00:00:00: Hello everyone, my name is Egle and I'm the host of UEG Podcast.

00:00:03: Educational and hopefully fun dive into GI world and beyond!

00:00:07: We're happy to have you with us for another exciting episode.

00:00:11: So today we are talking about The Rise and Hopefully Fall of Eosinophilic Oesophagitis.

00:00:16: It's a great pleasure to introduce this guest one of the discoverers of eosinaphilicus Oesophagitis, forefront researcher and renowned expert who had rare experience in recognizing new disease.

00:00:27: Professor Alex Straumann Welcome to UEG Podcast Professor.

00:00:31: Dear eager colleagues, the title The Rise of EOE is absolutely perfect because we have a good evidence that it's a new disease!

00:00:42: First description was in the early nineties by Stephen Atwood and myself.

00:00:50: This was the recognition.

00:00:54: it's speculative, but we have good evidence that the first appearance of this disease was few years before.

00:01:03: It is definitely a new disease!

00:01:06: Why?

00:01:06: The impaction of ordinary food in non-strictured esophagus didn't occur four or five decades ago... We had obstructions in a tumor or a peptic stricture, if patients will have fish one and things like that.

00:01:28: But ordinary food in non-strictured esophagus remains stuck – this didn't occur!

00:01:38: How did you recognise it?

00:01:40: You were one of the first to describe how separate entities are.

00:01:45: And what did they come about from... peculiar patients?

00:01:51: My first patient was a ten-year old boy.

00:01:56: February twenty six, nineteen hundred eighty nine he was referred as an emergency case with long lasting foot infection over eight hours.

00:02:09: The foot stuck in the esophagus and complete obstruction.

00:02:14: I removed the bolus And I took some biopsies and the pathologist called me two days later back.

00:02:22: This esophagus is full of eosinophils, i never have seen such a picture!

00:02:30: What was your first idea when he said that it's eosonophilic?

00:02:34: No idea... The only ...I had two ideas.

00:02:38: one I'd to make literature search but at that time in We had no search machines.

00:02:51: And I found only three case reports, one from eucalyptus, another case that had a systemic erosinophilic disease but an isolated EOV and we have new publications.

00:03:06: The second thing i did is to remind you of the fact a forty-five year old engineer with solid foot dysphagia.

00:03:19: I doubt you are stressed because you're an engineer, please keep cool.

00:03:24: and now i contacted the patient again.

00:03:27: I scoped him this time...I took biopsies!

00:03:30: And the pathologist said to me, Alex what are you doing?

00:03:37: This was number two in the same year.

00:03:40: Eighty-nine, a third patient.

00:03:43: And then I was convinced this is something that's not only a spleen in my head!

00:03:52: So what happened in the five years afterwards before you published your data?

00:04:02: I presented these three cases at an original gastro meeting and within a rather short time, we had total ten patients.

00:04:14: And this case series I published in nineteen four beginning ninety-four and few months before another publication, A Case Series with Twelve Patients Stephen Atwoods was the author of these publications and absolutely identical mainly male patients difficulties in swallowing solid food.

00:04:45: The majority of patients had other allergies and then the food impuction, and the esophagus full of eosinophils.

00:04:53: We have these two case series published in nineteen hundred ninety three and four.

00:05:02: And this I would say This was a recognition The appearance of EUA, the first appearance we don't know exactly.

00:05:12: But because that manifestation is so dramatic with food infections I think it's a new disease.

00:05:22: It might be an onset in the eighties of last century or maximum five decades ago and before this disease didn't exist.

00:05:37: Yeah, that's very peculiar.

00:05:39: Professor if it is not known entity a new one.

00:05:43: what did you do with those patients?

00:05:45: You still had to deal them with the impactions and things like that.

00:05:50: What were their first treatment options that you prescribed?

00:05:53: how did you deal with this?

00:05:55: I have The idea these are mainly These individuals or persons with allergies.

00:06:04: i tried antihistamines, no result.

00:06:08: And then I had the idea maybe some similarities with asthma.

00:06:16: let's try topical acting corticosteroids.

00:06:21: i took formulations designed for asthma or inhalation and instructed my patients to swallow this powder...and it worked!

00:06:35: With the interlator?

00:06:36: Yes, not to inhale but to swallow.

00:06:40: To swallow the liquid of bodezonide or othlyticazone and it worked!

00:06:47: It worked for symptoms... ...and it worked regarding inflammation The topical active corticosteroids.

00:06:57: This was a clue that opened up this way into treatment disease.

00:07:05: So it actually started with this theory instead of PPI, right?

00:07:10: Yes!

00:07:10: It's interesting...

00:07:11: Why didn't I use PPI?

00:07:16: Because the patients did not claim reflux symptoms.

00:07:26: They had a solid foot dysphagia and no endoscopic signs of reflx And therefore I started with steroids.

00:07:36: Seems logical, Professor full disclosure when i diagnose eosinophilic esophagitis am always very apprehensive not because it's something very dramatic but Because I know that at some point in the treatment or surveillance there will be a question That I don't know The answer and most probably There is no known Answer currently.

00:07:59: so It's Very very uncomfortable position to Be So.

00:08:03: one other question is, what's the actual difference between eosinophilic esophagitis and esophageal isonophilia that responds to PPI?

00:08:13: Esophageale eosynophilia briefly EE or AA is a histological diagnosis.

00:08:22: If the esophagus is inflamed, infiltrated with aerosinofils then you have an esophagesiophthalia.

00:08:32: But this is absolutely nonspecific, because an eosinophil infiltration can occur under many different conditions.

00:08:44: If you have a sunburn that in the late phase when pain disappears disappears, you take a biopsy from your skin then you have eosinophils.

00:08:57: The eosinofils is a late-phase inflammatory cell with a lot of repair capacities and absolutely nonspecific EE as an esophageal eosynophilia is a histological diagnosis and EOE eosinophilic as a vagitis is that clinical pathological diagnosis.

00:09:21: That means you need symptoms, solid food dysphagia.

00:09:26: drinking is no problem but as more solids the voodooism has more problems you have.

00:09:32: and on the other hand the histology And honestly the chronicity is third pillar of the diagnosis.

00:09:41: The symptoms, Solid Food Dysphagias, the Histology with them eosinophilic infiltration and the chronicity.

00:09:49: These are elements.

00:09:51: then you can diagnose EOE, it's a clinical pathological diagnosis.

00:09:57: Okay so basically EOe is always esophageal esonophilia but not every esophagile esonaphilia is EOEs?

00:10:06: Absolutely!

00:10:08: Good to know.

00:10:09: EOes is esophagesal eosinofilia and symptoms.

00:10:16: Problem, solid food this feature.

00:10:20: you have problems if you swallow solid food.

00:10:24: these both it's clinical pathological defined.

00:10:28: but

00:10:29: what do you think about the diagnostic?

00:10:31: here's the pathological diagnostic criteria.

00:10:33: in your EOE we have a cutoff of like fifteen eosinophilus per magnifying field.

00:10:40: is And does it reflect, and if the patient has fourteen?

00:10:46: Does that mean a patient doesn't have eosinophilic esophagitis?

00:10:50: No.

00:10:51: It's an arbitrary threshold in theory!

00:10:55: The esophagus is only the segment of the GI tract which is free from eosynophils.

00:11:02: but nature isn't black or white.

00:11:06: you need to accept to accept some eosinophils in the esophagus and even reflux, so GERD can induce an esophageal eosinofilia.

00:11:18: Also it's this threshold is arbitrary.

00:11:23: only in combination with symptoms you establish the diagnosis EOE a relevant inflammation Iosinophic inflammation together with symptoms of solid foot dysphagia.

00:11:39: Okay,

00:11:40: now that we've established this what do we need for the diagnosis?

00:11:44: But it is known there's a huge discordance between patient-reported symptoms and histological findings.

00:11:51: So... We need both but then they're not concordant.

00:11:56: And if can't have both in treatment which more important

00:12:00: Both are important.

00:12:03: But the symptoms are pitfall, a diagnostic pitfall.

00:12:10: Very often you hear I have no swallowing problems but i never would eat steak... ...I'd never ever eat pizza!

00:12:23: I only ate soups and drink a lot of tea and beer.

00:12:28: Patients adapt rapidly avoid critical food.

00:12:35: And therefore you have to ask, would you eat a dry sandwich without any mineral water?

00:12:44: Even in stress!

00:12:45: You are sitting at the car and meeting your own delay... nothing else to eat than your sandwich, would you eat under this situation as a sandwich without any mineral water?

00:13:01: And if the patient said yes then he has really no solid foot dysphagia.

00:13:08: This is the provocative question!

00:13:11: So this is your diagnostic criteria.

00:13:13: measurement

00:13:14: okay... Yes for symptoms the hidden symptom of dysphagia apparent to bring it on the surface.

00:13:26: Okay, but once we've diagnosed

00:13:28: their

00:13:29: treatment options as lacking as they are and you started with a topical steroids?

00:13:35: But what are the current options that we can safely prescribe or offer our patients?

00:13:42: EOE is a fidelity.

00:13:45: if without any food, then your EOE is quiet.

00:13:53: But as soon you eat food in particular proteins, then starts an allergy.

00:14:02: It's a food allergy.

00:14:04: it's a late phase food allergy unfortunately not IgE mediated and therefore You have two options Either you can identify the culprit food, then have an option of a diet or you suppress this chronic destructive inflammation with medications.

00:14:37: First-line topical corticosteroids.

00:14:40: if it not works with biologics The problem to figure out the culprit food is rather cumbersome.

00:14:50: Because we have no tests, it's not an IgE-mediated allergy that skin tests... That foot specific serum IgE values are NOT helpful!

00:15:05: You can.. We have NO Tests To Figure Out The Culprit Food Except a diet.

00:15:14: You say for instance, avoid for three months every milk product...every dairy products.

00:15:24: and then you have to ask the symptoms.

00:15:27: what happens with these symptoms?

00:15:29: You have to scope the patient or take biopsies ...and then it works!

00:15:34: Or if doesn't

00:15:35: work?!

00:15:36: With milk ,with dairy products a chance up to forty percent that it works, symptoms disappear and inflammation disappears.

00:15:47: But if does not work you can propose let's try with gluten.

00:15:53: maybe the chances is smaller than for dairy products could have about twenty per cent chance.

00:16:02: but this is cumbersome Time-consuming with repeated endoscopies.

00:16:10: Yeah, and also I was wondering because in all the schemes about using a phylicosophagitis there's one this one arrow allergen graph that contributes to their inflammation Because of cross reaction.

00:16:24: so even if we eliminate the culprit food How do we avoid?

00:16:29: The other allergens?

00:16:30: it might cause a reaction.

00:16:33: We have two case reports that EOE was induced by aero allergens.

00:16:43: But this is the exception and we know from treatment studies.

00:16:49: with amino acid formulation, a diet without any proteins you have in children the ninety percent response.

00:17:04: If you don't eat any food proteins, then you have a huge chance that your EOE gets quiet.

00:17:17: but these amino acid formulations has two handicaps they are expensive and they all have an ugly taste.

00:17:30: It's not a long-term solution.

00:17:36: Because if we will talk about the endpoints, quality of life.

00:17:40: on that thing I'm sure it is worth it!

00:17:45: We have two endpoint for treatment.

00:17:48: One important from patient perspective and physician perspective is control of symptoms.

00:17:59: If we start on a level of that visual analog scale, I would say if the symptoms are below three then you're happy and patients normally are happy as well!

00:18:15: And this second criteria is inflammation.

00:18:20: The histology... less than fifteen, maybe less than twenty in reality.

00:18:31: In practice then we have a good feeling that even over the long term... That you don't risk about evolution of things.

00:18:41: but quality-of life is pretty good for patients and no relevant longterm risks.

00:18:49: Okay

00:18:50: so what are trying to achieve?

00:18:53: But do The two treatment options, the diet is theoretically very attractive because we don't need any medications but has two handicaps.

00:19:08: First to figure out which food category it's the culprit food and second one almost always staple foods like milk products or gluten And you will need a long-term treatment.

00:19:22: It not only one month or one week and staple food.

00:19:27: elimination over long term is a challenge for the patients.

00:19:33: And, another option you suppress the ugly inflammation with medications.

00:19:41: in our cohort of almost thousand EUA patients only fourteen percent are under diet.

00:19:50: The vast majority uses medications to control their symptoms and to control the inflammation.

00:19:58: And how do you present these options as equal?

00:20:02: To the patient, is it their decision or do you favor one of which?

00:20:07: No!

00:20:08: We favor them.

00:20:09: medications Why?

00:20:11: The patient is symptomatic... ...and he's eager that something happens.

00:20:16: Then we start with medication because A huge chance, almost eighty percent that within few days or maybe one of two weeks symptoms disappear and the inflammation disappears.

00:20:35: And this is a dramatic experience for the patient.

00:20:39: he's immediately convinced.

00:20:42: now these works.

00:20:43: if you start with diet first You have to figure out which food category the culprit food, this takes time.

00:20:53: And if you have to culprit food and you avoid it... The onset is much slower!

00:21:00: Symptoms disappear over weeks and weeks at not as dramatic as rapid as with a medication.

00:21:08: Therefore we start with topical acting corticosteroids but we explain to patients that it's a food allergy we can start with, if the patient is eager.

00:21:22: We stop the medication and we discuss let's start with dairy product or let's starts with gluten?

00:21:31: We propose dairy because it's bigger than with gluten but at the start normally with medications.

00:21:43: Okay, so Professor we do have a consensus that we're starting our patients on steroids and let's see what happens next in the second part.