Eosinophilic illness. In the presence of eosinophilia (an

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  Eosinophilic Esophagitis MS Pharmacology-812 Quratulain Muzaffar                  Roll # 1773045   EosinophilicEsophagitis an overview: Abbreviations:Ø  GERD= Gastrophageal reflux diseaseØ  GI=GastrointestinalØ  EE/EoE=Eosinophilic EsophagitisØ  MDI=meter dose inhalerØ  IL=InterleukinØ  E=EosinophilAnatomyof esophagus:The esophagus or gullet is a muscular canal, about 23 to 25 cm. long, extending from the pharynxto the stomach. It begins in the neck at the lower border of the cricoidscartilage, opposite the sixth cervical vertebra, descends along the front ofthe vertebral column, through the superior and posterior mediastina, passesthrough the diaphragm, and, entering the abdomen, ends at the cardiac orificeof the stomach.

Introduction:Eosinophilic esophagitis is achronic immune system disease. It has been identified only in the past twodecades, but now days considered a major cause of digestive system(gastrointestinal) illness. In the presence of eosinophilia (an abnormally increasein a number of white blood cells) the esophagus has been noted in patients whowere believed to have had (GERD).

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It is an inflammatory condition of the esophagus.White blood cells build up in the lining of the tube that connectsyour mouth to your esophagus. This occurs, due to a reaction to foods,allergens or acid reflux; causes inflammation or injure the esophageal tissue.Damaged esophageal tissue can lead to difficulty swallow. ClinicalSign & Symptoms:In Adults:Ø DysphagiaØ Repeatedfood ImpactionØ Centrallylocated chest pain (not respond to antacid)Ø Notresponded to GERD medicationØ HeartburnØ Stomach-acheØ Undigestedfood backflowØ Diarrhea(Rarely)Ø NauseaIn Children:Ø Feedingproblem in infantsØ Eatingproblem in childrenØ EmesisØ AbdominalpainØ PoorgrowthØ MalnutritionØ WeightlossØ HeartburnØ Foodimpaction AgeGrouped:The patient age groupranged from 2 months to 89 years.

1 It was reported that males aremore commonly affected in both children (66%) and adults (76%). PossibleEtiology of Eosinophilic Esophagitis:Allergic responses havebeen powerfully recommended as a reason of EE. This has been evidenced withresults showing that 50% to 80% of patients with EE have simultaneousconditions such as atopic dermatitis, allergic rhinitis, asthma, and eczema. Thepatients with EE also show allergic antigen sensitization from skin testing orantigen-specific immunoglobulin E (IgE) presentation from plasma testing.Interleukin (IL)-4, IL-5, IL-13, and mast cells are found in the esophagus ofpatients with EE. Seasonal differences in symptoms have been reported, and casereports have shown seasonal changes in eosinophilic levels in the proximalesophagus. The elevated rate of eczema and other atopic allergies requires thatthe patient be evaluated by an allergist who is familiar with EE. Inhaledallergens may also play a role in EE, and the patient should thus be evaluatedfor this as a contributing factor.

 Diagnosis:Diagnostic test for EosinophilicEsophagitis includes:Upper endoscopy. Use a long narrow tube (endoscope) containing a light and tiny camera and put in it through mouth down the esophagus. Inspect the lining of esophagus for irritation and amplification, horizontal rings, vertical furrows, narrowing (strictures), and white patches.  Biopsy. In an endoscopy, perform a biopsy of esophagus by taking a small piece of tissue & take multiple samples from esophagus and then check the tissue under a microscope for eosinophils.Blood tests. If suspect EE, some additional tests to confirm the diagnosis and to begin to seem for the sources of allergens.

Blood tests to check for elevated than normal eosinophil counts or total immunoglobulin E levels, suggesting allergy.Treatmentof Eosinophilic Esophagitis:Treatment strategies for EE are include:Dietarycontrol: If patients have foodallergies, take allergen-free diets. If patients do not respond to food takingaway of specific antigens, amino acid-based formula management is the recentgold standard for evaluating.

This treatment has been very important inchildren, with a success rate of 92% to 98%.Resolution of symptoms occurredwithin 7 to 10 days, and with histological improvement seen within 4 to 5weeks. Amino acid-based formulas generally have an unlikable taste, and oftenthe feedings are given via nasogastral tubes. A slow introduction of certainfoods can be started when symptoms resolve and histology recover. The six mostcommon allergic foods are:Dairy,Eggs, Wheat, Soy, Peanuts and Fish or shellfishTreatment:Esophageal dilation may be requiredin patients with food impactions cause by fixed strictures as a effect ofesophageal narrowing.

Esophageal dilation may be done to treat the stricture incases of dysphagia or esophageal impaction. It is suggested that, if feasible,an endoscopy with biopsy be done earlier to an esophageal dilation, helpful formedical or dietary treatment. Complications from dilation can effect inesophageal tears or lacerations. Presently, there are no records to assesswhich patients will be at high risk for complications. However, patients whohave already developed esophageal rings, strictures, or narrowing areconsidered to be at high risk for difficulty. Role ofantibioticsA  new study information that antibiotic use inthe first year of infancy was related with six times the odds of developing EE.The usage of antibiotics has been linked to allergy development in mice.

Amusinglythe occurrence of Helicobacterpylori in gastric biopsies is also inversely associated with EE.There is, however, no indication to recommend that patients undergoingantibiotic induced Hpylori eradication are at higher risk for EE.In summary, EE is apolygenic disorder in which a dysregulated environment in the oesophagealmucosa shows to lead to inflammatory cell infiltration and disease developmentin response to food allergens and aeroallergen). Both genetic and/orenvironmental cause appear to manipulate the production of mediators such asTSLP and eotaxin-3 by epithelial and other stromal cells.

Eosinophils, Th2lymphocytes, and mast cells are conscript to the mucosa. B lymphocytes may gothrough local IgE class switching. Increasing evidence show that environmentalfactors, in particular medications such as antibiotics, particularly early inlife, could put in to disease development and may even account for the amplifiedoccurrence of disease observed.    Lifestyle modification home remedies:If heartburn, these way oflife modification may help decrease the occurrence or severity of indication:Maintain a well weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus. If weight is at a healthy level, work to maintain it. If obese, work to slowly drop weight — no more than 0.5 to 1 kg /week.

Evade foods and drinks that cause heartburn. General triggers, such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine, may create heartburn worse. Evade foods you know will cause your heartburn.Raise the top of your bed. Regularly experience heartburn at night or while trying to sleep, put gravity to work . If it’s not possible to elevate your bed, insert a lodge between your mattress and box spring to elevate your body from the waist up.

 Alternative medicineNo other medicine remedyhas been proved to treat eosinophilic esophagitis. Still, some complementaryand substitute treatment may provide some release from heartburn or reflux signs.Other treatments choiceS may include:Herbal therapy. Herbal therapy sometimes used for heartburn or reflux symptoms include licorice, slippery elm, chamomile, marshmallow and others. Herbal treatment can have serious side effects, and they may hinder with medications. Relaxation treatment.

Method to calm stress and anxiety may decrease signs of heartburn or reflux. such as progressive muscle relaxation.Acupuncture. Acupuncture involves introduce thin needles into definite points on your body. Limited data suggests it may help people with regurgitation and heartburn, but mostly studies have not show a benefit. ConclusionEE is a chronic disorder.

Earlier,it may have been misdiagnosed as GERD. Though GERD can co-exist with EE andboth have mostly same symptoms, EE not respond at high dose (2 mg/kg/day) PPItherapy. Allergic responses have been strongly recommended as a reason of EE,and many patients respond to an allergen-free diet.

Other non-FDA recommendedtreatments consist of short-term use of systemic and topical corticosteroids.Montelukast has been used to treat a lesser number of EE patients along inhaledallergens. Reslizumab, anti-IL-5, mepolizumab, and viscous budesonide are presentlyin clinical test for the treatment of EE. Finally, esophageal dilation may be necessaryin patients who develop a food impaction as a result of esophageal narrowing.

Main messages:·        Theoccurrence of eosinophilic oesophagitis (EE) is rising.·        EEis characterized clinicallyby signs of dysphagia, food impaction and proton pump inhibitor defiantdyspepsia, and histologicallyby major eosinophilic infiltration of the oesophageal mucosa.·        Aminimum of 2–4 oesophageal biopsies should be taken from the proximal anddistal oesophagus to identify EE.·        EEis related with atopy and a T helper type 2 (Th2) reaction. A detailed allergyhistory required to be taken before testing for food and aeroallergens in EEpatients.·        Genome-wideanalysis studies (GWAS) have found EE to be associated with a region onchromosome 5q22 in a paediatric cohort. The gene for thymic stromallymphopoietin (TSLP) is localised to this region.

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Erythema nodosum and eosinophilicoesophagitis: more than a chance association? Br J Dermatol.2007;156:1388-1389. 6.Straumann A, Spichtin HP, Grize L, et al. Natural history of primaryeosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.

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The small-caliber esophagus: anunappreciated cause of dysphagia for solids in patients with eosinophilicesophagitis. GastrointestEndosc. 2002;55:99-106. 8.Liacouras CA, Spergel JM, Ruchelli E, et al. Eosinophilic esophagitis: a10-year experience in 381 children. Clin Gastroenterol Hepatol.

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J Pediatr Gastroenterol Nutr.2006;42:22-26. 11.Straumann A, Bauer M, Fischer B, et al. Idiopathic eosinophilic esophagitis isassociated with a T(H)2-type allergic inflammatory response. J Allergy ClinImmunol. 2001;108:954-961. 12.

Onbasi K, Sin AZ, Doganavsargil B, et al. Eosinophil infiltration of theoesophageal mucosa in patients with pollen allergy during the season. Clin Exp Allergy.2005;35:1423-1431.

13.Fogg MI, Ruchelli E, Spergel JM. Pollen and eosinophilic esophagitis. J Allergy ClinImmunol. 2003;112:796-797.

14.Noel RJ, Putnam PE, Collins MH, et al. Clinical and immunopathologic effects ofswallowed fluticasone for eosinophilic esophagitis. Clin GastroenterolHepatol. 2004;2:568-575. 15.Brown-Whitehorn TF, Spergel JM. The link between allergies and eosinophilicesophagitis: implications for management strategies.

Expert Rev ClinImmunol. 2010;6:101-109. 16.    Straumann A, AcevesSS, Blanchard C, et al.Paediatric and adult eosinophilic esophagitis: similarities and differences. Allergy 2012;67:477–490.Comprehensive overview ofpaediatric and adult EoE.

17.    Eosinophilicesophagitis: a prevalent disease in the United States that           affects all age groups. Gastroenterology 2008;134:1316–21.  

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