24 May Eosinophilic Stomach & Intestinal Disorders Frequently Misdiagnosed
MedicalResearch.com Interview with:
Nicholas J. Talley, MD, PhD
Pro Vice-Chancellor, Global ResearchUniversity of Newcastle, Australia
Adjunct Professor of Medicine
Division of Gastroenterology and Hepatology; Department of Medicine
University of North Carolina at Chapel Hill
MedicalResearch.com: What is the background for this study? What is meant by Eosinophilic Gastritis and/or Duodenitis?
Response: Eosinophilic gastritis and/or eosinophilic duodenitis (EG/EoD) is an eosinophilic gastrointestinal disease (EGID) characterized by chronic gastrointestinal (GI) symptoms and elevated eosinophils in the stomach and/or the duodenum (the first part of the small intestine). When patients have both EG and EoD, it is sometimes referred to as eosinophilic gastroenteritis (EGE). You may have heard of eosinophilic esophagitis (EoE), which is the more well understood EGID characterized by elevated eosinophils in the esophagus.
Until recently, EG/EoD was thought to be very rare, but prevalence had never been assessed in a prospective, systematic manner. New research indicates that EG/EoD may be a common cause of chronic, moderate-to-severe GI symptoms. Related, millions of patients in the United States suffer with chronic GI symptoms or are diagnosed with a functional GI disorder (FGID). FGIDs are diagnoses of exclusion, and excitingly the study results we present at DDW 2021 suggest that EG/EoD may be the underlying cause of many of these patients’ chronic, moderate-to-severe GI symptoms.
MedicalResearch.com: What are the clinical manifestations?
Response: EG/EoD has a nonspecific clinical presentation. Symptoms can include, but are not limited to, early satiety, bloating, loss of appetite, diarrhea, abdominal pain/cramping, and nausea/vomiting. These symptoms overlap with those of other GI conditions, often resulting in EG/EoD being prematurely diagnosed as a functional GI disorder (FGID), such as irritable bowel syndrome (IBS) or functional dyspepsia, before a full assessment for EG/EoD is completed. New evidence indicates that EG/EoD may be a common cause of chronic GI symptoms and more common than other GI conditions such as ulcerative colitis and Crohn’s disease.
MedicalResearch.com: What are the main findings of the study? How is this disorder diagnosed and treated?
Response: In our prospective, multi-center study, out of 405 patients with moderate-to-severe GI symptoms who underwent EGD with biopsy, 45% were found to have EG/EoD. Prior to diagnosis, 93% of these patients had been diagnosed with another GI condition, such as IBS, GERD or functional dyspepsia. In addition, patients identified to have EG/EoD had suffered with GI symptoms for an average of 11 years before entering the study. The results of this study suggest that EG/EoD is highly underdiagnosed and that there is a heightened need to educate gastroenterologists about the clinical presentation of EG/EoD and how to appropriately diagnose it.
Testing for EG/EoD can be worked into the standard diagnostic workup of patients who present with chronic GI symptoms or an unresolved functional GI disorder. To do this, during EGD, a gastroenterologist would take multiple biopsies from the stomach and from the duodenum (2nd and 3rd parts), as eosinophilic inflammation is very patchy and can affect one or both regions although the duodenum has the highest yield. In the study 8 stomach (4 body, 4 antrum) and 4 duodenal biopsies were taken. This was the systematic biopsy protocol developed with GI experts. There is similar guidance to take multiple biopsies when diagnosing EoE given the patchy eosinophilic infiltration.
The participating pathologists reported gastric and/or duodenal eosinophil counts and applied an accepted threshold of ≥30 per high-power field (hpf). Diagnosing EG/EoD requires both a symptom assessment and histologic evaluation with tissue eosinophil counts. This approach has been uncommon in practice. Results from the study illustrate the importance of the partnership between gastroenterologists and pathologists so patients receive an accurate diagnosis.
MedicalResearch.com: What should readers take away from your report?
Response: EG/EoD is underdiagnosed and new evidence indicates that EG/EoD may be a common cause of chronic GI symptoms. In our prospective, multi-center study, out of 405 patients with moderate-to-severe GI symptoms who underwent upper endoscopy with biopsy, 45% met the diagnostic criteria for EG/EoD.
Our study highlights that there is a heightened need to educate gastroenterologists about the clinical presentation of EG/EoD and how to appropriately diagnose it. During an upper endoscopy (or esophagogastroduodenoscopy, EGD), it is necessary to take at least 8 biopsies from the stomach (4 body, 4 antrum) and 4 from the duodenum (2nd and 3rd parts), as eosinophilic inflammation is very patchy and can affect one or both regions. This was the systematic biopsy protocol developed with GI experts. Collaboration between gastroenterologists and pathologists will be important going forward, as diagnosis requires pathologists to count and report if there are ≥30 eosinophils per high-power field (hpf) in the stomach and/or duodenum. Finally, it will be important to educate patients to comprehensively communicate their symptoms and work together with their gastroenterologist to determine if EG/EoD may be the cause of their chronic GI symptoms.
MedicalResearch.com: Is there anything else you would like to add?
Response: While there are no formal guidelines for EG/EoD, I hope that the recent prospective, multi-center study findings will increase awareness of EG/EoD and help shape future diagnostic guidelines on how patients with chronic, moderate-to-severe GI symptoms are evaluated
Disclosures: NJT serves as a consultant for Allakos.
NJT reports personal fees from Allakos, from Aviro Health, from Antara Life Sciences, from Arlyx from Bayer, from Danone, from Planet Innovation, from Takeda, from Viscera Labs, from twoXAR, from Viscera Labs, from Dr Falk Pharma , from Censa, from Cadila Pharmaceuticals , from Progenity Inc, from Sanofi-aventis, from Glutagen, from ARENA Pharmaceuticals , from IsoThrive, from BluMaiden, from HVN National Science Challenge, non-financial support from HVN National Science Challenge NZ, outside the submitted work; In addition, NJT has a patent Biomarkers of IBS licensed (#12735358.9 -1405/2710383 and (#12735358.9 -1405/2710384), a patent Licensing Questionnaires Talley Bowel Disease Questionnaire licensed to Mayo/Talley, a patent Nestec European Patent licensed, and a patent Singapore Provisional Patent NTU Ref: TD/129/17 “Microbiota Modulation Of BDNF Tissue Repair Pathway” issued and copyright Nepean Dyspepsia Index (NDI) 1998 and Editorial: Medical Journal of Australia (Editor in Chief), Up to Date (Section Editor), Precision and Future Medicine, Sungkyunkwan University School of Medicine, South Korea, Med (Journal of Cell Press). NJT participates Committees: Australian Medical Council (AMC) Council Member (2016-2019), MBS Review Taskforce (2016-2020), NHMRC Principal Committee, Research Committee (2016-2021), Asia Pacific Association of Medical Journal Editors (APAME) (current), GESA Board Member (2017-2019). NJT Misc: Avant Foundation (judging of research grants) (2019). NJT community and patient advocacy groups: Advisory Board, IFFGD (International Foundation for Functional GI Disorders). NJT acknowledges funding from the National Health and Medical Research Council (NHMRC) for the Centre for Research Excellence in Digestive Health. NJT holds an NHMRC Investigator grant.
Citations: DDW 21 Abstracts May 22 2021
- “Endoscopy and Systematic Biopsy of Patients with Chronic Gastrointestinal Symptoms Leads to High Discovery Rate of Patients Who Meet Histologic Criteria for Eosinophilic Gastritis and/or Eosinophilic Duodenitis” (Presentation #537)
- “Gastroduodenal Eosinophilia is Under-Appreciated in Eosinophilic Esophagitis (EoE) Patients with Functional Bowel Symptoms: A Real Life Experience” (Presentation #Fr198)
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