their parent) this article. A simple dietary change could be all that is needed to improve this serious condition. If your health is not at the level you desire, consider contacting us for a free health analysis—call 408-733-0400. Our destination clinic treats patients from across the country and internationally so you do not need to live local to us to receive care. We are here to help! Reference: Gastroenterology. 2014 Feb 14. pii: S0016-5085(14)00217-0. doi: 10.1053/j.gastro.2014.02.006. [Epub ahead of print]

Celiac.com 09/11/2014 - What’s the relationship, if any, between eosinophilic esophagitis (EoE) and celiac disease? Research studies have produced variable results. Researchers A. J. Lucendo, Á. Arias, and J. M. Teniaso recently set out to conduct a systematic review of medical literature to determine if there’s any evidence of a connection between both diseases. They used the MEDLINE, EMBASE and SCOPUS databases to conduct electronic searches with keywords relating to EoE and celiac disease. Depending on study heterogeneity, they used random-effects models as needed (I2). To assess publication bias, they used funnel plot analysis, along with the Begg–Mazumdar, Harbord and Egger tests. Their keyword search produced 197 significant study references; 30 were included in the quantitative summary, with most showing serious methodological inconsistencies. The team found significant publication bias in favor of short studies reporting positive connections between the two diseases. The prevalence of EoE in celiac patients ranged from 0% to 10.7% (I2 = 78.9%). Rates of celiac disease in EoE varied wildly, between 0.16% and 57.1% (I2 = 89%). One high-quality, prospective, randomly selected, population-based study showed a celiac disease rate of 1.1%, with no cases of EoE. Numerous quantitative summaries of celiac prevalence suffer from clinical and methodological differences. That is, they are are not similar enough to draw good conclusions. A gluten-free diet produced histological remission of EoE in 32.1% of celiac patients (95% confidence interval, 14.9–52.2%; I2 = 52.2%), which was similar to that expected for wheat elimination in EoE patients. There are not really enough valid studies to completely rule in or out a true association between EoE and celiac disease, currently available evidence does not support any such connection. In fact, the only epidemiologically valid study indicates that these diseases are not connected. Source: Alimentary Pharmacology & Therapeutics Alimentary Pharmacology & Therapeutics Volume 40, Issue 5, pages 422–434, September 2014. DOI: 10.1111/apt.12859

Celiac.com 01/04/2012 - A number of cases have led researchers to suspect a connection between eosinophilic esophagitis and celiac disease in children. A research team sought to confirm this association in children, and determine whether it extends into adulthood. To do this, they reviewed data from a group of celiac disease patients to learn the number of patients who also had a diagnoses of eosinophilic esophagitis. The team included Jennifer S. Thompson, MD, Benjamin Lebwohl, MD, MS, Norelle Rizkalla Reilly, MD, Nicholas J. Talley, MD, PhD, Govind Bhagat, MD, and Peter HR. Green, MD. For their study, they reviewed histopathology reports of esophageal biopsies to identify all cases of increased esophageal eosinophilia. The team defined cases of eosinophilic esophagitis as those where biopsies showed Z15 eosinophils per high power field and, which also included associated symptoms. Using published US population-derived incidence data as a reference, they formulated age- and sex-adjusted standardized incidence ratios with corresponding 95% confidence intervals (CI). In all, the team found 4 children and 10 adults with eosinophilic esophagitis, which makes eosinophilic esophagitis more common in people with celiac disease than in the general population. Standardized incidence ratio was 35.6 (95% CI, 9.3-79.0) for children, and 13.1 (95% CI, 6.2-22.5) for adults. Overall, age-adjusted and sex-adjusted standardized incidence ratio was 16.0 (95% CI, 8.7-25.5). This study found higher rates of eosinophilic esophagitis in patients with celiac disease than in the general population. The researchers advise doctors to consider the possibility of eosinophilic esophagitis for celiac disease patients who suffer ongoing esophageal problems. Source: J Clin Gastroenterol. 2012 Jan;46(1):e6-e11.