Elsevier

Gastrointestinal Endoscopy

Volume 79, Issue 4, April 2014, Pages 577-585.e4
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
A phenotypic analysis shows that eosinophilic esophagitis is a progressive fibrostenotic disease

https://doi.org/10.1016/j.gie.2013.10.027Get rights and content

Background

Phenotypes of eosinophilic esophagitis (EoE) are not well-characterized.

Objective

To describe clinical features of patients with EoE with predefined phenotypes, determine predictors of these phenotypes, and make inferences about the natural history of EoE.

Design

Retrospective study.

Setting

Tertiary-care center.

Patients

Incident EoE cases from 2001 to 2011 that met consensus diagnostic guidelines.

Intervention

Review of records.

Main Outcome Measurements

Endoscopic phenotypes, including fibrostenotic, inflammatory, or mixed. Other groups of clinical characteristics examined included atopy, level of esophageal eosinophilia, and age of symptom onset. Multinomial logistic regression assessed predictors of phenotype status.

Results

Of 379 cases of EoE identified, there were no significant phenotypic differences by atopic status or level of eosinophilia. Those with the inflammatory phenotype were more likely to be younger than those with mixed or fibrostenotic (13 vs 29 vs 39 years, respectively; P < .001) and less likely to have dysphagia, food impaction, and esophageal dilation (P < .001 for all). The mean symptom length before diagnosis was shorter for inflammatory (5 vs 8 vs 8 years; P = .02). After multivariate analysis, age and dysphagia independently predicted phenotype. The odds ratio (OR) for fibrostenosis for each 10-year increase in age was 2.1 (95% CI, 1.7-2.7). The OR for dysphagia was 7.0 (95% CI, 2.6-18.6).

Limitations

Retrospective, single-center study.

Conclusion

In this large EoE cohort, the likelihood of fibrostenotic disease increased markedly with age. For every 10-year increase in age, the odds of having a fibrostenotic EoE phenotype more than doubled. This association suggests that the natural history of EoE is a progression from an inflammatory to a fibrostenotic disease.

Section snippets

Study design, data source, and phenotype definitions

This was a retrospective study conducted at the University of North Carolina Center for Esophageal Diseases and Swallowing. By using the University of North Carolina EoE clinicopathology database from 2001 to 2011, we included patients with an incident diagnosis of EoE made at the University of North Carolina who met consensus diagnostic guidelines. Specifically, all patients had symptoms of esophageal dysfunction, ≥15 eosinophils per high-power field (eos/hpf) (hpf area = 0.24 mm2), and did

Characteristics of EoE cases

A total of 379 EoE cases were identified in the database (Table 1). The mean age was 25 years (6 months-82 years), 73% were male, and 81% were white. The most common symptoms were dysphagia (66%), heartburn (39%), and food impaction (28%), with a mean duration of symptoms before diagnosis of 7 years. More than one-third of patients had some form of atopy. On endoscopy, typical findings of EoE were common, with 40% having esophageal rings and 40% having linear furrows. The average maximum

Discussion

With increasing knowledge about EoE, the variability in the disease has been recognized,2 and differences in characteristics between adults and children7, 9, 10, 11, 12 and by race or sex have been described.29, 30, 31 This has raised the question of whether underlying EoE phenotypes are responsible for different clinical presentations and outcomes and whether such phenotypes might impact or be the result of the natural history of the condition. The purpose of this study was to characterize

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    DISCLOSURE: This work was supported, in part, by National Institutes of Health Award K23 DK090073. No other financial relationships relevant to this publication were disclosed.

    If you would like to chat with an author of this article, you may contact Dr Dellon at [email protected].

    See CME section: p. 663.

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