Patients with eosinophilic esophagitis symptoms may benefit from gastric emptying studies
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Gastric emptying studies may benefit patients with persistent symptoms of eosinophilic esophagitis who do not respond to treatment, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
These studies may enable clinicians to consider delayed gastric emptying and other concomitant diagnoses, Emad Khosh-Hemmat, BS, a clinical research coordinator at the University of California, San Diego, at the time of the study and a current student at Wake Forest University School of Medicine, and colleagues wrote in the study.
The study involved 84 patients aged 2 to 18 years diagnosed with EoE who underwent a clinically indicated nuclear medicine gastric emptying scan due to persistent symptoms or incomplete histologic response to therapy.
Clinicians performed these scans to see if delayed gastric emptying was the cause of chronic symptoms or pathogenic reflux, in turn causing persistent esophageal eosinophilia.
Twenty-eight patients (86% male; average age at EoE diagnosis, 8.4 years) fit criteria for the normal group, which included studies with a half emptying time of less than 60 minutes. The delayed group, which included studies with a half emptying time of longer than 90 minutes, included 25 patients (64% male; average age at EoE diagnosis, 8.1 years). The borderline group — for those studies between 60 and 90 minutes — included 31 patients (55% male; average age at EoE diagnosis, 7.7 years). The average duration of EoE across all groups was 4 years.
Also, the normal group had an average half emptying time of 39 minutes, the delayed group had an average of 126 minutes, and the borderline group average was 74 minutes (P < .0001).
The researchers found significantly higher odds for having abnormal gastric emptying, inclusive of the delayed and borderline groups, among females compared with males (OR = 4.6; 95% CI, 1.4-15), which the researchers called consistent with documented sexual dimorphism for gastric motility.
Females experienced constipation (56%) more commonly than males as well. Constipation also was significantly more common in the delayed vs. normal group (P = .018).
The patients with delayed emptying were slightly taller than those with normal or borderline emptying, although there were no significant differences in BMI or weight between the groups.
Twenty-three patients received erythromycin as a promotility agent, including 16 in the delayed group, five in the borderline group and two in the normal group. Five of these patients reported clear symptomatic improvement.
Eight of these delayed patients and one of the borderline patients had post-treatment upper gastrointestinal endoscopies, with only four showing improved distal eosinophilia.
Overall, the nuclear medicine scans did not reveal any significant differences between the groups regarding esophageal eosinophilia, the researchers wrote. There also were similar rates of gastroesophageal junction erosions in the normal (36%), delayed (28%) and borderline (29%) groups, with the numerally lower incidence in the delayed group suggesting an etiology not based on motility or reflux for these erosions, according to the researchers.
Considering the similar diagnostic ages and durations of EoE between the groups, the researchers suggested that delayed gastric emptying might not be related to disease course, but it could be a cause of persistent symptoms of eosinophilia.
Further studies are needed, the researchers continued, but patient clinical features and symptom persistence could help determine the need for gastric emptying tests.
When patients experience persistent EoE symptoms such as early satiety, bloating and reflux in particular, the researchers wrote, gastric emptying studies should be considered. Children with delayed gastric emptying and concurrent constipation may have a more global dysmotility requiring diagnosis and management, the researchers concluded.
Perspective
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The results are a bit surprising, as EoE is a disease that is thought to be limited to the esophagus, yet the finding of gastric dysmotility is consistent with EoE being a more systemic disease process.
That being said, gastric dysmotility could be secondary to medications or therapy, or it may be due to selection bias in this relatively small cohort. Also, as an allergic disease, it is important to control for atopy in all the groups to be certain that the phenotype (dysmotility) is not related to the atopy rather than the EoE.
We have not conducted a formal study of dysmotility in EoE, but the reported findings are interesting and consistent with the presence of persistent symptoms in some patients with EoE despite histologic improvement following therapeutic intervention.
Doctors should consider dysmotility as a cause of symptoms in EoE, particularly among those patients with persistent symptoms following therapies that appear to be successful based on endoscopic biopsies.
The next steps in this research might include reproducibility in independent cohorts, elucidation of the pathobiological mechanism, and studying the impact of therapeutic intervention for the dysmotility.Perspective
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Santhosh Kumar, MD, FAAAAI, FACAAI
This study by Khosh-Hemmat and colleagues is thought provoking, as there is a small percentage of patients with EoE who continue to have symptoms in spite of histologic remission of their disease. We do not have a clear explanation for their ongoing symptoms, and sometimes we think it is behavioral.
This study highlights the importance of exploring the role of delayed gastric emptying in these patients with persistent symptoms. Previous studies have shown some association with celiac disease and other gastrointestinal disorders with EoE.
In our EoE center, we do not routinely do gastric emptying studies, but we do have a handful of patients with the diagnosis. Although this study is limited by a small sample size, it is clinically relevant, and all physicians treating EoE should consider this diagnosis in their poorly controlled patients.
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