*If clinically visible, the achievement of histological remission before proceeding to esophageal dilatation is advisable. †Assessment of poor esophageal distensibility by means of esophageal panometry before dilatation is advisable.
ABBREVIATIONS: b.i.d., twice a day; BOT, budesonide orally disintegrating tablet; FFED, four-food elimination diet; GERD, gastroesophageal reflux disease; PPIs, proton pump inhibitors; OFED, one-food elimination diet; SFED, six-food elimination diet; TFED, two-food elimination diet; Th2, T-helper cell type 2.
REFERENCE: <a href="https://www.sciencedirect.com/science/article/pii/S1590865824003013?via%3Dihub" target="_blank">de Bortoli N, Visaggi P, and Penagini R, et al. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis-Current Treatment and Monitoring. Dig Liver Dis. 2024;56(7):1173-1184.</a>

EOSINOPHILIC-ESOPHAGITIS-EOE

GASTROENTEROLOGY

EoETaly Guidelines Part-2

EoETaly Guidelines Part-1

EoE, eosinophilic esophagitis. 1. Hirano I, Furuta GT. Gastroenterology. 2020;158(4):840-851. 2. Muir AB, et al. Clin Exp Gastroenterol. 2019;12:391-399. 3. Lucendo AJ, et al. United European Gastroenterol J.2017;5(3):335-358.​​​​​​​ 4. Chang JW, et al. Dis Esophagus. 2022;35(6):doab073.​​​​​​​ 5. Schoepfer AM, et al. Gastroenterology. 2014;147(6):1255-66.e21.​​​​​​​ 6. Kennedy KV, et al. Am J Gastroenterol. Published online January 18, 2024.​​​​​​​ 7. Alexander R, et al. Clin Gastroenterol Hepatol. 2019;17(11):2371-2373.​​​​​​​ 8. COREOS Collaborators; Ma C, et al. J Allergy Clin Immunol.&nbsp; 
 2022;149(2):659-670.​​​​​​​ 9. von Arnim U, et al. Clin Gastroenterol Hepatol. 2023;21(10):2526-2533. 10. Dellon ES, et al. Gastroenterology. 2022;163(1):59-76.

Adaptive Eating Behaviors in EoE

<h1>Pediatric EoE: Indicators for Early Diagnosis and Intervention</h1>

Not an actual EoE patient. *Data from a retrospective, single-center study with 379 patients.3 † Symptoms reported by patients or parent/proxy.17 
 EoE, eosinophilic esophagitis; hpf, high-power field; QoL, quality of life. 1. Chehade M, et al. J Allergy Clin Immunol Pract. 2018;6(5):1534-1544.e5. 2. Oliva S, et al. J Pediatr Gastroenterol Nutr. 2022;75(3):325-333. 3. Dellon ES, et al. Gastrointest Endosc. 2014;79(4):577-585.e4. 4. Visaggi P, et al. Therap Adv Gastroenterol. 2021;14:1756284820980860. 5. Hannan N, et al. J Pediatr Psychol. 2021;46(1):100-111. 6. Lucendo AJ, et al. United European Gastroenterol J. 2017;5(3):335-358. 7. Amil-Dias J, et al. J Pediatr Gastroenterol Nutr. 2024;79(2):394-437. 8. Chehade M. Rev Paul Pediatr. 2016;34(4):395-396. 9. Barni S, et al. Ital J Pediatr. 2021;47(1):230. 10. Votto M, et al. Front Pediatr. 2022;920192. 11. Klinnert MD. Immunol Allergy Clin North Am. 2009;29(1):99-107. 12. Pokrzywinski RB, et al. Adv Ther. 2020;37(10):4458-4478. 13. Mukkada V, et al. Clin Gastroenterol Hepatol. 2018;16(4):495-503.e8 14. Jensen ET, et al. J Pediatr Gastroenterol Nutr. 2020;71(4):524-529. 15. Dellon ES, Gupta SK. Clin Gastroenterol Hepatol. 2019;17(11):2149-2160. 16. Aceves SS, et al. Gastrointest Endosc. 2022;96(4):576-592.e1. 17. COREOS Collaborators: Ma C, et al. J Allergy Clin Immunol. 2022;149(2):659-670

Pediatric EoE: Indicators for Early Diagnosis and Intervention

<h2>EoE is a&nbsp;chronic, progressive, inflammatory disease&nbsp;with rising prevalence among children and adults&nbsp;1-3</h2>
<ul>
 <li>Approximately&nbsp;1 in 4000&nbsp;people have EoE worldwide4</li>
 <li>Misdiagnosis or underdiagnosis&nbsp;can cause delays of up to&nbsp;10 years2</li>
 <li>Behavior modification</li>
 <li>can mask symptoms and further delay correct diagnosis and treatment2</li>
 <li>EoE has a High disease burden,causing daily disruptions and restrictions for patients and caregivers1</li>
</ul>

<h3>Dysphagia</h3>
Characterized by discomfort during meals due to difficulty swallowing and the need to frequently intake fluids while eating
<h3>Chest pain (noncardiac)</h3>
Presents in the majority of patients with eosinophilic esophagitis
<h3>Fibrostenosis of the esophagus</h3>
Fibrosis gradually leads to stenosis (narrowing) in many patients with eosinophilic esophagitis
<h3>Food impaction and bolus removal</h3>
Food impaction is a direct consequence of esophageal fibrosis and tissue remodeling. Removal of food bolus impaction frequently involves an urgent endoscopic intervention
<h3>Impaired quality of life</h3>
Frequent vomiting, restricted diets, social isolation and rejection, fatigue, increased emergency room visits, and higher economic burden

<h2>Eosinophilic esophagitis is a chronic, progressive, inflammatory disease, characterized by endoscopic and histologic changes to the esophagus1,4</h2>

<h2>Progressive remodeling and fibrosis may lead to esophageal strictures, which worsen dysphagia and may result in food impaction and require dilation1,4</h2>
<h3>Despite current management strategies, many patients continue to have active EoE symptoms9,10</h3>
There remains an unmet need to reduce esophageal dysfunction and eosinophil-predominant inflammation in order to improve endoscopic signs, clinical symptoms, and quality of life in patients with EoE
<h3>While successful for some patients, current standard of care9,10:</h3>
<ul>
 <li>Leaves many patients symptomatic, with no long-term treatment options</li>
 <li>Does not fully address type 2 inflammation — the underlying cause of EoE</li>
 <li>Does not always address symptoms, histology, and endoscopic findings</li>
 <li>Fails to consider the everyday challenges faced by patients and caregivers</li>
</ul>

References

Understanding Eosinophilic Esophagitis (EoE)

<h2>Peak esophageal intraepithelial eosinophil counts</h2>
Most studies use&nbsp;peak esophageal intraepithelial eosinophil counts&nbsp;(eosinophils per high-power field, or EOS/HPF) to determine histologic outcome, using both percent change in peak EOS/HPF as well as proportion of patients achieving a treatment response, as shown below.4

<h3>How treatment responses are classified4</h3>
<ul>
 <li>&lt;1 EOS/HPF
 <ul>
 <li>(Normal biopsy)&nbsp;Considered a&nbsp;complete histological remission</li>
 </ul></li>
 <li>≥1 to &lt;15 EOS/HPF
 <ul>
 <li>(Reduced eosinophilia)&nbsp;Considered the&nbsp;histologic response threshold</li>
 </ul></li>
 <li>≥15 EOS/HPF
 <ul>
 <li>(Persistent eosinophilia)&nbsp;Considered a&nbsp;non-response</li>
 </ul></li>
</ul>

<h2>Peak EOS/HPF is the most common histologic measure of disease severity4</h2>
&lt;1 complete normalization
<h3>Normalized enrichment score</h3>
The&nbsp;Normalized Enrichment Score (NES)&nbsp;is an additional assessment to confirm the diagnosis using gene expression of interest in eosinophilic esophagitis compared with healthy controls.5
<h3>How NES is assessed</h3>
The EoE diagnostic panel, or EDP (shown below), is a molecular diagnostic test that differentiates patients with eosinophilic esophagitis from normal controls based on 94 EoE genes; a heatmap shows which gene transcripts are upregulated (red) relative to normal controls (blue).5

<h2>EoE Diagnostic panel heatmap5</h2>
<ul>
 <li>Patients with EoE&nbsp;</li>
 <li>Normal controls&nbsp;</li>
</ul>

<h2>NES scores appear to normalize in EoE patients after successful treatment6</h2>

<h3>EoE-HSS Composite score</h3>
The&nbsp;Eosinophilic Esophagitis Histologic Scoring System (EoE-HSS)&nbsp;is a scoring system that measures histologic changes in the esophagus beyond eosinophil count, including barrier function and remodeling, grading 8 features of eosinophilic esophagitis to quantify frequency, severity, and extent of abnormalities.7
<h3>How NES is assessed</h3>
Pathologists score histological degree of abnormality (grade) and histological extent of pathologic severity (stage) using a 4-point scale for each feature (0=normal; 3=most severe or extensive). The maximum possible grade or stage score for each biopsy is 24.7

<h3>EoE-HSS Composite scores are more predictive of treatment response than eosinophil count alone4,7</h3>
<ul>
 <li>0 (normal)</li>
 <li>24 (most severe or extensive)</li>
</ul>

Measures of Disease Severity in Eosinophilic Esophagitis (EoE)

<h2>WHY IS IT IMPORTANT TO ASSESS MULTIPLE DISEASE DOMAINS IN EoE?</h2>

Outcomes from different disease domains may be discordant with one another14
<ul>
 <li>Symptoms may persist and fibrotic changes may still occur despite histologic remission 9,15,16</li>
 <li>Symptoms may not be present despite endoscopic and histologic evidence of inflammation3</li>
 <li>Subtle esophageal findings of EoE may not be recognized by the less-experienced endoscopist and routine endoscopic findings alone may not detect sections of reduced luminal diameter and microscopic inflammation, thereby requiring additional histologic assessments 9,14,15,17,18</li>
 <li>EoE specific QoL assessments may not correlate with mild forms of endoscopic features of EoE and basal layer hyperplasia, thus requiring confirmation from endoscopic and histologic findings 3</li>
</ul>

black

<table border="1" cellpadding="1" cellspacing="1" style="width: 100%;">
 <tbody>
 <tr>
 <td style="text-align: center; background-color: rgb(91, 37, 148);">&nbsp; Comprehensive assessment using symptoms and QoL, histology, and endoscopy, enables an individualized, patient-centric approach to the management of EoE7,9,11,15</td>
 </tr>
 </tbody>
</table>

Importance of assessing key disease domains in EOE

<ul>
 <li>
 Median diagnostic delay of EoE is&nbsp;1-2 years&nbsp;in children, and increases with age1</li>
 <li>
 Every year of symptoms before diagnosis Increases the chance of fibrostenosis by&nbsp;5%2*</li>
</ul>
Early diagnosis and intervention may improve QoL of children with EoE and reduce progression of disease&nbsp;3-5

Unmasking the Hidden Symptoms!&nbsp;Gain critical insights into the often-overlooked signs of eosinophilic esophagitis (EoE) in children, understand the underlying pathophysiology, and explore cutting-edge diagnostic and treatment options.

This must-read content will equip you with the knowledge to better identify and manage EoE, ensuring improved outcomes for your pediatric patients.

EOE Pediatric - Unmasking the Hidden Symptoms

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Eosinophilic esophagitis (eoe)

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