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Review
, 12 (7), 379-386

Distinguishing GERD From Eosinophilic Oesophagitis: Concepts and Controversies

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Review

Distinguishing GERD From Eosinophilic Oesophagitis: Concepts and Controversies

Leila Kia et al. Nat Rev Gastroenterol Hepatol.

Abstract

Over the past three decades, the detection of oesophageal mucosal eosinophils has transitioned from a biomarker of GERD to a diagnostic criterion for eosinophilic oesophagitis (EoE). In GERD, oesophageal eosinophils are considered part of the chronic inflammatory response to acid reflux, whereas the marked eosinophilia in EoE is viewed as a central feature of the immune response to ingested food and/or environmental antigen stimulation. Descriptions of a considerable subset of patients with symptomatic, endoscopic and histological findings of EoE that resolve with PPI therapy has led to confusion and controversy regarding the distinction of EoE from GERD. Study findings indicate that PPI-responsive oesophageal eosinophilia (PPI-REE) more closely resembles EoE than GERD, both from a clinical and immunological aspect. Although responsiveness to PPI therapy should not be utilized to exclude EoE, PPI therapy is effective at reducing oesophageal eosinophilia in ∼40% of patients, and PPI therapy is both a safe and practical initial step in the management of patients with oesophageal eosinophilia. Ongoing studies elucidating the mechanism behind PPI-REE will improve our understanding and management of EoE. In this Review, the mechanisms and evidence that underlie the controversy in the distinction between GERD and EoE are evaluated.

Figures

Figure 1
Figure 1
Historical aspects regarding the associations between oesophageal eosinophilia, GERD and EoE. Abbreviations: EoE, eosinophilic oesophagitis; PPI-REE, PPI-responsive oesophageal eosinophilia.
Figure 2
Figure 2
Histopathology of EoE. Demonstrated findings include oesophageal mucosal eosinophilia with superficial distribution, eosinophilic microabscess formation (arrowhead), basal zone hyperplasia, dilated intercellular spaces (spongiosis) and lamina propria fibrosis (asterisk). None of these histological features appear to differentiate EoE from PPI-responsive oesophageal eosinophilia. Image courtesy of Dr Elizabeth Montgomery, Johns Hopkins School of Medicine. Abbreviation: EoE, eosinophilic oesophagitis.
Figure 3
Figure 3
Endoscopic features of EoE. Characteristic findings of EoE include rings (asterisk), longitudinal furrows (arrowhead), white exudates (arrow), and loss of vascular marking (oedema). Strictures and narrow calibre oesophagus are commonly identified in adults but not younger children with EoE. Abbreviation: EoE, eosinophilic oesophagitis.
Figure 4
Figure 4
Proposed mechanism identifying the role of GERD in the pathogenesis of EoE. Oesophageal acid exposure results in epithelial barrier injury with widening of gaps between squamous epithelial cells. The impaired mucosal integrity allows for antigen exposure to Langerhans (dendritic) cells in the oesophageal mucosa resulting in sensitization with expansion of TH2 cells and the recruitment of eosinophils. Activation of mast cells leads to the release of mediators involved in oesophageal remodelling. Abbreviations: EoE, eosinophilic oesophagitis; TH2 cell, type 2 T helper cell.

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