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Eosinophilic esophagitis (EoE) is an IgE-mediated allergic condition of the esophagus characterized by dense eosinophilic infiltrates. An association with atopic conditions suggests that EoE may be driven by both genetic and environmental factors, including food related exposures. Here, we present two cases of EoE in adult brothers with an update on the known genetic involvement in this disease. An 18-yearold male with allergic rhinitis and food allergies presented with abdominal pain, foul smelling BMs, and weight loss for 1 year. Upper endoscopy revealed linear furrows throughout the esophagus, biopsies of which demonstrated eosinophilia up to 150 per high-power field (HPF). Serum allergen testing indicated elevated IgE and multiple food sensitivities. His brother is a 36-year-old with a history of GERD and progressive dysphagia. He has no known allergies or atopic conditions. On EGD, the esophageal mucosa appeared normal, however biopsies also yielded eosinophilia up to 150/HPF. Serum allergen panel was negative with a mildly elevated IgE. Studies have supported a heritable component in EoE with recurrence risk ratios in first-degree relatives of patients ranging from 10-64. One retrospective study attributed 72% of heritability to a combined effect of genes and environment within nuclear families. Here we describe siblings who presented with symptomatic EoE within the same year. Both were diagnosed with a high burden of eosinophilia on endoscopic biopsies; however, their clinical presentation and findings differed. One patient had classic endoscopic findings of linear furrows with a history of atopic disease (food allergies and allergic rhinitis). While prior studies have not shown a statistically significant difference in signs and symptoms, endoscopic appearance, or atopic status between familial and sporadic EoE patients, our patients suggest there may be more variability within the familial EoE population than previously recognized. The histopathologic similarity between these two patients is consistent with reports of a conserved genomic "EoE transcriptome" in which eotaxin-3 (eosinophil-specific chemoattractant) was significantly over-expressed with levels correlating with end-organ eosinophilia. However, a longer latency period of disease in one brother points to possible differences in underlying susceptibility. Additional research is needed to refine our understanding of the complex interactions between genes and environment in this disorder. (Figure Presented)

Introduction: Single balloon enteroscopy (SBE) is a method used for evaluation of the small intestine. It is most frequently used to investigate the cause of obscure gastrointestinal (GI) bleeding, and is useful to investigate other disorders as well. In a case series of obscure overt GI bleeding, Pinto-Pais et al. demonstrated that 93.3% of patients with active bleeding underwent SBE that identified the source, and 64.3% of patients with inactive GI bleeding had a definitive bleeding source identified. The aim of our study was to evaluate the efficacy of SBE at Bellevue Hospital from its introduction at our institution in 2008 through 2015. Methods: A query of our endoscopic software was performed of SBE procedures from January 2008 through September 2015. The main inclusion criterion was patients at least 18 years of age who underwent SBE. The patient's age, past medical history, pertinent laboratory tests, procedural indications, capsule endoscopy findings, pathology results, SBE outcomes, and adverse events were collected. Results: Forty SBEs were performed during this period: twenty-nine anterograde and eleven retrograde. The average age of the patients was 51.9. Procedural indications including bleeding (18), anemia (9), retained video capsule (4), intussusception (2), mass (2), and other abnormal imaging findings (5). Nineteen procedures were successful in reaching the area in question. Diagnoses included one paraganglioma, one adenocarcinoma, one GIST, and one carcinoid. Six procedures led to treatment of AVMs with subsequent improvement in anemia. Adverse events included abdominal pain in 3 procedures. Two of these episodes resolved without intervention and the third patient was lost to follow-up. One patient had mucosal trauma and oozing. One patient had melena and a decline in hemoglobin, which resolved without intervention. One patient had a possible retroperitoneal hematoma after the procedure. Conclusion: This study outlines the diagnostic and therapeutic utility of SBE in varied clinical scenarios in the diverse patient population at Bellevue Hospital, a large tertiary care referral center in New York City. Ongoing studies would include investigating the utility of SBE in symptomatic patients without abnormal findings on imaging or laboratory studies, the use of enteroscopic localization technology to improve patient comfort, safety, and procedural efficiency, and optimizing procedural timing to determine if sensitivity and yield are enhanced

A 54-year old man with HIV/AIDS was evaluated in the outpatient setting for chronic diarrhea, with watery stools up to 12 times daily. At the time, his HIV was well-controlled on antiretroviral therapy. Stool studies did not reveal an infectious source apart from likely commensal organisms. He underwent colonoscopy for further evaluation, with colonic mucosa appearing grossly normal. Random segmental biopsies revealed lymphocytic colitis, and he was prescribed budesonide 9mg daily. One week after starting budesonide, he presented to the emergency department with worsened diarrhea, up to 50 episodes daily, complicated by a 10-pound weight loss, severe dehydration, and near syncope. Stool pathogen PCR panel was positive for enteroinvasive E. coli and Shigella. Repeat colonoscopy revealed severe enterocolitis involving the entire colon and terminal ileum (see figures). Random biopsies demonstrated active colitis with regenerative epithelial cell change and fibrinopurulent exudate, compatible with an acute infectious colitis. The patient received a 7-day course of ciprofloxacin, with rapid symptomatic improvement. Following discharge he was maintained on bismuth subsalicylate and loperamide for microscopic colitis, without re-initiation of budesonide, and his diarrhea has remained under adequate control. Oral budesonide is commonly used in the treatment of microscopic (lymphocytic and collagenous) colitis and also in inflammatory bowel disease. Due to its high first-pass metabolism, this agent has a more favorable side effect profile than systemic corticosteroids, although there remains some risk of adrenal insufficiency and immunosuppression. To our knowledge, however, there have not been previous reports of dysentery from enteroinvasive E. coli or shigellosis among patients receiving budesonide for microscopic colitis. Although HIV patients are at increased of acute or chronic diarrhea from these organisms, stool cultures were negative at the time of the initial evaluation and there was no macroscopic colitis seen at the index colonoscopy. We therefore consider the possibility that budesonide therapy contributed to an acute infectious enterocolitis and thus the dramatic clinical and endoscopic change that occurred over short interval of a few weeks. It may be important to consider the infectious risks of budesonide when treating microscopic colitis and other conditions, particularly in patients with HIV or other immunosuppressed states