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Eosinophilic EsophagitisNow, how do you say that?
Presenters:Sean Jameson, BA
Jennifer Jacob, RN, BSNAnnette Ahrens, BA
Cincinnati Center for Eosinophilic DisordersDivision of Gastroenterology, Hepatology, and Nutrition
and The Division of Allergy and Immunology
Objectives
• Define Eosinophilic Esophagitis (EE)
• Recognize the psycho-social aspects of Eosinophilic Esophagitis in the pediatric population.
• Discuss research findings related to EE.
Magnet Forces
• Force 6: Quality Care
• Force 7: Quality Improvement
• Force 8: Consultation & Resources
• Force 13: Interprofessional Relationships
The Cincinnati Center for Eosinophilic Disorders (CCED)
The CCED is a:
Fast Growing
High Volume
Multidisciplinary Care Center
The mission of the CCED is to provide the best personal care for each patient and to learn from each patient through research.
LeadershipDirectorMarc Rothenberg M.D., Ph.DDirector, Division of Allergy and ImmunologyDirector, Cincinnati Center for Eosinophilic DisordersProfessor of Pediatrics
Medical DirectorPhilip Putnam, M.D.Associate Professor of PediatricsDivision of Gastroenterology, Hepatology and Nutrition
Allergy/Immunology Research CoordinatorsMarc Rothenberg, MD, PhD Bridget Buckmeier, BA, CCRPPablo Abonia, MD Annette Ahrens, BA Kimberly Risma, MD, PhD Maggie Palazzolo, MSSean Jameson, BABarb Hanlon, RNDeborah Seider, RN NutritionChristine Steinmetz, RN Mandy Clemons, RD, LD
PathologyMargaret Collins, MD Social Work
Maleshia Neugebauer, MSW, LSWENT
Alessandro D’Alarcon, MD Speech Pathology
Gastroenterology Drew Gerwin, MA-CCC/SLPJames Franciosi, MDPhilip Putnam, MDJennifer Jacob, RN, BSN PsychologyAisha Williams Wendi Lopez, PsyDTerryll Richardson, LPNBrandy Snyder, LPNAnn Weaver, RN
CCED Members
What We Do
Diagnose the disorder
Provide medical care
Conduct significant research about Eosinophilic Gastrointestinal Disorder (EGID)
Link patients to the latest treatments
How We Do It Coordinated care is critical to managing eosinophilic disorders. The C.C.E.D has members from eight divisions and has 35 clinical and research professionals. The center utilizes a number of ancillary services within the hospital during the process of treating patients.
The C.C.E.D Model (Research Driven Patient Centered Care)
Allergy
GI
Nutrition
PathologySocialwork
Psychology Speech Pathology
ENT
Week Long EvaluationCCED New Patient Evaluation Week:
Monday Tuesday Wednesday Thursday Friday
GI clinic visit X XEndoscopy/Colonoscopy XAllergy skinprick test XAllergy patch
test XSocial work
visit XEducation
Class XTreatment planpresented XDietary consult XPatch testreading XResearch X X X
EE at CCHMC
• Over 40 new diagnoses of EE from Hamilton County presented to GI clinic last year
• Over 100 additional patients referred to the CCED per year nationally
• The CCED treats over 300 patients each year
• The CCED performs greater than 25% of endoscopies at CCHMC
Patient Distribution through the CCED 2004 to 2007
The CCED Impact
The CCED was the first center in the country dedicated to research and treatment of eosinophilic disorders
Three other Centers now exist since the CCED’s conception following a similar model. ( CHOP, Denver Children’s, San Diego Children’s)
EE in the Literature
01020304050607080
1998 2001 2004 2007
Number of Articles
CCED Publications
FIGERSFirst International Gastrointestinal Eosinophil Research Symposium
Eosinophilic Esophagitis (EE)
Who has Eosinophilic Esophagitis?
• 70% are males
• Predominantly Caucasian
• Personal/family history of allergic conditions
• Familial tendency
What is an Eosinophil?
• Type of white blood cell produced in the bone
• Serves as a protection against infections
• Found in the GI tract, spleen, thymus and lymph nodes
• Within the GI tract eosinophils are found in the lining of the– Stomach– Small intestine– Cecum– Colon
Definition of Eosinophilic Esophagitis
Clinico-pathologic disorder
– Histologic changes
– Clinical symptoms
**Present with adequate proton pump inhibitor (PPI) treatment**
Esophagogastroduodenoscopy (EGD)
Histologic Changes
• Greater than 15 eos/hpf• Basal cell hyperplasia• Thickened epithelium• Fibrotic lamina propria• Long papillae
Abnormal
Normal
Eosinophilic infiltration
EE
White exudate
Basal layer hyperplasia
Degranulation
Endoscopic Appearance Normal Esophagus
Endoscopic Appearance Abnormal Esophagus
Furrows Rings
Exudate
Normal
But…
Abnormal histology
Clinical SymptomsPain
Heartburn / refluxSubsternal pressureEpigastric pain
Vomiting
Associated with specific foodsNon-specific
Dysphagia
Feeding disordersDifficulty getting food downFood impaction
Clinical Symptoms
Noel, et al, 2004
Associated Conditions
• Eczema• Chronic rhinitis• Food allergies• Reactive airway problems• Developmental delays• Failure to thrive
So, what now?
Types of EE
Allergic• responds to elimination of foods• reoccurs when offending foods are put back into
diet.
Non-allergic• no response to food elimination
Treatment Allergic type
Elemental diet—amino acid-based, hypo-allergenic formula– Elecare– Neocate
Elimination diet– Directed– “Six Food” ( Milk, egg, wheat, soy, seafood, peanut)
Food Trials
If biopsy confirms resolution of esophagitisReintroduce dietary antigens• 1 new food every 2 weeks• 1-4 new foods between EGDs
EGD every 2-3 months• Until there is a nutritionally adequate diet acceptable to the
family and child
**Recurrent esophagitis requires withdrawal of the recently added foods**
Non- Allergic Treatment Pharmacotherapy
SteroidsTopical
Fluticasone (Flovent)Budesonide (Pulmicort)
SystemicPrednisone
BiologicAnti-IL5 ( Monoclonal antibody)
Immodulators6MP
Treatment flow chart
Complications of EE
• Food impactions
• Strictures
Psycho-Social Issues
Financial• Foods• Formula• Frequent surgeries• Travel (hotel, meals,
airfare)• Work/ school absence
Social• Speech and feeding• Poor adjustment• Self image• School interactions • Meal times
Nursing Considerations
• EE is a REAL disease
• EE is a chronic disease
• Off label use of medications
• Children often have food restrictions
• Parents under stress
• Parents advocates for children
Support for Families
• “The Eddy project”
• Family education day
• Family Education and Enrichment for Eosinophilic Disorders
Support for Families• The American Partnership for Eosinophilic
Disorders (APFED)www.apfed.org
• Campaign Urging Research for Eosinophilic Disorders (CURED)www.curedfoundation.org
• The Cincinnati Center for Eosinophilic Disorderswww.cincinnatichildrens.org/cced
Research
How it works What we find How it helps
Research Process
Clinical Visit
Clinical Research
Coordinator
Lab Personnel
Patient Participation in Research
The quality of DNA extracted from saliva is comparable to DNA from blood!
Patient
Blood&
Tissue Biopsy
Questionnaires&
AssessmentsSaliva DNAfrom Parents
Our Studies 19 Active Eosinophilic Studies
Live sample• Quality of Life and Treatment Adherence • Longitudinal Sample Collection of blood, tissue, & saliva
Drug• Flovent Dosing • Anti-IL 5
• Anti-IL 13 (coming soon)
Data• EE Long Term Follow-up • Prevalence and Incidence of EE
• EE and Celiac (coming soon)
Findings
We have:
• Identified 500 specific genes increased in EE. (Biopsy)
• Identified Eotaxin 3, a key gene in EE. (Biopsy & Blood)
• Implemented Anti-IL 5 in patients with EGID
• Created several EE mouse models for experimentation.
The EE transcript signature
EE NL
Eotaxin-3 is the number one gene over expressed
EE Normal
Difficulty swallowing
Reflux
Difficulty swallowing & frequent dilatations
Eosinophilic Esophagitis (EE)
Real EE Patient Pedigree
Recruitment Data of EE Patients From 2005-Current
203
337
6015
Adult Tissue & Blood (UC Affiliate)
Clinical SymptomScore
Pediatric Tissue &Blood
DNA, Saliva Study
The Impact of Research
• Application of Flovent for treatment
• Positive outcome from utilization of Anti-IL 5
• Understanding the difference in quality of life
• Familial inheritance identified, 1 in 1,000 individuals have EE
How we make it happen
Research Staff (27)11 Research Assistants3 Clinical Research Coordinators6 Post-Docs5 Graduate Students2 Visiting Research Fellows
Representation of 11 Countries in our LabIsrael Chile AustraliaEgypt Japan IndiaCroatia Spain FranceKazekstan China
