Search

Patients with clinical symptoms of esophageal dysfunction and dense eosinophilic infiltration of the esophageal mucosa are suspected to have eosinophilic esophagitis (EoE). Topical steroids are often used as first-line therapy for EoE, although some patients respond clinically to proton pump inhibitors (PPIs). The purpose of this study was to compare the histological and clinical response of patients with esophageal eosinophilia treated with aerosolized swallowed fluticasone propionate vs. esomeprazole.This prospective single-blinded randomized controlled trial enrolled newly diagnosed patients with suspected EoE, defined as having clinical symptoms related to esophageal dysfunction with at least 15 eosinophils/high power field (hpf). Patients underwent 24-h pH/impedance monitoring to establish gastroesophageal reflux disease (GERD). Patients were stratified by the presence of GERD and randomized to receive fluticasone 440 mcg twice daily or esomeprazole 40 mg once daily for 8 weeks followed by repeat endoscopy with biopsies. The primary outcome was histological response of esophageal eosinophilia, defined as7 eosinophils/hpf. Secondary outcomes included clinical change in symptoms using the validated Mayo dysphagia questionnaire (MDQ) and interval change in endoscopic findings following treatment.Forty-two patients (90% male, 81% white, mean age 38 ± 10 years) were randomized into fluticasone (n = 21) and esomeprazole (n = 21) treatment arms. In all, 19% (8/42) of patients had coexisting GERD and were equally stratified into each arm (n = 4). Overall, there was no significant difference in resolution of esophageal eosinophilia between fluticasone and esomeprazole (19 vs. 33%, P = 0.484). In patients with established GERD, resolution of esophageal eosinophilia was noted in 0% (0/4) of the fluticasone group compared with 100% (4/4) of the esomeprazole group (P = 0.029). In GERD-negative patients, there was no significant difference in resolution of esophageal eosinophilia between treatment arms with fluticasone and esomeprazole (24 vs.18%, P = 1.00). The MDQ score significantly decreased after treatment with esomeprazole (19 ± 21 vs. 1.4 ± 4.5, P0.001), but not with fluticasone (17 ± 18 vs. 12 ± 16, P = 0.162). Improvement in endoscopic findings and other histological markers were similar between treatment groups.Fluticasone and esomeprazole provide a similar histological response for esophageal eosinophilia. With regard to clinical response, esomeprazole was superior to fluticasone, particularly in patients with established GERD.

While colonoscopy is currently the preferred test for colorectal cancer (CRC) screening, the invasive and time-consuming characteristics of the test are often cited as reasons for noncompliance with screening. CT colonography (CTC) is a less invasive screening method that is comparable to colonoscopy for the detection of advanced neoplasia. The aim of this project was to assess patient preferences between colonoscopy and CTC in an open access system.Two hundred fifty consecutive average-risk patients undergoing CRC screening completed a survey that assessed reasons for choosing CTC in lieu of colonoscopy, compliance with CRC screening if CTC was not offered, and which of the two tests they preferred.The most common reasons for undergoing CTC included convenience (33.6%), recommendation by referring provider (13.2%), and perceived safety (10.8%). Had CTC not been an available option, 91 of the 250 patients (36%) would have foregone CRC screening. Among the 57 patients who had experienced both procedures, 95% (n = 54) preferred CTC.These findings show the importance of providing CTC as an alternative screening option for CRC at our institution, which may increase CRC adherence screening rates.

Methylene blue (MB) selectively stains specialized intestinal metaplasia (SIM) and may assist in surveying a columnar-lined esophagus for Barrett's esophagus associated dysplasia.This is a prospective, randomized crossover study comparing 4-quadrant random biopsies (4QB) versus MB-directed biopsies for the detection of SIM and dysplasia in 48 patients with long segment Barrett's esophagus (LSBE). Patients randomly underwent two endoscopies over a 4-wk time period with either 4QB or MB-directed biopsies as their first or second exam. Our aim was to correlate stain intensity with histology.The sensitivity of MB for SIM and dysplasia was 75.2% and 83.1%, respectively. The yield of 4QB for identifying nondysplasia SIM was 57.6% (523/917) and for dysplasia was 12% (111/917). Dark staining was significantly associated with histologic grade (P0.007). The final diagnosis was correct in 43 (90%) patients using MB and in 45 (94%) using 4QB. The 4QB technique missed dysplasia in 3 of 21 patients while MB biopsies missed dysplasia in 5 of 21 patients. The discordance between the two techniques was not significant (P= 0.727, McNemar's test). The mean number of biopsies taken during 4QB was 18.92 +/- 6.36 and with MB was 9.23 +/- 2.89 (P0.001).MB requires significantly fewer biopsies than 4QB to evaluate for SIM and dysplasia. Dark staining correlates more with HGD than LGD in our experience. While MB is not more accurate than 4QB, MB may help to define areas to target for biopsy during surveillance endoscopy in patients with LSBE.

Background & Aims: Adenocarcinoma of the esophagus and esophagogastric junction (EGJ) is increasing, the earliest lesion being specialized intestinal metaplasia (SIM). This study determined the prevalence and demographic features of patients with SIM, dysplasia, and cancer in the esophagus and EGJ. Methods: Two antegrade biopsy specimens were taken distal to the squamocolumnar junction (SCJ) and any tongues of pink mucosa proximal to the SCJ. Patients were categorized endoscopically and histologically as having long-segment (LSBE) or short-segment Barrett's esophagus (SSBE), EGJ-SIM, or a normal EGJ. Results: Of 889 patients studied, 56 were undergoing esophagoduodenoscopy screening or surveillance and were not included in the prevalence calculation. The overall prevalence of SIM was 13.2%, with 1.6% LSBE, 6.0% SSBE, and 5.6% EGJ-SIM. Dysplasia or cancer was noted in 31% of LSBE, 10% of SSBE, and 6.4% of EGJ-SIM patients ( P ≤ 0.043). Two cancers were associated with LSBE, 1 with SSBE, and 1 with EGJ-SIM. Patients with LSBE and SSBE were predominantly white ( P ≤ 0.001), male ( P ≤ 0.009), and smokers ( P ≤ 0.004), with LSBE patients having a longer history of heartburn ( P ≤ 0.009). In contrast, patients with EGJ-SIM were similar in gender and ethnicity to the reference group, tended to be older ( P ≤ 0.05), drank less alcohol ( P ≤ 0.02), and had a higher prevalence of Helicobacter pylori infection ( P ≤ 0.05). Conclusions: The prevalence of SSBE and EGJ-SIM is similar, but each entity is 3.5 times more prevalent than LSBE. However, the prevalence of dysplasia in LSBE is 2 times greater than in SSBE and 4 times greater than in EGJ-SIM. Demographically, EGJ-SIM patients are different from patients with Barrett's esophagus and have a higher prevalence of H.pylori infection. These data help to explain the increasing incidence of adenocarcinoma of the distal esophagus and EGJ. GASTROENTEROLOGY 1999;116:277-285

The purpose of this study is to evaluate the impact of extracolonic findings when screening is undertaken by CT colonography (CTC).We performed a retrospective cohort study of patients completing a screening CTC from August 2003 to June 2006 at Walter Reed Army Medical Center. Extracolonic findings were categorized using a CTC reporting and data system that classifies findings as highly significant, likely significant, and insignificant. All final diagnoses, surgeries, malignancies, and costs of diagnostic radiology procedures were calculated for each category.Of 2,277 patients (mean +/- SD age, 59 +/- 11 years; 60% white; 56% male) undergoing CTC, extracolonic findings were identified in 1,037 (46%) patients, with 787 (34.5%) insignificant and 240 (11.0%) significant findings. Evaluation of significant findings generated 280 radiology procedures and 19 surgeries over a mean follow-up time of 19 +/- 10 months. The total cost of the radiology studies was $113,179; the studies added approximately $50 extra per patient. Seven high-risk lesions were identified (six extracolonic malignancies and one large aortic aneurysm) in patients with significant findings. CTC also identified six intracolonic malignancies and three adenomas with high-grade dysplasia. When considering extracolonic findings, CTC increased the odds of identifying high-risk lesions by 78% (nine intracolonic lesions vs 16 intracolonic plus extracolonic lesions; p = 0.0156). Of the 16 intracolonic and extracolonic high-risk lesions, 11 (69%) underwent curative resection, and 5 of 11 (44.4%) were extracolonic.CTC increased the odds of identifying high-risk lesions by 78%. CTC should be considered as an alternative to optical colonoscopy for colorectal cancer screening or as a onetime procedure to identify significant treatable intracolonic and extracolonic lesions.

To the Editor: Eosinophilic esophagitis (EoE) is an allergic-mediated disorder, which is associated with dramatic endoscopic features (rings, furrows, white plaques) in the majority of patients (1). We have observed an additional endoscopic feature commonly associated with EoE, which we believe is an important finding of this disease worth noting. When performing biopsy of the esophageal mucosa during diagnosis or surveillance, a more forceful than expected “tug” is often required to obtain a sample when pulling on the closed forceps. This may be secondary to chronic esophageal remodeling and fibrosis, a feature previously described in EoE (2).

Prospective evidence supporting lifestyle modifications, including avoidance of late evening meals, for gastroesophageal reflux disease (GERD) sufferers is lacking. The aim of this study was to determine the difference of supine esophageal acid exposure in patients consuming an early or late standard meal relative to bedtime.This is a prospective, randomized unblinded crossover trial. Thirty-two patients with typical reflux symptoms were enrolled and randomized to consume a standard meal either at 6 h or 2 h prior to going to bed for 2 consecutive nights. Acid exposure was measured for 48-h using a Bravo wireless pH system. Reflux symptom frequency and severity were recorded.Thirty patients successfully completed the study (63% male, 70% white, mean age 46 [24-74], mean body mass index [BMI] 28 kg/m(2)[18-40]). EGD revealed esophagitis in 37% and hiatal hernia (HH) in 47% of patients. Following the late evening meal, there was significantly more supine reflux (P= 0.002) when compared to the early meal. Significantly more supine reflux was also noted following the late evening meal in patients with HH, in overweight individuals (25/= BMI/= 29.9), and those reporting heartburn as their chief complaint. Patients with esophagitis had more supine reflux following both the late and early evening meals. There was no significant difference in total symptom score between the 2 days.GERD patients consuming a late-evening meal had significantly greater supine acid reflux compared to when they consumed an early meal, especially in overweight patients, and in patients with esophagitis or HH. These findings support the recommendations to our GERD patients to eat dinner early and to lose weight.

on the 8 point score was r=.64. There was no correlation between shifts in religiosity and IBD symptom scores, or in IBD symptom shift (years 1-4 compared to years 8-10), or with pain scores (SF-36) at years 1-4. IBD symptoms did not drive people to or from religion. Spiritual values gave strength to face everyday difficulties: A lot for 26%, Some for 21%, A little for 20%, Not at all for 32%. Spiritual values helped in understanding the difficulties of life: A lot, 21%; Some, 25%; A little, 21%; Not at all, 32%, Missing, 1%. Doctors were seen as the most important factor in health, with a mean of 4.2 out of 6, followed by self, score of 3.5, fate score of 2.9 and finally God, score of 1.7. Doctor health locus of control correlated with cross-sectional IBDQ bowel symptoms r = -18 (p = .02), Self health locus of control showed a correlation of r = -.16 (p = .04). Conclusions Spirituality was used as a coping strategy but believing that oneself and one's doctors are in charge of health correlated with lower levels of symptoms. Belief that fate or God is in charge is neither good nor bad.

BACKGROUND: In inflammatory bowel disease (IBD) care non-adherence to out-patient visits can be detrimental for various reasons including the lack of monitoring drug-related side effects, disease progression and complications. The actual focus on adherence is mainly addressed to evaluate optimal therapy assumption. The aim of our study is to evaluated the determinants of non adherence to medical therapy and to out-patients follow up.METHODS: Patients selected from our IBD database not referring for regular follow-up visits in the last 24 months have been compared to patients regularly attending the clinic in a ratio 2:1. A structured questionnaire has been administered during a telephone call by the nurse in order to assess: disease activity (Modified Truelove Witts Severity Index MTWSI in UC, Harvey Bradshaw Index HBI in CD) and adherence to medical therapy (Morisky-8 scale: 55 yrs (OR=4.06 IC =1.77-9.27), with UC (OR=1.71, IC=1.00-2.91) and with disease duration less than 12 months (OR= 2.52, IC 0.88-7.16). The Morisky score was significantly lower in non-adherent than in adherent patients (p= 0.003). Higher risk of non-adherence was found in patients with a Morisky score lower than 6 (OR 3.46 -IC=1.89-6.33) or equal to 8 (OR = 5.75IR 2.53-13.06), in females (p=0.000), in younger patients (p=0.007) and in CD vs UC (p=0.003). The 30% of non-adherence patients after the call made by the nurse accepted to return to out-patient visits. CONCLUSIONS: The majority of the patients did accept positively the telephone call. Patients not-attending regular follow up visits are at high risk of non-adherence to medical therapy as well. Females, patients older than 55 years, patients with UC and a short disease duration are at higher risk of out-patient non-adherence. Efforts need to be addressed to improve global adherence, included regular attendance of follow up visits. Reinforcement and motivation by the IBD nurse may help to increase patients' empowerment.

Attention has focused on whether normalization, regression, and development of dysplasia and cancer in specialized intestinal metaplasia (SIM) differ among long-segment Barrett's esophagus (LSBE), short-segment BE (SSBE), and esophagogastric junction SIM (EGJSIM). We prospectively followed a cohort of SIM patients receiving long-term antisecretory medications to determine: (a) histologic normalization (no evidence of SIM on biopsy), (b) change in SIM length, (c) incidence of dysplasia and cancer, and (d) factors associated with normalization.One hundred forty-eight patients with SIM were identified in our original cohort. Of these, 60.5% (23/38) LSBE, 69.8% (44/63) SSBE, and 72.3% (34/47) EGJSIM patients underwent repeat surveillance over a mean 44.4 +/- 9.7 months. Demographic, clinical, and endoscopic data were obtained.(a) With long-term, antisecretory therapy, normalization occurred in 0/23 LSBE, 30% (13/44) of SSBE, and 68% (23/34) of EGJSIM (P0.001). (b) Normalization was more likely with EGJSIM (odds ratio [OR] 6.7, CI 2.3-19.3, P= 0.005), female gender (OR 7.3, CI 2.3-23.1, P= 0.001), or absence of hiatal hernia (OR 2.9, CI 1.02-8.06, P= 0.002). (c) A significant decrease in mean SIM length was noted for the entire population (2.5 +/- 0.3 to 2.13 +/- 0.3 cm, P= 0.004). (d) Follow-up incidence of dysplasia and cancer was 26.1% (3 indefinite, 2 low-grade dysplasia [LGD], 1 cancer) for LSBE, 6.8% (2 indefinite, 1 LGD) for SSBE, and none for EGJSIM (P0.004).(a) Normalization of SIM occurs most frequently in EGJSIMSSBELSBE. (b) Factors associated with normalization favor less severe GER and shorter segments of SIM. (c) Surveillance of LSBE results in the greatest yield for identifying dysplasia and cancer.

Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory condition which causes esophageal remodeling and stricture formation over time. Aim: To explore the natural course of symptoms, endoscopic findings to include stricture development, and histology in EoE patients. Methods: EoE adult patients (age > 18 years) were prospectively enrolled from databases of two medical centers (Walter Reed and Mayo Clinic Jacksonville). All EoE patients were diagnosed per recent consensus guidelines. All patients completed index and follow-up symptom surveys. Endoscopic features (rings, furrows, plaques, strictures) and histology from index and follow-up endoscopies were recorded. Disease behavior was classified as inflammatory if endoscopic findings demonstrated furrows or white plaques and classified as fibrostenotic if endoscopic findings included rings or strictures. Results: 165 EoE patients were identified, mean age 42 ± 14 years; 88.5% Caucasian and 70% male. Median (range) duration of symptoms prior to EoE diagnosis was 66 months (0.1-425). Median follow-up time was 19.2 months (0.9-120). At index, the majority (124/165, 75%) presented with fibrostenotic EoE and 25% (41/165) presented with inflammatory disease. Patients who presented with a stricture had a significantly longer duration of symptoms prior to diagnosis (130 vs 86 months, p=0.011). Patients with fibrostenotic features had more food allergies than those with inflammatory disease (23.4% vs. 4.9%, p=0.010); otherwise, other allergic conditions were similar. At index endoscopy, significantly more patients with fibrostenotic disease had dense proximal eosinophilia (>15 eos/hpf) than patients with inflammatory disease (81.1% vs. 64.3%, p=0.015), but were similar in degree of distal eosinophilia (86.4% vs. 85.3%, p=0.415). Over time, disease behavior remained unchanged in the majority (87.3%, 144/165) of patients. Of the 41 patients presenting with inflammatory disease, 21 patients (51%) developed fibrostenotic features with 15 of these developing a stricture at follow-up endoscopy. Patients who developed fibrostenosis had more dense eosinophilia on biopsies (proximal 68.4% vs. 20.0%, p=0.015; distal 68.2% vs. 36.8%, p=0.049) than those who maintained inflammatory features. The majority of patients (68%) reported improved symptoms over time regardless of their disease behavior. Conclusions: The majority of patients with EoE present with or develop fibrostenotic disease. Duration of symptoms was significantly greater in patients presenting with stricture. Dense proximal esophageal eosinophilia is associated with the presence of fibrostenosic disease and higher levels of eosinophilia may predict transformation from inflammatory to fibrostenotic disease.

Background: Patients are frequently referred for evaluation of extraesophageal (EXT) symptoms (cough, hoarseness, globus sensation) presumably related to gastroesophageal reflux disease (GERD). 24 hour pH/impedance is the most sensitive test for the diagnosis of GERD, however limited data exist in examining the relationship between distal and proximal impedance episodes in patients with EXT symptoms versus classic reflux symptoms. Aim: To compare the number and percentage of proximal impedance episodes in patients with EXT symptoms to those with classic GERD symptoms undergoing 24 hour pH/impedance testing. Patients & Methods: A retrospective review of adult patients undergoing esophageal manometry and 24 hour pH/impedance studies off acid suppressing therapy between 20062011 was performed. Indications for these studies included typical GERD symptoms (heartburn and regurgitation) or atypical symptoms (cough, asthma, hoarseness or globus sensation). GERD was defined using the validated Johnson-DeMeester (JD) score. The results of the esophageal manometry and 24 hour pH/impedance studies between the classic GERD and EXT groups were compared using Chi squared test and students independent t-test. Continuous data is expressed as means (sd). Results: A total of 220 patients were included in the analysis [172 GERD vs. 48 EXT]. GERD and EXT groups were similar in race and gender, however GERD patients were younger than EXT patients [46 (13) years vs. 50 (8) years, p = 0.048]. There was no significant difference between GERD and EXT in the mean number of proximal impedance episodes [33 (22) vs. 28 (22), p = 0.188], the percentage of proximal impedance episodes migrating from the distal esophagus [55 (20) % vs. 50 (17) %, p=0.178), or the mean number of distal impedance episodes [57 (33) vs. 49 (34), p = 0.157]. There was no significant difference between GERD and EXT with regards to mean lower esophageal sphincter pressures [13.3 (11) mmHg vs. 15.3 (7.8) mmHg, p = 0.251] or mean esophageal amplitude [95.4 (44.6) mmHg vs. 84.9 (41.0) mmHg, p=0.146]. Based on 24 hour pH monitoring there was no significant difference between the classic GERD and EXT groups in the JD scores [22.6 (33) vs 17.8 (22), p = 0.358] or percent total time pH ,4 [4.6 (5.3) vs. 4.2 (5.3), p = 0.642]. There was a significant correlation between the number of proximal and distal episodes between the two groups (R = 0.724, p , 0.001). Conclusion: Patients with EXT symptoms are similar to classic GERD patients in the number proximal impedance reflux episodes and percentage of distal episodes migrating to the proximal esophagus. Furthermore, both groups have a similar degree of acid reflux.

Background: A subset of patients with gastroesphageal reflux disease (GERD) symptoms has erosive esophagitis (E+) on upper endoscopy (EGD). Those whose symptoms persist despite proton pump inhibitor (PPI) therapy may further undergo testing with combined multichannel intraluminal impedance and 24 hour pH (MII-pH) to determine if acid is adequately suppressed and if non-acid reflux plays a role in symptoms. Aim: To determine which factors on esophageal manometry (EM) and MII-pH were associated with E+. A secondary aim is to examine the relationship between the degree of E+ and 24 hour pH score. Methods: A clinical database was searched for EM and MII-pH studies performed off acid suppressive therapy between 2006 and 2011. Patients referred for evaluation had typical GERD symptoms (heartburn or acid regurgitation) or atypical symptoms (chest pain, cough, hoarseness, dysphagia or dyspepsia). Data was further extracted to patients who had an EGD performed within 6 months of the MII-pH study. Patients with a normal esophagus on EGD or eosinophilic esophagitis were excluded from this study. Erosive esophagitis was defined and graded according to the Los Angeles classification system. A Johnson-DeMeester score of ≥22 was considered diagnostic for GERD by pH testing. An abnormal impedance study was defined as .73 distal reflux episodes. Categorical data was expressed as percentages and continuous data as means and standard deviation. Fisher's exact tests and parametric statistics were used to analyze data. A p-value ≤ 0.05 was considered statistically significant. Results: Of 348 patients identified in the database, 21 patients had E+ (67% were males, 76% were Caucasians and 79%hadGrade A esophagitis). Themajority of patients (95%)were previously treated with PPI, however all cases were performed off PPI for at least one week. Significantly more patients with E+ had hiatal hernias compared to patients without esophagitis (E-), (43% vs 19%,p=0.021). E+ patients had significantly more acid reflux episodes than Epatients (46±40 vs 27±26, p=0.011). There was also significantly more distal impedance episodes (73±59 vs 49±27,p=0.014) and decreased lower esophageal sphincter (LES) pressure in E+ patients (12±11 mm Hg vs 15±11 mm Hg, p=0.012). E+ and Epatients had similar degree of upright acid reflux (pH:4.91±4.0 vs pH:4.98±6.3, p=0.224). E+ patients had more supine acid reflux than Epatients without statistical significance (pH:5.8 ±14.8 vs pH:2.4±7.3, p=0.177). Conclusions: Hiatal hernia, decreased LES pressure, and total number of reflux episodes were associated with E+. There was a trend in more supine reflux in E+ patients, however no difference in upright reflux was observed between the two groups. Due to the small number of higher grade E+ cases, a correlation could not be made between severity of degree of E+ and 24 hour pH score.

Background: Gastroesophageal reflux disease (GERD) is thought to be the most common cause of Non-Cardiac Chest Pain (NCCP), present in up to 60% of these patients. Esophageal manometry (EM) and 24 pH with impedance are commonly used in the evaluation of NCCP once an empiric proton pump inhibitor (PPI) trial has failed. However, the diagnostic utility of EM and 24 hour pH with impedance in NCCP patients has not been well studied. Aim: To evaluate the utility of esophageal EM and 24 hour pH with impedance in the evaluation of NCCP Methods: A retrospective chart review was performed on patients referred for the evaluation of NCCP. All patients underwent EM and 24-hour pH with impedance studies between 2006 and 2011. Esophageal manometry results were reviewed for underlying neuromuscular dysfunction and motility disorders. 24 hour pH with impedance data was reviewed for the presence or absence of acid or non-acid reflux. The validated JohnsonDeMeester (JD) score (normal , 22) was used to assess for the presence of GERD. Additionally, correlation between chest pain and reflux events was assessed. Prior endoscopic reports were reviewed for the presence of esophageal changes, such as, erosive esophagitis, salmon colored tongues, Schatzki's ring or changes suggestive of eosinophilic esophagitis. Categorical data was expressed as percentages and continuous data as means and standard deviation. Fisher's exact tests and parametric statistics were used to analyze data. A p-value ≤ 0.05 was considered statistically significant. Results: Esophageal manometry and 24-hour pH with impedance studies of 112 patients were reviewed (52.3% male, 60.4% Caucasian, mean age 51 ± 13.4, mean BMI 27.8 ± 5.1). Of the cohort, 65% of EM studies were normal (mean DCI 1574 ± 1107, mean lower esophageal sphinchter (LES) pressure 14.91 ± 9.75). Of the 34.5% abnormal manometry studies, ineffective esophageal motility disorder (n=25), hypotensive LES (n=5), nutcracker esophagus (n=4), and hypertensive LES (n=1) were present. Ninety percent (n= 88) had normal 24 hour pH studies (mean JD score 9.86 ¬¬± 17.9). Eighty-six percent (n= 88) had normal impedance studies and only 6.25% of patients (n=7) had at least one episode of chest pain correlating with acid or non-acid reflux. On endoscopy, 16% of patients (n=18) had esophageal changes suggestive of reflux and 8% (n=9) had a hiatal hernia. Conclusion: The majority of patients who underwent EM and 24 hour pH with impedance examination had normal studies. The role of these studies for the evaluation of NCCP is limited.

To the Editor: We read with interest the article by Sperry et al. (1) describing the influence of race and gender on the presentation of eosinophilic esophagitis (EoE). EoE is commonly thought of as a disease predominantly affecting white men (2). In their study of 208 EoE cases, some differences were noted in presentation based on race and gender. Specifically, Caucasian patients were significantly older than African Americans (27 vs. 19 years of age, P=0.05) and more likely to have concentric rings (41% vs. 12%, P=0.05). At our institution, we also reported some racial differences with regards to the clinical presentation in 198 EoE patients (3).