Background Eosinophilic esophagitis is a chronic, immune-mediated inflammatory disorder that responds to dietary therapy; however, data evaluating the effectiveness of dietary therapeutic strategies are limited. Objective This study compared the effectiveness of 3 frequently prescribed dietary therapies (elemental, 6-food elimination, and skin prick and atopy patch–directed elimination diets) and assessed the remission predictability of skin tests and their utility in directing dietary planning. Methods A retrospective cohort of proton-pump inhibitor–unresponsive, non–glucocorticoid-treated patients with eosinophilic esophagitis who had 2 consecutive endoscopic biopsy specimens associated with dietary intervention was identified. Biopsy histology and remissions ( Results Ninety-eight of 513 patients met the eligibility criteria. Of these 98 patients, 50% (n = 49), 27% (n = 26), and 23% (n = 23) received elemental, 6-food elimination, and directed diets, respectively. Remission occurred in 96%, 81%, and 65% of patients on elemental, 6-food elimination, and directed diets, respectively. The odds of postdiet remission versus nonremission were 5.6-fold higher ( P  = .05) on elemental versus 6-food elimination diets and 12.5-fold higher ( P  = .003) on elemental versus directed diets and were not significantly different ( P  = .22) on 6-food elimination versus directed diets. After 116 single-food reintroductions, the negative predictive value of skin testing for remission was 40% to 67% (milk, 40%; egg, 56%; soy, 64%; and wheat, 67%). Conclusion All 3 dietary therapies are effective; however, an elemental diet is superior at inducing histologic remission compared with 6-food elimination and skin test–directed diets. Notably, an empiric 6-food elimination diet is as effective as a skin test–directed diet. The negative predictive values of foods most commonly reintroduced in single-food challenges are not sufficient to support the development of dietary advancement plans solely based on skin test results.

/pdf/comparative-dietary-therapy-effectiveness-in-remission-of-4xklgw1gt1.pdf

Comparative dietary therapy effectiveness in remission of pediatric eosinophilic esophagitis

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett’s esophagus, and enteroesophageal and duodenogastroesophageal reflux. The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session. Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD. Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

EAES recommendations for the management of gastroesophageal reflux disease.

Background Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett’s esophagus, and enteroesophageal and duodenogastroesophageal reflux. Methods The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session. Results Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplica

EAES recommendations for the management of gastroesophageal reflux disease Karl Hermann FuchsBenjamin BabicWolfram BreithauptBernard Dallemagne • Abe FingerhutEdgar FurneeFrank GranderathPeter Horvath • Peter KardosRudolph PointnerEdoardo SavarinoMaud Van Herwaarden-Lindeboom •

https://www.surgical.theclinics.com/article/S0039-6109(12)00059-X/pdf

Pediatric gastroesophageal reflux disease

Background: Gastro-oesophageal reflux is common and benign in children, especially during infancy. Distinguishing between gastro-oesophageal reflux, gastro-oesophageal reflux disease and other illnesses presenting as chronic vomiting can be difficult. The general practitioner has a key role to play in identifying if a child requires referral for further investigation. Objective: This article outlines the main differential diagnoses to be considered in children presenting with chronic vomiting and/ or regurgitation. We also discuss key management decisions regarding gastro-oesophageal reflux disease in children and when to refer to a specialist for further investigation. Discussion: Chronic vomiting and regurgitation frequently occurs in infancy and is most commonly due to simple, benign gastro-oesophageal reflux, which is usually self limiting without requirement for further investigation. In contrast, gastro-oesophageal reflux disease requires considered management and may be a presenting symptom of food allergy requiring more intensive therapy than simple acid suppression. Regular review by the general practitioner to ascertain warning signs will ensure that other serious illnesses are not overlooked and that appropriate investigation and specialist referral are made.

/pdf/gastro-oesophageal-reflux-in-children-what-s-the-worry-5at730tbxq.pdf

Gastro-oesophageal reflux in children--what's the worry?

Eosinophilic esophagitis (EoE) is a newly recognized condition that appears to be increasing in incidence for as yet unknown reasons. It can occur at any age and presents both to gastroenterologists and allergists. Clinical manifestations range from gastrointestinal symptoms (vomiting, feeding difficulties, dysphagia or food bolus impaction) to co-existing atopic conditions (asthma, allergic rhinitis or eczema). The diagnosis requires demonstration of at least 15 eosinophils per high power field on esophageal histology, usually in the context of resistance to proton pump inhibitor treatment or a normal 24-h esophageal pH monitoring study. The differential diagnosis between EoE and gastroesophageal reflux disease (GERD) can be problematic as there is significant clinical overlap between both conditions. Although difficult-to-manage esophageal strictures are well recognized in patients with long-standing EoE, little is known about risk factors for the development of this complication. There is a paucity of data on both the natural history and optimal long-term management of EoE. Current treatment options include food allergen elimination diets, use of topical aerosolized corticosteroids, or a combination of the two. Pediatric case studies have been provided to illustrate the complexity of decision points that often arise in the management of these patients. This paper aims to discuss the various strategies currently available to clinicians in the management of EoE and highlights gaps in the current evidence base that urgently require further research.

Emerging management concepts for eosinophilic esophagitis in children

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Emerging management concepts for eosinophilic esophagitis in children