NORD gratefully acknowledges Marc E. Rothenberg, MD, PhD, Director of the Division of Allergy and Immunology, and The Cincinnati Center for Eosinophilic Disorders, Professor of Pediatrics, Dave and Denise Bunning Endowed Chair of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, for assistance in the preparation of this report.
Eosinophilic esophagitis (EoE) is a chronic disorder of the digestive system in which large numbers of a particular type of white blood cell called eosinophils are present in the esophagus. The esophagus is the tube that carries food from the mouth to the stomach. Eosinophils are part of the immune system and play a role in immune regulation and fighting certain infection, and their accumulation is a hallmark of allergic diseases. This condition is characterized by vomiting, stomach or chest pain, failure to thrive (particularly in children), difficulty swallowing, and food getting stuck in the throat.
The symptoms of eosinophilic esophagitis are variable, especially in people of different ages. Common symptoms include difficulty swallowing (dysphagia); food getting stuck in the throat (impaction); nausea; vomiting; poor growth; weight loss; stomach pain; poor appetite; and malnutrition. Because of an overlap of these symptoms with gastroesophageal reflux disease (GERD), many patients are initially thought to have GERD, but EoE patients do not typically respond to anti-GERD therapy and can be found not to have GERD upon diagnostic workup. Recently, it has been appreciated that some patients with pronounced esophageal eosinophilia can have complete responses to proton pump inhibitor (PPI) therapy, typically used for the treatment of GERD, but these patients with PPI responsive esophageal eosinophilia (PPI-REE) do not typically have GERD but rather a disease variant similar to EoE; the PPI appears to exert its effects by direct action rather than blockade of stomach acid alone. Because PPI responsive esophageal eosinophilia has largely overlapping clinical, histological and molecular characteristics with PPI-resistent esophageal eosinophilia, but entities are referred to as EoE and usage of PPIs is now considered a treatment of EoE. Individuals with eosinophilic esophagitis often have allergic diseases such as asthma or eczema.
Eosinophilic esophagitis is caused by the presence of a large number of eosinophils in the esophagus. The production and accumulation of eosinophils may be caused by many factors such as immune hypersensitivity responses to particular foods or environmental proteins (allergens) in some affected individuals. Some individuals with this condition have been found to have an unusually high expression of a particular gene called eotaxin-3. This gene codes for a protein that is important in controlling the accumulation of eosinophils. Eosinophilic esophagitis can run in families but the risk for additional family members is <5% unless they are twins with the EoE patient. Several genes have been identified to contribute to EoE including CAPN14 and TSLP. A fundamental step in the development of EoE is loss of esophageal barrier function which is mediated by loss of anti-proteases such as SPINK7 and desmosomal proteins such as desmoglein-1 and dysregulated expression of the CAPN14 gene product (calpain-14).
The frequency of eosinophilic esophagitis has been estimated to be approximately 1 in 2,000 individuals. This condition has been reported in multiple continents including Europe, Australia, and America.
The diagnosis of eosinophilic esophagitis is often delayed because of a lack of awareness of this condition. A small tube is inserted through the mouth into the esophagus (upper endoscopy) and small tissue samples are removed (biopsy) in order to count eosinophils, and look for tissue injury and thickening of tissue.
Elevated expression of eotaxin-3 is part of a whole panel of dysregulated genes expressed by the esophagus of EoE patients, termed the “EoE transcriptome” which divides patients into different subgroups, referred to as endotypes.
Many children and adults with EoE show improvement with proton pump inhibitor therapy, as well diet modification so that allergenic food is removed, most commonly milk, egg, soy, wheat, nuts and fish. Some affected individuals require a liquid formula diet fed through a feeding tube. Steroid medications are often used to control inflammation if dietary changes alone are not sufficient. Additional endoscopies and biopsies are usually necessary to monitor the effectiveness of treatment.
Research is underway to develop medications to block the proteins produced as a result of the EoE transcriptome and the tissue inflammation. In addition, research is in progress concerning the role of Interleukin-13, and clinical studies with antibodies that block this cytokine as well as its receptor (IL-4Ra, which is also shared with IL-4) are in advanced stages. Clinicians offer consider off-label existing targeted therapy that blocks this pathway (e.g. dupilumab), as well as the eosinophil growth factor (IL-5 using reslizumab or mepolizumab). Eosinophil depleting antibodies are also now available, including benralizumab (now approved for eosinophilic asthma) as well as AK002 (in development), but these have not yet been approved for EoE, although early clinical trials look very promising. Companies involved in this research include GlaxoSmithKline, Teva Pharmaceuticals, Celgene, Regeneron, Shire, AstraZeneca and Allakos.
A major advance in EoE is the formation of the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR), which is part of the Rare Diseases Clinical Research Center Network (RDCRN), supported by the National Institute of Health through the National Center for Advancing Translational Science (NCATS). CEGIR is directly funded by NCATS, as well as two other NIH institutes, the National Institute of Allergy and Infectious Disease (NIAID) and the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), as well as funds from the American Partnership for Eosinophilic Disorders (APFED) and the Campaign Urging Research for Eosinophilic Disorders (CURED). CEGIR aims to improve the lives of individuals with eosinophilic gastrointestinal disease (EGID) through innovative research, clinical expertise and education via collaboration between scientists, health care providers, patients and professional organizations. CEGIR also carries out a series of pilot studies testing new hypotheses concerning EGID. A key mission of CEGIR is to train the next generation of physicians with expertise in EGID through its training program. Educational material and full description is available through the CEGIR website.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
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Some current clinical trials also are posted on the following page on the NORD website:
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For information about clinical trials conducted in Europe, contact:
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