Proton pump inhibitor-responsive oesophageal eosinophilia

An entity challenging current diagnostic criteria for eosinophilic oesophagitis

Javier Molina-Infante, Albert J. Bredenoord, Edaire Cheng, Evan S. Dellon, Glenn T. Furuta, Sandeep Gupta, Ikuo Hirano, David A. Katzka, Fouad J. Moawad, Marc E. Rothenberg, Alain Schoepfer, Stuart J. Spechler, Ting Wen, Alex Straumann, Alfredo J. Lucendo

Research output: Contribution to journalArticle

123 Citations (Scopus)

Abstract

Consensus diagnostic recommendations to distinguish GORD from eosinophilic oesophagitis (EoE) by response to a trial of proton pump inhibitors (PPIs) unexpectedly uncovered an entity called 'PPI-responsive oesophageal eosinophilia' (PPI-REE). PPI-REE refers to patients with clinical and histological features of EoE that remit with PPI treatment. Recent and evolving evidence, mostly from adults, shows that patients with PPI-REE and patients with EoE at baseline are clinically, endoscopically and histologically indistinguishable and have a significant overlap in terms of features of Th2 immune-mediated inflammation and gene expression. Furthermore, PPI therapy restores oesophageal mucosal integrity, reduces Th2 inflammation and reverses the abnormal gene expression signature in patients with PPI-REE, similar to the effects of topical steroids in patients with EoE. Additionally, recent series have reported that patients with EoE responsive to diet/topical steroids may also achieve remission on PPI therapy. This mounting evidence supports the concept that PPI-REE represents a continuum of the same immunological mechanisms that underlie EoE. Accordingly, it seems counterintuitive to differentiate PPI-REE from EoE based on a differential response to PPI therapy when their phenotypic, molecular, mechanistic and therapeutic features cannot be reliably distinguished. For patients with symptoms and histological features of EoE, it is reasonable to consider PPI therapy not as a diagnostic test, but as a therapeutic agent. Due to its safety profile, ease of administration and high response rates (up to 50%), PPI can be considered a first-line treatment before diet and topical steroids. The reasons why some patients with EoE respond to PPI, while others do not, remain to be elucidated.

Original languageEnglish (US)
Pages (from-to)521-531
Number of pages11
JournalGut
Volume65
Issue number3
DOIs
StatePublished - Mar 1 2016

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Eosinophilic Esophagitis
Proton Pump Inhibitors
Eosinophilia
Steroids
Therapeutics
Diet
Inflammation

ASJC Scopus subject areas

  • Gastroenterology

Cite this

Proton pump inhibitor-responsive oesophageal eosinophilia : An entity challenging current diagnostic criteria for eosinophilic oesophagitis. / Molina-Infante, Javier; Bredenoord, Albert J.; Cheng, Edaire; Dellon, Evan S.; Furuta, Glenn T.; Gupta, Sandeep; Hirano, Ikuo; Katzka, David A.; Moawad, Fouad J.; Rothenberg, Marc E.; Schoepfer, Alain; Spechler, Stuart J.; Wen, Ting; Straumann, Alex; Lucendo, Alfredo J.

In: Gut, Vol. 65, No. 3, 01.03.2016, p. 521-531.

Research output: Contribution to journalArticle

Molina-Infante, J, Bredenoord, AJ, Cheng, E, Dellon, ES, Furuta, GT, Gupta, S, Hirano, I, Katzka, DA, Moawad, FJ, Rothenberg, ME, Schoepfer, A, Spechler, SJ, Wen, T, Straumann, A & Lucendo, AJ 2016, 'Proton pump inhibitor-responsive oesophageal eosinophilia: An entity challenging current diagnostic criteria for eosinophilic oesophagitis', Gut, vol. 65, no. 3, pp. 521-531. https://doi.org/10.1136/gutjnl-2015-310991
Molina-Infante, Javier ; Bredenoord, Albert J. ; Cheng, Edaire ; Dellon, Evan S. ; Furuta, Glenn T. ; Gupta, Sandeep ; Hirano, Ikuo ; Katzka, David A. ; Moawad, Fouad J. ; Rothenberg, Marc E. ; Schoepfer, Alain ; Spechler, Stuart J. ; Wen, Ting ; Straumann, Alex ; Lucendo, Alfredo J. / Proton pump inhibitor-responsive oesophageal eosinophilia : An entity challenging current diagnostic criteria for eosinophilic oesophagitis. In: Gut. 2016 ; Vol. 65, No. 3. pp. 521-531.
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abstract = "Consensus diagnostic recommendations to distinguish GORD from eosinophilic oesophagitis (EoE) by response to a trial of proton pump inhibitors (PPIs) unexpectedly uncovered an entity called 'PPI-responsive oesophageal eosinophilia' (PPI-REE). PPI-REE refers to patients with clinical and histological features of EoE that remit with PPI treatment. Recent and evolving evidence, mostly from adults, shows that patients with PPI-REE and patients with EoE at baseline are clinically, endoscopically and histologically indistinguishable and have a significant overlap in terms of features of Th2 immune-mediated inflammation and gene expression. Furthermore, PPI therapy restores oesophageal mucosal integrity, reduces Th2 inflammation and reverses the abnormal gene expression signature in patients with PPI-REE, similar to the effects of topical steroids in patients with EoE. Additionally, recent series have reported that patients with EoE responsive to diet/topical steroids may also achieve remission on PPI therapy. This mounting evidence supports the concept that PPI-REE represents a continuum of the same immunological mechanisms that underlie EoE. Accordingly, it seems counterintuitive to differentiate PPI-REE from EoE based on a differential response to PPI therapy when their phenotypic, molecular, mechanistic and therapeutic features cannot be reliably distinguished. For patients with symptoms and histological features of EoE, it is reasonable to consider PPI therapy not as a diagnostic test, but as a therapeutic agent. Due to its safety profile, ease of administration and high response rates (up to 50{\%}), PPI can be considered a first-line treatment before diet and topical steroids. The reasons why some patients with EoE respond to PPI, while others do not, remain to be elucidated.",
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AU - Hirano, Ikuo

AU - Katzka, David A.

AU - Moawad, Fouad J.

AU - Rothenberg, Marc E.

AU - Schoepfer, Alain

AU - Spechler, Stuart J.

AU - Wen, Ting

AU - Straumann, Alex

AU - Lucendo, Alfredo J.

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