Gastrointestinal symptoms may indicate eosinophilic esophagitis among adults with atopy
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Key takeaways:
- A cohort of patients with atopic disease showed a high rate of gastrointestinal symptoms including food impaction.
- Weighted prevalence of EoE in the cohort ranged from 8.8% to 16.5%.
The prevalence of eosinophilic esophagitis may be several times higher among patients with atopic disease than among the general population, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
Such patients already have high rates of solid food dysphagia, food impaction and other abdominal symptoms, Ryan Eid, MD, a second-year fellow with the division of allergy and immunology, University of Virginia School of Medicine, and colleagues wrote.
The study included 100 adults (average age, 36 years; range, 27-48; 46% men; 70% non-Hispanic white) from a tertiary care allergy clinic who presented with allergic rhinitis, asthma, atopic dermatitis or IgE-mediated food allergy. Participants completed the Patient-Reported Outcomes Measurement Information System, or PROMIS, questionnaire between February and October 2021.
Results showed patients experienced:
- nausea or vomiting (18.6%);
- at least one episode of reflux in the previous 7 days (43%);
- belly pain at least once in the previous 7 days (42%);
- difficulty swallowing solid foods at least once in the previous 7 days (38.5%);
- at least one esophageal food impaction in the previous 12 months (10%); and
- more than one episode of food impaction in the previous 12 months (7%).
Overall, the researchers found that 44 of these patients had experienced typical EoE symptoms, 37 had atypical EoE symptoms and 19 were asymptomatic. The patients with typical or atypical symptoms were offered the Cytosponge (Medtronic) procedure, which retrieves surface cells from the esophagus for analysis and screening.
Five of the patients with typical EoE symptoms had the procedure, and one tested positive for EoE. This result was confirmed by an endoscopy 19 days later.
One of the patients with a negative Cytosponge result had an endoscopy 18 days later that uncovered distal esophageal eosinophilia and duodenal erosions, which the researchers attributed to gastroesophageal reflux disease.
Also, three other patients with typical EoE symptoms who did not have the Cytosponge procedure had endoscopies, and two of them were diagnosed with EoE.
Five of the 37 patients with atypical EoE symptoms had the Cytosponge procedure as well, but none of them were diagnosed with EoE.
Using the Cytosponge results alone, the researchers determined that the weighted estimate of EoE prevalence in their cohort was 8.8%. When the researchers also included those patients who had esophagogastroduodenoscopy, this weighted estimate increased to 16.5%.
Considering the high proportion of adults with allergic conditions and gastrointestinal symptoms without a known diagnosis of EoE, the researchers said they suspected that the prevalence of EoE is high in this population and that their estimates of prevalence are reasonable.
Further, the researchers said they were concerned by the high prevalence of patients with one or more food impactions during the previous year, suggesting that many of these patients had been experiencing ongoing inflammation for years.
Early diagnosis, the researchers continued, could prevent these complications. The researchers also suggested that clinicians should routinely ask patients about esophageal dysfunction symptoms and refer them for EoE workups if indicated, eliminating delays in diagnosis and improving patient outcomes.
Perspective
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These results are consistent with the general understanding that EoE is an atopic disease and that, indeed, patients with EoE are enriched for other atopic diseases. However, the results extend this general knowledge by indicating that EoE may be a missed diagnosis in a substantial proportion of adult patients suffering from common allergic diseases. The finding that approximately 10% of their adult population likely has EoE is quite notable, as it represents a concerning level.
These findings also are consistent with our experience, although we have not formally conducted this type of analysis. Doctors can use these findings to focus attention on the possibility that EoE may coexist in patients presenting to the allergy clinic. As such, doctors should include a history of gastrointestinal symptoms (especially dysphagia) in their evaluation of their general clinic population. It is important to note that the diagnosis of EoE will still depend upon microscopic analysis of esophageal samples.
The next step in this research should be replication with a larger, preferably multicenter, study and inclusion of control groups, with nonatopic as well as atopic patients without gastrointestinal symptoms.
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