78 Gastroenterology I NTERNAL M EDICINE N EWS • November 1, 2005 ‘Persistent GERD’ May Actually Be Food Allergy

Allergic eosinophilic esophagitis, first reported in at the meeting, jointly sponsored by Sym- eosinophilic esophagitis described 10 chil- posia Medicus and Stanford University. dren diagnosed with GERD whose symp- 1995, can begin anytime from infancy to adolescence. Endoscopy will show little circular toms persisted despite separate treatments rings that can be “fairly dramatic” and with five antireflux therapies, including BY SHERRY BOSCHERT sibly using steroids. Often multiple anti- white plaques composed of eosinophilic Nissen fundoplication in six patients. San Francisco Bureau gens are involved, with poor correlation complexes. After 6 weeks on an L-amino acid–based with skin tests for allergy, he added. Restricting consumption of cow’s milk formula (Neocate or Neocate One), eight S TANFORD, CALIF. — Adults or chil- First identified in a landmark 1995 study will resolve symptoms in about 80% of patients had no symptoms, and symptoms dren whose symptoms of gastroesophageal of 10 children, allergic eosinophilic cases. In infants with allergic eosinophilic improved in the other two patients. reflux disease continue despite treatment esophagitis produces symptoms that look esophagitis, 80% Esophageal biopsies may have allergic eosinophilic esophagitis, like chronic gastroesophageal reflux dis- will improve after The proteins that before and after the John A. Kerner Jr., M.D., said at a confer- ease (GERD). The child may refuse food, switching to a hy- are implicated 6 weeks of treat- ence on perinatal and pediatric nutrition. fail to thrive, vomit, have abdominal pain, drolyzed protein come from the ment showed that An esophageal biopsy will show major be irritable, and have difficulty sleeping. formula such as Al- ‘usual suspects’ in intraepithelial eosinophilic infiltration of the mucosa Symptoms return despite treatment with imentum or Nu- the diet—cow’s eosinophil counts and submucosa in a patient with allergic histamine2-receptor blockers or even fun- tramigen. Those in- milk, wheat, soy, decreased signifi- eosinophilic esophagitis. The proteins that doplication. Serum IgE levels are normal fants who do not peanut, or egg. cantly, from a medi- are implicated in this disorder come from or slightly elevated, and peripheral respond usually do an of 41 per high- the “usual suspects” in the diet—cow’s eosinophils are uncommon in allergic well when switched DR. KERNER power field to less milk, wheat, soy, peanut, or egg, said Dr. eosinophilic esophagitis. to an L-amino acid than 1 per high- Kerner, professor of pediatrics and direc- Older children and adults who have had formula. Breast-fed infants with eczema power field (Gastroenterology 1995;109: tor of nutrition at Stanford (Calif.) Uni- allergic eosinophilic esophagitis for some and allergic eosinophilic esophagitis usu- 1503-12). versity Medical Center. time commonly turn up in emergency de- ally need an L-amino acid formula, Dr. Symptoms returned in all patients, how- Allergic eosinophilic esophagitis can be- partments or clinics with esophageal stric- Kerner said. ever, after open food challenges. “This is gin anytime from infancy to adolescence. ture. Biopsies will show “sheets” of An inhaled steroid will alleviate acute a real disorder,” Dr. Kerner said. “More and more of the adult literature is eosinophils in these patients. Seeing more symptoms, but they recur when the in- The study showed that chronic GI pointing out that patients have been missed than 20 eosinophils per high-power field in haled treatment is stopped. Dr. Kerner said symptoms and histologic changes of the with this disorder,” Dr. Kerner said. a biopsy is a “classic count” for diagnosing he prefers prescribing both inhaled and esophagus that were unresponsive to stan- Treatment consists of avoiding the anti- allergic eosinophilic esophagitis, although topical forms. Oral steroids for a systemic dard GERD treatments could be improved gens, if they can be identified, switching there is some debate about the exact num- effect also are an option, he said. by using an elemental formula. “This was infants to an elemental formula, and pos- ber needed for diagnosis, Dr. Kerner said The first published study of allergic a breakthrough,” he said. ■ H. pylori Eradication Reduces β-Blockers Cut Risk of First Bleed Dyspepsia Prescriptions, Costs From Esophageal Varices by 50% BY MICHELE G. SULLIVAN every 1-2 years is indicated, depending BY KATHLEEN LOUDEN cation therapy consisting of omeprazole, Mid-Atlantic Bureau on the severity of liver disease. Contributing Writer clarithromycin, and tinidazole for 7 days; Patients with large varices should be 440 had been randomized to receive place- C AMBRIDGE, MD. — β-Blockers re- offered prophylactic therapy. β-Blockers C HICAGO — A community screening bo. main the best choice for primary pre- are the medical therapy of choice. They and treatment program for Helicobacter The findings lend support to eradication vention of bleeding from esophageal reduce portal pressure by reducing car- pylori infection significantly reduced the therapy for H. pylori–positive individuals varices in patients with end-stage liver diac output and increasing resistance in use of dyspepsia-related health resources, who have nonulcer dyspepsia, an approach disease. collateral veins. The drugs have been Alexander Ford, M.B., reported at the an- for which Dr. Ford said there has been con- Variceal banding, while at least as ef- shown to reduce the risk of a first nual Digestive Disease Week. flicting evidence. fective as β-blockers in preventing a first variceal bleed by half and to reduce Antimicrobial eradication therapy for In the United Kingdom, physicians give bleed, should be reserved for those who mortality by up to 45%, compared with H. pylori yielded a 10-year mean savings in H. pylori eradication therapy in dyspeptic don’t respond to or can’t tolerate β- placebo. total dyspepsia-related patients, he said in an inter- blockers, or who are noncompliant with Unfortunately, Dr. Kantsevoy said, costs of $117 per treated The reductions in view. However, in the Unit- drug therapy, Sergey Kantsevoy, M.D., β-blockers are contraindicated in up to individual, said Dr. Ford, total dyspepsia- ed States, the National Insti- said at a hepatobiliary update sponsored 20% of end-stage liver disease patients. of Leeds (England) Gener- tutes of Health does not by Johns Hopkins University. In addition, “despite adequate β-block- al Infirmary. related health recommend eradication Esophageal varices develop in up to age, at least 30% will not achieve reduc- The savings, mainly due care costs and therapy for persons who 60% of patients with cirrhosis. If varices tion in portal pressure sufficient to pre- to reduced prescriptions for have nonulcer dyspepsia or rupture, they carry a significant mortal- vent bleeding, and about 30% will have dyspepsia, were greater dyspepsia-related are asymptomatic, accord- ity risk of 20%-40%, depending on the side effects including heart failure, hy- than the cost of the screen- prescribing costs ing to a 1994 consensus state- severity of the liver disease. Therefore, potension, bronchoconstriction, fatigue, ing, according to Dr. Ford. ment. all patients with end-stage liver disease and impotence.” The reductions in total dys- due to H. pylori In the current study, erad- should undergo upper endoscopy to Endoscopic variceal banding may be pepsia-related health care eradication were ication therapy was associat- screen for varices, said Dr. Kantsevoy of considered for these patients. Band liga- costs and dyspepsia-related ed with a reduction in dys- Johns Hopkins University, Baltimore. tion has been shown to be as effective as prescribing costs were both both statistically pepsia symptoms that was Unselected patients don’t benefit from β-blockage at reducing the incidence of statistically significant. significant. not statistically significant. primary prevention strategies for bleeding, but the procedure carries no “This could be the first Of the subjects who had dys- esophageal varices, but there is great significant mortality advantage over screening study to pay for itself,” he com- pepsia symptoms at baseline, 59% of the benefit for high-risk patients, he said. medical therapy. mented. treated group remained symptomatic at 10 However, despite the mortality risk of Endoscopic sclerotherapy has been in- Study subjects were H. pylori–positive in- years vs. 66% who received placebo, Dr. bleeds and the proven benefit of treat- vestigated in these patients, but it is not dividuals who had participated in a com- Ford said in an interview. ment, only 46% of those referred for liv- recommended for primary prevention munity screening program (conducted by There was a possible selection bias in lo- er transplantation had been screened for because it is associated with a high rate the Leeds HELP study group, Lancet cating original participants of the screen- esophageal varices (Am. J. Gastroenterol. of adverse events. 2000;355:1665-9) and who returned a re- ing program. 2001;96:833-7). Postsclerotherapy complications oc- cent dyspepsia questionnaire and con- “We were more likely to contact people If the initial endoscopy does not iden- cur in up to 20% of patients and include sented to have their medical records ex- of higher socioeconomic status, and they tify varices, the patient should have a re- ulceration, stricture formation, and amined. Of these 914 participants, 474 were more likely to respond,” Dr. Ford peat endoscopy every 2 years. If the esophageal perforation, Dr. Kantsevoy had originally been randomized to eradi- said. ■ varices are small, a repeat endoscopy said. ■

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