Alimentary Pharmacology and Therapeutics Letters to the Editors therapy before the development of septic shock had a paradoxically lower survival rate (3/25, 12%). This is likely due to selection bias. To be included within this retrospective database, patients had to develop septic shock (hypotension). Hence, patients who were diagnosed with sepsis and received appropriate anti-microbial therapy, but did not become hypotensive, did not meet the entry criteria for the CATSS registry. In contrast, patients who got appropriate anti-microbials and subsequently developed shock likely failed appropriate anti-microbial therapy, and are a subset of patients with a poorer prognosis (87.5% mortality). Hence, only the ‘failures’ were identified. This phenomenon has been demonstrated in other studies from the CATTS registry. In a study of 2731 critically ill patients with septic shock, 21% of the patients (n = 577) failed appropriate anti-microbial therapy and progressed to septic shock, with similar results [survival vs. the overall group (52.2% vs. 58.0%)].3 In cirrhotics, it can be very difficult to differentiate between ‘liver-related deaths’ and ‘multiorgan failure’. For example, hepatorenal syndrome or acute kidney injury are a consequence of cirrhosis and spontaneous bacterial peritonitis, but lead to multiorgan failure.4 Unfortunately, the CATSS database was initially constructed as a registry for general critical care patients. While this granular data is not available, trying to dissect ‘liver related’ vs. ‘nonliver related’ is virtually impossible as shown by Moreau et al. in the CANONIC study.5 Finally, our high (100%) mortality rate in fungal peritonitis/shock is consistent with other studies.6 Prior studies have shown that directed anti-fungal therapy did not
Letter: increasing incidence and prevalence of eosinophilic oesophagitis S. E. Attwood Department of Surgery, North Tyneside Hospital, North Shields, UK. E-mail: [email protected] doi:10.1111/apt.13223
SIRS, The article published by Dellon et al. makes very interesting reading.1 First, the authors are to be congratulated on their methodology, achieving a true national perspective and for the first time providing direct evidence of a true rise in the frequency of eosinophilic oesophagitis. Their current rate of diagnosis at an incidence of 2.6/ 124
improve patient outcomes.7 Hence, fungal peritonitis may potentially be a poor prognostic marker. Given that we had 11 patients in our cohort, however, these are relatively small numbers to make any overarching recommendations for empirical anti-fungal therapy.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Chen P-Z, Wang C-C. Letter: what else can improve survival in cirrhotic patients with spontaneous bacterial peritonitis and associated septic shock? Aliment Pharmacol Ther 2015; 42: 123. 2. Karvellas CJ, Abraldes JG, Arabi YM, Kumar A; Cooperative Antimicrobial Therapy of Septic Shock Database Research G. Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study. Aliment Pharmacol Ther 2015; 41: 747–57. 3. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34: 1589–96. 4. Wong F, O’Leary JG, Reddy KR, et al. New consensus definition of acute kidney injury accurately predicts 30-day mortality in patients with cirrhosis and infection. Gastroenterology 2013; 145: 1280–8. e1. 5. Moreau R, Jalan R, Gines P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144: 1426– 37, 1437 e1–9 6. Hwang SY, Yu SJ, Lee JH, et al. Spontaneous fungal peritonitis: a severe complication in patients with advanced liver cirrhosis. Eur J Clin Microbiol Infect Dis 2014; 33: 259–64. 7. Bremmer DN, Garavaglia JM, Shields RK. Spontaneous fungal peritonitis: a devastating complication of cirrhosis. Mycoses 2015; doi: 10.1111/myc.12321. [Epub ahead of print]
100 000 per annum, and their prevalence of 13.8/100 000 places the frequency of this condition as no longer rare. Previous studies of cohorts, and institutional series suspected such a rise, but lacked objective evidence. The methodology of Dellon et al. has provided invaluable evidence on the rising incidence and prevalence of eosinophilic oesophagitis. As the natural history of this condition is to remain chronic in the majority,2 the likelihood is that eosinophilic oesophagitis will become even more frequent over the next decade in the western world. Could the authors explain the relatively low rate of respiratory asthma (7%) seen in Denmark when most other series have an association with asthma in up to 50%4? The list of therapies in Table 2 describes systemic steroids being used in adults in 29%, but topical steroids Aliment Pharmacol Ther 2015; 42: 121–129 ª 2015 John Wiley & Sons Ltd
Letters to the Editors being used in only 22%. It is now well established that topical steroids are at least, if not more, effective as systemic steroids but without the side effects. For a chronic condition that might require years of therapy, I would strongly advise against systemic steroid use. Is there a reason for such high systemic steroid use in Denmark, and is it possible for the authors to influence future prescribing patterns? It is over 25 years since the condition was first publicised3–5 and, following a period of being regarded as a rare disease, eosinophilic oesophagitis may now be regarded as the second most common disease in the oesophagus. It is now essential that all gastroenterologists and ear nose and throat surgeons are aware of the condition, and know how to diagnose and treat it.
ACKNOWLEDGEMENT Declaration of personal and funding interests: None.
Letter: increasing incidence and prevalence of eosinophilic oesophagitis – author’s reply E. S. Dellon*,† *Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA. † Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA. E-mail: [email protected]
REFERENCES 1. Dellon ES, Erichsen R, Baron JA, et al. The increasing incidence and prevalence of eosinophilic oesophagitis outpaces changes in endoscopic and biopsy practice: national population-based estimates from Denmark. Aliment Pharmacol Ther 2015; 41: 662–70. 2. Straumann A, Spichtin HP, Grize L, Bucher KA, Beglinger C, Simon HU. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology 2003; 125: 1660–9. 3. Attwood SEA, Smryk TC, DeMeester TR. Oesophageal asthma: episodic dysphagia with eosinophilic infiltrates. Gut 1989; 30: A1493. 4. Attwood SE, Smyrk TC, Demeester TR, Jones JB. Esophagealeosinophilia with dysphagia: a distinct clinicopathologic syndrome. Dig Dis Sci 1993; 38: 109–16. 5. Straumann A, Spichtin HP, Bernoulli R, Loosli J, V€ ogtlin J. Idiopathic eosinophilic esophagitis: a frequently overlooked disease with typical clinical aspects and discrete endoscopic findings. Schweiz Med Wochenschr 1994; 124: 1419–2.
effective in the short term, these agents should be reserved for patients who require rapid improvement in symptoms.4 In our study, while it is correct that 29% of adults with EoE received systemic steroids at some point during the study time frame, we did not examine the specific indication for their use, or the length of the course prescribed. While these medications could have been used for EoE, they also could have been used for any other indication. Further studies would be required to fully examine the extent to which systemic steroids are being used for EoE.
doi:10.1111/apt.13233
SIRS, We thank Dr Attwood for the interest in our recent paper,1, 2 and appreciate his thoughts about the importance for practitioners to be aware of eosinophilic oesophagitis (EoE). We do not have a definitive explanation for the relatively low rate of asthma in the EoE subjects in the Denmark health registries, and agree that the prevalence of asthma and other atopic disorders is typically reported to be higher in patients with EoE than we found in this study.3 However, because our asthma definition used selected ICD-10 codes (J45.0, J45.1, J45.8 and J45.9, as noted in Table S2) and not medical record validation of this condition, it is possible that not all cases of asthma were identified. We agree with Dr Attwood that chronic use of systemic steroids should be avoided in EoE, and recent guidelines highlight that while these are potentially Aliment Pharmacol Ther 2015; 42: 121–129 ª 2015 John Wiley & Sons Ltd
ACKNOWLEDGEMENTS The author’s declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Attwood S. Letter: increasing incidence and prevalence of eosinophilic oesophagitis. Aliment Pharmacol Ther 2015; 42: 124–5. 2. Dellon ES, Erichsen R, Baron JA, et al. The increasing incidence and prevalence of eosinophilic oesophagitis outpaces changes in endoscopic and biopsy practice: national population-based estimates from Denmark. Aliment Pharmacol Ther 2015; 41: 662–70. 3. Dellon ES, Liacouras CA. Advances in clinical management of eosinophilic esophagitis. Gastroenterology 2014; 147: 1238–54. 4. Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras C, Katzka DA. ACG Clinical Guideline: evidence based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis. Am J Gastroenterol 2013; 108: 679–92.
125
Letter: increasing incidence and prevalence of eosinophilic oesophagitis S. E. Attwood Department of Surgery, North Tyneside Hospital, North Shields, UK. E-mail: [email protected] doi:10.1111/apt.13223
SIRS, The article published by Dellon et al. makes very interesting reading.1 First, the authors are to be congratulated on their methodology, achieving a true national perspective and for the first time providing direct evidence of a true rise in the frequency of eosinophilic oesophagitis. Their current rate of diagnosis at an incidence of 2.6/ 124
improve patient outcomes.7 Hence, fungal peritonitis may potentially be a poor prognostic marker. Given that we had 11 patients in our cohort, however, these are relatively small numbers to make any overarching recommendations for empirical anti-fungal therapy.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Chen P-Z, Wang C-C. Letter: what else can improve survival in cirrhotic patients with spontaneous bacterial peritonitis and associated septic shock? Aliment Pharmacol Ther 2015; 42: 123. 2. Karvellas CJ, Abraldes JG, Arabi YM, Kumar A; Cooperative Antimicrobial Therapy of Septic Shock Database Research G. Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study. Aliment Pharmacol Ther 2015; 41: 747–57. 3. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34: 1589–96. 4. Wong F, O’Leary JG, Reddy KR, et al. New consensus definition of acute kidney injury accurately predicts 30-day mortality in patients with cirrhosis and infection. Gastroenterology 2013; 145: 1280–8. e1. 5. Moreau R, Jalan R, Gines P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144: 1426– 37, 1437 e1–9 6. Hwang SY, Yu SJ, Lee JH, et al. Spontaneous fungal peritonitis: a severe complication in patients with advanced liver cirrhosis. Eur J Clin Microbiol Infect Dis 2014; 33: 259–64. 7. Bremmer DN, Garavaglia JM, Shields RK. Spontaneous fungal peritonitis: a devastating complication of cirrhosis. Mycoses 2015; doi: 10.1111/myc.12321. [Epub ahead of print]
100 000 per annum, and their prevalence of 13.8/100 000 places the frequency of this condition as no longer rare. Previous studies of cohorts, and institutional series suspected such a rise, but lacked objective evidence. The methodology of Dellon et al. has provided invaluable evidence on the rising incidence and prevalence of eosinophilic oesophagitis. As the natural history of this condition is to remain chronic in the majority,2 the likelihood is that eosinophilic oesophagitis will become even more frequent over the next decade in the western world. Could the authors explain the relatively low rate of respiratory asthma (7%) seen in Denmark when most other series have an association with asthma in up to 50%4? The list of therapies in Table 2 describes systemic steroids being used in adults in 29%, but topical steroids Aliment Pharmacol Ther 2015; 42: 121–129 ª 2015 John Wiley & Sons Ltd
Letters to the Editors being used in only 22%. It is now well established that topical steroids are at least, if not more, effective as systemic steroids but without the side effects. For a chronic condition that might require years of therapy, I would strongly advise against systemic steroid use. Is there a reason for such high systemic steroid use in Denmark, and is it possible for the authors to influence future prescribing patterns? It is over 25 years since the condition was first publicised3–5 and, following a period of being regarded as a rare disease, eosinophilic oesophagitis may now be regarded as the second most common disease in the oesophagus. It is now essential that all gastroenterologists and ear nose and throat surgeons are aware of the condition, and know how to diagnose and treat it.
ACKNOWLEDGEMENT Declaration of personal and funding interests: None.
Letter: increasing incidence and prevalence of eosinophilic oesophagitis – author’s reply E. S. Dellon*,† *Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC, USA. † Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA. E-mail: [email protected]
REFERENCES 1. Dellon ES, Erichsen R, Baron JA, et al. The increasing incidence and prevalence of eosinophilic oesophagitis outpaces changes in endoscopic and biopsy practice: national population-based estimates from Denmark. Aliment Pharmacol Ther 2015; 41: 662–70. 2. Straumann A, Spichtin HP, Grize L, Bucher KA, Beglinger C, Simon HU. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology 2003; 125: 1660–9. 3. Attwood SEA, Smryk TC, DeMeester TR. Oesophageal asthma: episodic dysphagia with eosinophilic infiltrates. Gut 1989; 30: A1493. 4. Attwood SE, Smyrk TC, Demeester TR, Jones JB. Esophagealeosinophilia with dysphagia: a distinct clinicopathologic syndrome. Dig Dis Sci 1993; 38: 109–16. 5. Straumann A, Spichtin HP, Bernoulli R, Loosli J, V€ ogtlin J. Idiopathic eosinophilic esophagitis: a frequently overlooked disease with typical clinical aspects and discrete endoscopic findings. Schweiz Med Wochenschr 1994; 124: 1419–2.
effective in the short term, these agents should be reserved for patients who require rapid improvement in symptoms.4 In our study, while it is correct that 29% of adults with EoE received systemic steroids at some point during the study time frame, we did not examine the specific indication for their use, or the length of the course prescribed. While these medications could have been used for EoE, they also could have been used for any other indication. Further studies would be required to fully examine the extent to which systemic steroids are being used for EoE.
doi:10.1111/apt.13233
SIRS, We thank Dr Attwood for the interest in our recent paper,1, 2 and appreciate his thoughts about the importance for practitioners to be aware of eosinophilic oesophagitis (EoE). We do not have a definitive explanation for the relatively low rate of asthma in the EoE subjects in the Denmark health registries, and agree that the prevalence of asthma and other atopic disorders is typically reported to be higher in patients with EoE than we found in this study.3 However, because our asthma definition used selected ICD-10 codes (J45.0, J45.1, J45.8 and J45.9, as noted in Table S2) and not medical record validation of this condition, it is possible that not all cases of asthma were identified. We agree with Dr Attwood that chronic use of systemic steroids should be avoided in EoE, and recent guidelines highlight that while these are potentially Aliment Pharmacol Ther 2015; 42: 121–129 ª 2015 John Wiley & Sons Ltd
ACKNOWLEDGEMENTS The author’s declarations of personal and financial interests are unchanged from those in the original article.2 REFERENCES 1. Attwood S. Letter: increasing incidence and prevalence of eosinophilic oesophagitis. Aliment Pharmacol Ther 2015; 42: 124–5. 2. Dellon ES, Erichsen R, Baron JA, et al. The increasing incidence and prevalence of eosinophilic oesophagitis outpaces changes in endoscopic and biopsy practice: national population-based estimates from Denmark. Aliment Pharmacol Ther 2015; 41: 662–70. 3. Dellon ES, Liacouras CA. Advances in clinical management of eosinophilic esophagitis. Gastroenterology 2014; 147: 1238–54. 4. Dellon ES, Gonsalves N, Hirano I, Furuta GT, Liacouras C, Katzka DA. ACG Clinical Guideline: evidence based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis. Am J Gastroenterol 2013; 108: 679–92.
125
