Reply
Authors: H WOLFSEN, S ACHEM
Journal: Clinical Gastroenterology and Hepatology (2008)

We appreciate the interest of Mukkada, et al in our “Image of the Month”.1Wolfsen H.C. Hemminger L.L. Achem S.R. Eosinophilic esophagitis and Barrett's esophagus with dysplasia.Clin Gastroenterol Hepatol. 2007; 5 (Dec;): A18Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar They suggest that our case represents eosinophilic infiltration related to GERD rather than coexistence of eosinophilic esophagitis (EE) and Barrett's esophagus (BE). Their assertion is based on a retrospective chart review of 3 patients from their institution who had esophageal symptoms and eosinophilc infiltration (>20 eos/HPF) and after treatment with proton-pump inhibitors (PPI) alone, became asymptomatic, and normalized their endoscopy and histological findings suggestive of EE.2Ngo P. Furuta G.T. Antonioli D.A. et al.Eosinophils in the esophagus–peptic or allergic eosinophilic esophagitis? Case series of three patients with esophageal eosinophilia.Am J Gastroenterol. 2006; 101: 1666-1670Crossref PubMed Scopus (271) Google Scholar They also cite their recently published Consensus Recommendation for the Diagnosis and Treatment of EE.3Furuta G.T. Liacouras C.A. Collins M.H. et al.Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.Gastroenterology. 2007; 133 (Oct;): 1342-1363Abstract Full Text Full Text PDF PubMed Scopus (1335) Google ScholarAlthough at the time we submitted our report for publication the above mentioned guidelines3Furuta G.T. Liacouras C.A. Collins M.H. et al.Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.Gastroenterology. 2007; 133 (Oct;): 1342-1363Abstract Full Text Full Text PDF PubMed Scopus (1335) Google Scholar had not yet been published, it has been our practice to exclude GERD in patients with esophageal eosinophilic infiltration (regardless of the magnitude of the infiltrate) by either a PPI trial or pH testing. We regret that that in our submission we omitted to address this important point and thank Dr Mukkada and colleagues for raising this valid concern. Indeed, our patient was receiving esomeprazole 40 mg twice daily for over 6 months at the time he underwent endoscopic surveillance. Despite acid inhibition therapy we noted a ringed esophagus and vertical furrows in the areas of the esophagus uninvolved with BE and esophageal biopsies confirmed > 20 Eos/HPF.Our case report is not intended to establish that EE is a pre-malignant condition, although our patient did have BE with dysplasia. Instead, we felt that our case illustrates that BE (with or without dysplasia) may coexist with EE. Indeed, we believe this case underscores the comments made by Spechler et al,4Spechler S.J. Genta R.M. Souza R.F. Thoughts on the complex relationship between gastroesophageal reflux disease and eosinophilic esophagitis.Am J Gastroenterol. 2007; 102 (Jun;): 1301-1306Crossref PubMed Scopus (286) Google Scholar regarding the complex relation between esophageal eosinophilic infiltration and GERD, supporting the notion that further studies are needed to address whether GERD and EE coexist and are unrelated or EE contributes to, or causes, GERD. We appreciate the interest of Mukkada, et al in our “Image of the Month”.1Wolfsen H.C. Hemminger L.L. Achem S.R. Eosinophilic esophagitis and Barrett's esophagus with dysplasia.Clin Gastroenterol Hepatol. 2007; 5 (Dec;): A18Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar They suggest that our case represents eosinophilic infiltration related to GERD rather than coexistence of eosinophilic esophagitis (EE) and Barrett's esophagus (BE). Their assertion is based on a retrospective chart review of 3 patients from their institution who had esophageal symptoms and eosinophilc infiltration (>20 eos/HPF) and after treatment with proton-pump inhibitors (PPI) alone, became asymptomatic, and normalized their endoscopy and histological findings suggestive of EE.2Ngo P. Furuta G.T. Antonioli D.A. et al.Eosinophils in the esophagus–peptic or allergic eosinophilic esophagitis? Case series of three patients with esophageal eosinophilia.Am J Gastroenterol. 2006; 101: 1666-1670Crossref PubMed Scopus (271) Google Scholar They also cite their recently published Consensus Recommendation for the Diagnosis and Treatment of EE.3Furuta G.T. Liacouras C.A. Collins M.H. et al.Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.Gastroenterology. 2007; 133 (Oct;): 1342-1363Abstract Full Text Full Text PDF PubMed Scopus (1335) Google Scholar Although at the time we submitted our report for publication the above mentioned guidelines3Furuta G.T. Liacouras C.A. Collins M.H. et al.Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.Gastroenterology. 2007; 133 (Oct;): 1342-1363Abstract Full Text Full Text PDF PubMed Scopus (1335) Google Scholar had not yet been published, it has been our practice to exclude GERD in patients with esophageal eosinophilic infiltration (regardless of the magnitude of the infiltrate) by either a PPI trial or pH testing. We regret that that in our submission we omitted to address this important point and thank Dr Mukkada and colleagues for raising this valid concern. Indeed, our patient was receiving esomeprazole 40 mg twice daily for over 6 months at the time he underwent endoscopic surveillance. Despite acid inhibition therapy we noted a ringed esophagus and vertical furrows in the areas of the esophagus uninvolved with BE and esophageal biopsies confirmed > 20 Eos/HPF. Our case report is not intended to establish that EE is a pre-malignant condition, although our patient did have BE with dysplasia. Instead, we felt that our case illustrates that BE (with or without dysplasia) may coexist with EE. Indeed, we believe this case underscores the comments made by Spechler et al,4Spechler S.J. Genta R.M. Souza R.F. Thoughts on the complex relationship between gastroesophageal reflux disease and eosinophilic esophagitis.Am J Gastroenterol. 2007; 102 (Jun;): 1301-1306Crossref PubMed Scopus (286) Google Scholar regarding the complex relation between esophageal eosinophilic infiltration and GERD, supporting the notion that further studies are needed to address whether GERD and EE coexist and are unrelated or EE contributes to, or causes, GERD. Uncertain Association of Barrett's Esophagus With Eosinophilic EsophagitisClinical Gastroenterology and HepatologyVol. 6Issue 7PreviewWe were interested to view the “Image of the Month” by Wolfsen et al1 suggesting the first association between eosinophilic esophagitis (EE) and Barrett's esophagus with esophageal dysplasia. Because the field of EE is rapidly evolving and the literature is dynamic, this report carries significant impact; until now, no report supports possible malignant transformation of EE. If EE is a premalignant condition, much more aggressive treatment and surveillance will be necessary. Full-Text PDF