Sage Journals: Discover world-class research

Abstract

Background

Eosinophilic esophagitis (EoE) affects health-related quality of life (HRQoL). Data on determinant factors and the influence of dietary interventions are scarce.

Objective

The objective of this article is to evaluate factors influencing HRQoL in adult EoE patients.

Methods

We conducted a multicenter observational, cross-sectional study. A validated Spanish version of the self-administered Adult Eosinophilic Esophagitis Quality of Life (EoE-QoL-A) questionnaire and specific surveys were used. Multiple linear regression was used to identify and quantify determinant factors of HRQoL.

Results

Responses provided by 170 patients were assessed (73.5% male; mean age 33.5 ± 11.4 years). Overall mean score for the EoE-QoL-A index was 1.4 ± 0.8, with no differences between patients on dietary or pharmacological therapy (1.82 ± 0.8 vs. 1.62 ± 0.8; p = 0.132). Disease anxiety showed the highest mean score (2.13 ± 0.9 points), followed by choking anxiety (1.97 ± 1.1); social impact (1.77 ± 1.1), and diet/eating impact (1.68 ± 0.9). Emotional impact had the lowest rating (1.15 ± 0.9), and only with a significantly worse score in patients under dietary restrictions. Recurrent food impaction, a higher educational level, dietary interventions and symptom duration were all independent determinant factors significantly impairing HRQoL. Female gender and empiric elimination diets negatively influenced on diet/eating impact.

Conclusion

Recurrent food impaction, dietary interventions and symptom duration are the most important factors influencing the perception of HRQoL in adults with EoE.

Keywords

Eosinophilic esophagitis quality of life adult questionnaire

Introduction

Eosinophilic esophagitis (EoE) is a chronic esophageal inflammatory disease, characterized clinically by symptoms related to esophageal dysfunction, and histologically by eosinophil-predominant inflammation.^1,2 EoE affects children and young adults³ and has rapidly grown over the past decade, especially in developed countries.⁴ Presently, it represents the second leading cause of chronic esophagitis after gastroesophageal reflux disease (GERD)⁵ and the main cause of dysphagia in children and young adults.⁶

From a clinical point of view, predominant clinical manifestations in EoE are chronic dysphagia and food impaction in adult patients, whereas children usually present with food refusal, vomiting, GERD-like symptoms, abdominal pain and even failure to thrive.¹ Consequently, EoE may negatively affect the health-related quality of life (HRQoL) of patients and their families by causing emotional distress, limiting normal feeding and restricting social activities.^7–9 Disease activity, as determined by the severity of symptoms and biological markers,^10,11 as well as disease duration⁸ have been demonstrated to affect patients HRQoL. Adult patients with dysphagia develop adaptive strategies to cope with chronic symptoms, including selective food avoidance, slow-paced eating and increased water drinking.¹² The frequent diagnostic delay in most EoE patients, usually of several years after the onset of initial symptoms,¹³ also aggravates the disease. The duration of the untreated disease directly correlates with the presence of fibrostricturing findings in the esophageal lumen, including narrow-caliber esophagus and strictures.^14,15

Currently, EoE is recognized as a particular form of food allergy, in which esophageal inflammation and symptoms remit after avoidance of exposure to potential food triggers.^16,17 Dietary therapy constitutes a main pillar in the management of EoE patients, which is able to achieve and maintain remission in a high proportion of patients.¹⁷ Like in other food allergies, long-term management of EoE may rely on avoidance of food triggers. As such, dietary restrictions may result in psychological burden for patients and their relatives that can result in stress, anxiety, and impairment of socialization, with a negative impact on their daily life.¹⁸ However, the impact of food avoidance on QoL of patients with EoE has not been evaluated.

HRQoL constitutes one of the most important primary patient-reported outcome (PRO) measures for assessing an individual’s burden of any given chronic condition, and provides valuable information for developing interventions to promote the greatest possible well-being as well as a better optimization of health care resources.¹⁹ Identifying the aspects that influence HRQoL in EoE might allow implementation of strategies to reduce the impact of the disease.

In this study we aimed (1) to determine for the first time the HRQoL in a representative sample of Spanish adults with EoE, and (2) to identity determinants of impaired HRQoL, including the effect of dietary restrictions.

Materials and methods

Study population and procedures

A prospective cross-sectional observational study was conducted in 2014 at eight different tertiary centers located in several regions of Spain. The diagnosis of EoE was based on esophageal dysfunction symptoms in conjunction with characteristic histopathological findings (≥15 eosinophils per high-power field) that persisted after an eight-week trial with proton pump inhibitor (PPI) therapy at double doses.²⁰ Male and female patients aged 18 years or older and consecutively recruited provided written informed consent to participate in the study. Demographic data including age, gender, education level, residence characteristics, as well as comorbidities, concomitant allergic disorders, EoE symptoms and current therapy, were collected in a standardized fashion.

QoL measures

The EoE-QoL-A is a validated instrument to measure QoL developed by Taft et al. specifically for adult patients with EoE.²¹ The initial 37-item symptom inventory was later refined to a 30-item scale subsequently published by the same researchers.²² A translated and validated Spanish version of this questionnaire²³ was used.

For the purposes of this study, 24 items applicable for all patients were scored, falling into five following subscales: eating/diet impact (four items), social impact (four items), emotional impact (eight items), disease anxiety (five items) and swallowing anxiety (three items). Six additional items were completed by patients undergoing elimination diet only (that were scored within the eating/diet impact subscale). The EoO-QoL-A score ranges from 0 (very good QoL) to 4 (very poor QoL) for every item. The final score was the weighted average of all QoL subscales, following previously used methods.¹¹

Statistical methods

Results for continuous variables are expressed as the mean and SD or as the median and interquartile range (IQR); qualitative variables are presented as absolute and relative frequencies. The χ²-test (Fisher’s exact test, where appropriate) or Student’s t-test (analysis of variance (ANOVA) test, where appropriate) were used to compare qualitative and quantitative variables, respectively. Spearman test was used for correlation analysis of nonparametric variables and Pearson test for parametric variables

Variables with a p value <0.1 in the univariable analysis were selected for the multivariable analysis. Variables were selected by backward selection. Multiple linear regression analysis with backward selection was used to model the relationship between the factors analyzed and QoL in EoE patients. Multiple lineal regression was performed for the overall series of patients for the EoE-QoL-A questionnaire score overall and within each subscale of it. The selection criterion of p < 0.1 was used for elimination of a variable. Analyses and summaries were carried out with the PASW statistical program (version 18.0; SPSS Inc, Chicago, IL, USA). A significance level of 0.05 was used throughout.

Results

Study participants

A total of 170 adult patients diagnosed with EoE filled out the questionnaire correctly and were included. The baseline characteristics are shown in Table 1. A total of 125 men (73.5%) and 45 women (26.5%) with a mean age of 33.35 years old (SD 11.4; range 18 to 77.5) were evaluated. No significant differences were observed in terms of age (p = 0.413), diagnostic delay from the onset of EoE symptoms (p = 0.865), and diagnostic delay of EoE between men and women (p = 0.790), or between patients with or without dietary-based therapeutic interventions (p = 0. 478) (Table 1).

Table 1.

Demographic and clinical characteristics of adult patients with eosinophilic esophagitis.

Characteristics	All patients (n = 170)	Dietary restriction (n = 102)	No dietary restriction (n = 68)	p
Age (SD)	33.35 (11.4)	33.9 (10.6)	32.9 (12.7)	0.608
Gender (M/F)	125 (73.5%)/ 45 (46.5%)	73 (71.6%)/ 29 (28.4%)	76.5 (76.5%)/ 16 (23.5%)	0.478
Overall time of evolution, years (SD; range)	8.7 (7.7; 0–37.7)	9 (7.6)	8.4 (7.9)	0.636
Diagnostic delay, years (SD; range)	6.4 (7.6; 0–35.6)	6.7 (7.8)	6 (7.3)	0.565
Number of endoscopes (SD; range)	5.2 (4.5; 1–23)	6.1 (5.2)	3.7 (3)	<0.001
Number of endoscopes under propofol sedation (SD; range)	3.5 (4.1; 0–19)	4.4 (4.5)	2 (2.6)	<0.001
Education level
Primary	22 (13.7%)	11 (11.1%)	11 (17.7%)
High school	66 (41%)	38 (38.4%)	28 (45.2%)	0.205
University	73 (45.3%)	50 (50.5%)	23 (37.1%)
Symptoms at diagnosis
Food impaction	133 (78.2%)	82 (80.4%)	51 (75%)	0.404
Dysphagia	131 (77.1%)	79 (75.5%)	52 (76.5%)	0.882
Heartburn	63 (37.1%)	35 (34.3%)	28 (41.2%)	0.364
Regurgitation	22 (12.9%)	11 (10.8%)	11 (16.2%)	0.305
Chest pain	22 (12.9%)	14 (13.7%)	8 (11.8%)	0.709
Vomiting	6 (3.5%)	5 (4.9%)	1 (1.5%)	0.404
Working status
Student	21 (13%)	13 (13.4%)	8 (12.5%)
Employed	115 (71.4%)	68 (70.1%)	47 (73.4%)
Unemployed	17 (10.6%)	10 (10.3%)	7 (10.9%)	0.506
Housewife/Househusband	4 (2.5%)	4 (4.1%)	0
Retired	3 (1.9%)	1 (1%)	2 (3.1%)
Marital status
Partnered	85 (53.5%)	55 (55.6%)	30 (50%)
Separated	1 (0.6%)	0	1 (1.7%)	0.556
Widow/Widower	2 (1.3%)	1 (1%)	1 (1.7%)
Personal allergic background
Aeroallergen sensitization	92 (55.8%)	57 (57.6%)	35 (57.4%)	0.980
Food sensitization	83 (50.3%)	61 (63.5%)	22 (36.1%)	<0.001
Allergic rhinitis	82 (50%)	52 (52.5%)	30 (50%)	0.757
Bronchial asthma	68 (41.5%)	46 (45.1%)	22 (36.7%)	0.294
Dermatitis	19 (11.6%)	12 (12.9%)	7 (11.9%)	0.850
Drug allergy	14 (8.6%)	10 (13%)	4 (7.3%)	0.293
Angioedema	8 (4.9%)	3 (3.2%)	5 (8.5%)	0.262
Drug treatment
Any	109 (64.1%)	51 (50%)	58 (85.3%)	<0.001
Topical steroids	73 (42.9%)	40 (39.2%)	33 (48.5%)	0.229
PPI	64 (37.6%)	32 (31.4%)	32 (47.1%)	0.039
Montelukast	4 (2.4%)	4 (3.9%)	0	0.151
Dietary interventions
Any	102 (60%)	102 (60%)	–	–
Empiric food elimination	60 (35.3%)	60 (35.3%)	–	–
Endoscopic dilation
Dilated patients (%)	16 (9.4)	9 (8.8)	7 (10.3)	0.748
Mean number of dilations per patient (SD; range)	2.2 (3.3; 1–14)	1.44 (1)	3.14 (4.8)	0.316

SD: standard deviation; M/F: male/female; PPI: proton pump inhibitors.

Regarding EoE treatment, 102 patients (60%) had been prescribed some kind of dietary restriction. No differences were observed in the demographic data (including educational level, employment or marital status, or size of the residence) between patients with or without dietary-based therapeutic interventions, despite a trend toward a lower QoL overall among patients under food restriction. Family and self-reported personal allergic background were similar in patients with and without dietary restrictions, except for the presence of associated food sensitizations that were more frequent in patients under food restriction-based treatment. Patients receiving dietary interventions underwent a significantly higher number of endoscopies, due to individual food reintroduction followed by endoscopy in responders to diet.

HRQoL levels

The average overall HRQoL level in our sample, as assessed with the EoE-QoL-A questionnaire, was 1.74 ± 0.8 (range 0.11–3.71), with no significant overall differences among patients with and without dietary restrictions (1.82 vs. 1.62; p = 0.132) (Table 2).

Table 2.

Mean quality of life score ± standard deviation (rank) in our series of 170 adult patients with eosinophilic esophagitis, determined by the Adult Eosinophilic Esophagitis Quality of Life (EoE-QOL-A) instrument, and differential impact in patients undergoing some kind of dietary restriction compared with those who were not.

Five-factor structure	All patients (n = 170)	Dietary restriction (n = 102)	No dietary restriction (n = 68)	p
Overall EoE-QoL score	1.74 (0.8; 0.11–3.71)	1.82 (0.8)	1.62 (0.8)	0.132
Eating/diet impact	1.68 (0.9; 0–4)	1.79 (0.96)	1.52 (0.9)	0.069
Social impact	1.77 (1.1; 0 – 4)	1.86 (1.2)	1.70 (1.1)	0.394
Emotional impact	1.15 (0.9; 0–3.75)	1.29 (0.9)	0.92 (0.8)	0.009
Disease anxiety	2.13 (0.9; 0–4)	2.20 (1)	1.03 (0.9)	0.266
Choking anxiety	1.97 (1.1; 0–4)	2.99 (1.1)	1.95 (1.1)	0.839

Likewise, no differences in HRQoL were observed between men and women (1.73 ± 0.8 vs. 1.8 ± 0.9, respectively; p = 0.617) nor among age groups in our sample.

As for the five dimensions included in EoE-QoL-A scale, Disease anxiety showed the highest mean score (2.13 ± 0.9), followed by choking anxiety (1.97 ± 1.1), social impact (1.77 ± 1.1) and diet/eating impact (1.68 ± 0.9). Emotional impact had the lowest rating, namely 1.15 ± 0.9. This was the only dimension that obtained a significantly higher impact in patients with dietary restrictions compared to those without (1.29 ± 0.9 vs. 0.92 ± 0.8, p = 0.09) (Table 2).

With regards to individual items, numbers 1 (“I have to be cautious about eating because I have EoE”), 15 (“I worry that EoE will get worse or turn into something else”), and 12 (“I worry about never identifying the cause of my EoE”) received the greater scores. In contrast, items 23 (“I feel isolated from others because of my EoE”) and 9 (“I find it embarrassing when I have to make special requests at restaurants”) received the lowest mean scores, as shown in Supplementary Table 1).

HRQoL determinants

Table 3 shows the results of the linear regression analyses using the EoE-QoL-A score values as the dependent variables, and included the independent variables identified in univariate analyses (Supplementary Table 2). Food impaction, a higher educational level (including high school and university, as compared to primary school), dietary restriction and length from onset of symptoms (or disease evolution) were the strongest determinants (p < 0.05) for a worse EoE-QoL-A overall score (Table 3).

Table 3.

Multivariate analysis by means of multiple linear regression between quality of life assessed by the Adult Eosinophilic Esophagitis Quality of Life (EoE-QoL-A) instrument and its five dimensions, with regard to all determinant factors.

Variables	β-coefficient (95% CI)	p
(a) Overall EoE-QoL-A score
(Constant)	0.573 (0.014; 1.132)	0.045
Higher educational level	0.410 (0.009; 0.810)	0.045
Food impaction	0.348 (0.010; 0.687)	0.044
Drug treatment for EoE	0.300 (–0.017; 0.616)	0.063
Dietary restriction	0.303 (0.001; 0.607)	0.049
Length of disease evolution	0.022 (0.005; 0.040)	0.013
(b) Eating/diet impact
(Constant)	0.406 (–0.165; 0.976)	0.162
Female gender	0.472 (0.136; 0.808)	0.006
Concomitant food allergy	0.176 (–0.025; 0.378)	0.086
Food impaction	0.485 (0.106; 0.865)	0,013
Regurgitation	0.384 (–0.067; 0.836)	0,095
Higher educational level	0.531 (0.086; 0.976)	0,020
Empiric food elimination diet	0.409 (0.094; 0.723)	0,011
(c) Social impact
(Constant)	0.558 (–0.047; 1.164)	0,070
Food impaction	0.550 (0.101; 0.999)	0,017
Drug treatment for EoE	0.453 (0.032; 0.874)	0,035
Dietary restriction	0.368 (–0.033; 0.770)	0,072
Length of disease evolution	0.037 (0.014; 0.061)	0,002
(d) Emotional impact
(Constant)	0.639 (0.037; 1.242)	0,038
Higher educational level	0.447 (0.021; 0.874)	0,040
Food impaction	0.415 (0.047; 0.784)	0,027
Regurgitation	0.434 (0.001; 0.868)	0,050
Drug treatment for EoE	0.343 (0.006; 0.680)	0,046
Dietary restriction	0.600 (0.275; 0.925)	<0,001
Esophageal dilatation	0.435 (–0.063; 0.932)	0,086
Length of disease evolution	0,017 (–0.002; 0.036)	0.080
(e) Disease anxiety
(Constant)	1.774 (1.151; 2.396)	<0,001
Food impaction	0.342 (0.001; 0.696)	0.049
Regurgitation	0.461 (0.012; 0.910)	0.044
Drug treatment for EoE	0.603 (0.255; 0.951)	0.001
Dietary restriction	0.417 (0.079; 0.754)	0.016
Higher educational level	0.392 (–0.050; 0.833)	0.082
Length of disease evolution	0.025 (0.005; 0.044)	0.013
(f) Choking anxiety
(Constant)	1.632 (1.230; 2.034)	<0.001
Food impaction	0.482 (0.032; 0.932)	0.036

CI: confidence interval. Boldface values denote the variables that reached statistical significance in the mutivariate analysis.

Regarding the Eating/diet impact dimension, female gender and a higher education level directly determined an impaired HRQoL. Having presented symptoms of food impaction and being under an empiric elimination diet were additional independent variables that were significantly associated with worse QoL perception.

The Social impact dimension of EoE was significantly determined by food impaction symptoms, drug treatment and length of disease evolution (all with p < 0.05). An increased Emotional impact of EoE was strongly determined by a higher educational level, EoE symptoms (including both food impaction and regurgitation) and the need of therapy for EoE (including food restriction, drug therapy and esophageal dilation, the first two reaching statistical significance).

Disease anxiety was significantly worse among patients with symptoms of food impaction and regurgitation, drug treatment and dietary restriction, and length of disease evolution. Finally, having experienced food impaction was the only independent factor that determined choking anxiety.

Discussion

The present study assessing HRQoL in adult EoE patients shows that EoE symptoms at diagnosis (specially food impaction), length of disease evolution, therapies for EoE and patients’ characteristics are the major determinants for this PRO measure. They all contribute in a different way to each one of the five dimensions resulting in the overall EoE-QoL-A score. Although recurrent food impaction significantly affected most of the EoE-QoL-A dimensions, female gender exclusively affected the eating/diet impact dimension.

Our research reinforces symptoms as a strong determinant for disease-specific HRQoL, as previously shown in a recent research,¹¹ that assessed overall EoE symptoms by measured with the Eosinophilic Esophagitis Activity Index (EEsAI) symptoms score. The EEsAI score is a seven-item instrument that derives five components of the overall score (frequency of trouble swallowing, duration of trouble swallowing, swallowing-associated pain, the visual dysphagia question score and the avoidance, modification and slow eating score), providing a total score ranging from 0 (inactive EoE) to 100 points (very active EoE).¹² Because the EEsAI does not assess the specific symptoms referred to by patients, our research adds to the current knowledge that certain specific symptoms at diagnosis, including food impaction and regurgitation, significantly contributed to the perception of HRQoL by adult EoE patients. Additionally, a long-standing duration of symptoms, defined as the length of time from the onset of initial symptoms of EoE to the moment of answering the questionnaire, even before the effective diagnosis of the disease, was significantly associated with worse HRQoL scores, significantly affecting disease anxiety, social impact and overall EoE-QoL-A score. A similar association has also been shown in patients with celiac disease, for which long-standing symptoms and a previous diagnosis of functional disorders were associated with worse HRQoL.^24,25 In fact, a diagnostic delay of up to six years from the onset of symptoms is commonly recognized in EoE, both in children and adults.^13,15 Based on these results, early diagnosis of the disease may help in resolving long-lasting QoL impairments in EoE.

Adult patients on a dietary-based therapy for EoE did not exhibit worse EoE-QoL-A overall scores compared to those who were receiving drugs for EoE. These data are conflicting with recent results in children with EoE who were assessed with the PedsQL™ EoE module: Children under diet-elimination therapy exhibited worse QoL scores, compared to those with no restrictions, reaching statistical significances both in child self-reported and parent proxy-reported subscales.²⁶ Differences in the capacity of adapting or even accepting food restriction as a relevant measure to improve EoE may explain these differences between children and adults. However, our findings show that dietary restrictions led to a significantly worse emotional impact as compared to nondietary exclusions (p = 0.009), but this fact seemed not to contribute to the overall HRQoL perception. Previous studies have demonstrated that patients under dietary restriction usually exhibit an impaired QoL compared to healthy controls, as documented in several disorders, including immunoglobulin (Ig)E-mediated food allergy^27–29 and celiac disease.³⁰ In addition, numerous studies in pediatric and adult celiac patients have repeatedly shown that a gluten-free diet achieves not only symptom relief, but also improvements in HRQoL.^30–33 We did not evaluate the efficacy of dietary intervention in every patient who participated in our survey, and studies evaluating this issue are currently lacking. It is tempting to speculate whether identification and long-term exclusion of individual food triggers could also lead to improvements in HRQoL, as suggested in a recent study that assessed EoE with a nonspecific instrument.⁹

Our study analyzed all determinant factors for each of the scores constituting the five subscales that integrate the EoE-QoL-A questionnaire. Among them, food impaction was the most relevant, significantly influencing the five subscales. In fact, it was the only one that significantly determined Choking anxiety. An additional symptom, regurgitation, was a significant determinant of both Emotional impact and Disease anxiety. Interestingly, no additional symptom at diagnosis had a significant role in determining HRQoL of adult EoE patients. Unfortunately, our research did not assess the influence of current symptoms manifested by our EoE patients on the EoE-QoL-A overall score, because at the moment no validated instrument to assess esophageal symptoms is available in the Spanish language (e.g. a Spanish version of the EEsAI score). However, our research poses the hypothesis that some specific EoE symptoms at the time of disease onset may determine the emotional impact on QoL of EoE patients and generate disease anxiety, even when the disease has been diagnosed and a treatment has been instituted. Disease duration was also a significant determinant for HRQoL in several subscales of the EoE-QoL-A questionnaire. Therapy for EoE, including food restriction, drug therapy and even endoscopic dilation (although this last one did not have statistical significance) influenced Social impact, Emotional impact and Diet/eating impact of EoE; specifically, an empiric food elimination impaired the Diet/eating impact subscale in our patients. Certainly, the empiric six-food elimination diet, which has been demonstrated to be a highly effective and reproducible dietary option for inducing disease remission in EoE patients,³⁴ had a deleterious effect on HRQoL of our EoE patients; the number of foods excluded in each respondent patient was not recorded, preventing us from evaluating this fact properly. In any case, and despite the fact that scores for Diet/eating impact tended to be worse among EoE patients under food restriction compared to those who were not, the difference was not significant. Finally, a higher education level and female gender determined a worse HRQoL perception. The relationship of HRQoL with education level has shown to behave differently for several diseases; while both positively correlated in bronchial asthma exacerbations,^35,36 they did the opposite in inflammatory bowel disease.³⁷ In our study, patient gender was shown to be an independent factor associated with the perception of HRQoL in EoE that had a significant effect on the Diet/eating impact dimensions of the EoE-QoL-A questionnaire, with women providing worse scores. One speculative explanation for this may be the greater difficulty perceived by the Spanish women in our series in finding substitutions or alternatives for foods when following a food elimination-based therapy in comparison to men, or the greater value placed on the act of eating on the part of women. In the Spanish socio-cultural context, women generally bear greater responsibility for buying and preparing food, perhaps conditioning them more than men in this respect.

Strengths of our study include its sample size, inclusion of patients from different Spanish geographical areas, measurement of HRQoL with a validated instrument previously adapted to the Spanish socio-linguistic environment,²³ the inclusion of patients with different therapeutic modalities for EoE, and control of confounding factors by means of multivariate analysis. Several drawbacks to this study, however, should be acknowledged. Recruited patients may not be representative of the Spanish adult population with EoE or EoE patients from other countries, mostly because of selection bias by including only hospital-controlled patients. Cultural and emotional aspects influencing food restrictions could also affect the generalization of our results. Additional limitations might be using self-reported symptoms, and lacking evaluation of treatment efficacy and the correlation of HRQoL with clinical and histological outcomes after therapy.

In summary, the present study demonstrates that EoE-specific HRQoL in adult patients with EoE is strongly associated with baseline presenting symptoms, especially food impaction, dietary restrictions and long-lasting disease. The type of therapy (drug treatment or dietary therapy) did not significantly affect the perception of HRQoL. Women with a higher educational level showed the highest concerns with dietary therapy.

Footnotes

Acknowledgments

We are grateful to all collaborators who recruited patients to participate in this research: Isabel Pérez-Martínez, Jesús Barrio, Óscar Nantes, Marta Sánchez-Cazalilla, Constanza Ciriza de los Ríos, and Antonia Perelló. We thank all the patients who participated in this study. Author contributions are as follows: AJL and AA designed the study; AJL and JM-I included the patients; AA and LAG managed and performed the statistical analyses and interpretation of the data; AJL wrote the manuscript; LAG, JM-I and AA interpreted the data and review the draft providing with relevant critical comments. All authors read and approved the final manuscript.

Declaration of conflicting interests

None declared.

Funding

This work was funded by the Instituto de Salud Carlos III through the project “PI 14/01417” (co-funded by the European Regional Development Fund, “Investing in your future”).

Ethics approval

This article does not contain any studies with animals performed by any of the authors. The study was carried out in accordance with the Declaration of Helsinki. Ethical approval was granted by the La Mancha Centro General Hospital Ethics Committee.

Informed consent

Informed consent was obtained from all individual participants included in the study. All participants included in the study consented to the publication of the data extracted from the statistical study. No individual patient data are reported.

References

Lucendo AJ, Molina-Infante J, Arias Á, et al. Guidelines on eosinophilic esophagitis: Evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J 2017; 5: 335–358.

Molina-Infante

Bredenoord

Cheng

et al.

Proton pump inhibitor-responsive oesophageal eosinophilia: An entity challenging current diagnostic criteria for eosinophilic oesophagitis. Gut 2016; 65: 521–531.

DeBrosse

Franciosi

King

et al.

Long-term outcomes in pediatric-onset esophageal eosinophilia. J Allergy Clin Immunol 2011; 128: 132–138.

Arias

Perez-Martinez

Tenias

et al.

Systematic review with meta-analysis: The incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies. Aliment Pharmacol Ther 2016; 43: 3–15.

Ronkainen

Talley

Aro

et al.

Prevalence of oesophageal eosinophils and eosinophilic oesophagitis in adults: The population-based Kalixanda study. Gut 2007; 56: 615–620.

Lucendo

Sánchez-Cazalilla

. Adult versus pediatric eosinophilic esophagitis: Important differences and similarities for the clinician to understand. Expert Rev Clin Immunol 2012; 8: 733–745.

Taft

Kern

Keefer

et al.

Qualitative assessment of patient-reported outcomes in adults with eosinophilic esophagitis. J Clin Gastroenterol 2011; 45: 769–774.

van Rhijn

Smout

Bredenoord

. Disease duration determines health-related quality of life in adult eosinophilic esophagitis patients. Neurogastroenterol Motil 2014; 26: 772–778.

Larsson

Bergman

Finizia

et al.

Dysphagia and health-related quality of life in patients with eosinophilic esophagitis: A long-term follow-up. Eur Arch Otorhinolaryngol 2015; 272: 3833–3839.

10.

Hewett R, Alexakis C, Farmer AD, et al. Effects of eosinophilic oesophagitis on quality of life in an adult UK population: A case control study. Dis Esophagus 2017; 30: 1–7.

11.

Safroneeva

Coslovsky

Kuehni

et al.

Eosinophilic oesophagitis: Relationship of quality of life with clinical, endoscopic and histological activity. Aliment Pharmacol Ther 2015; 42: 1000–1010.

12.

Schoepfer

Straumann

Panczak

et al.

Development and validation of a symptom-based activity index for adults with eosinophilic esophagitis. Gastroenterology 2014; 147: 1255–1266.

13.

Lucendo

Arias

Molina-Infante

et al.

Diagnostic and therapeutic management of eosinophilic oesophagitis in children and adults: Results from a Spanish registry of clinical practice. Dig Liver Dis 2014; 45: 562–568.

14.

Dellon

Kim

Sperry

et al.

A phenotypic analysis shows that eosinophilic esophagitis is a progressive fibrostenotic disease. Gastrointest Endosc 2014; 79: 577–585.

15.

Schoepfer

Safroneeva

Bussmann

et al.

Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology 2013; 145: 1230–1232.

16.

Kelly

Lazenby

Rowe

et al.

Eosinophilic esophagitis attributed to gastroesophageal reflux: Improvement with an amino acid-based formula. Gastroenterology 1995; 109: 1503–1512.

17.

Lucendo

Arias

. Treatment of adult eosinophilic esophagitis with diet. Dig Dis 2014; 32: 120–125.

18.

van der Velde

Flokstra-de Blok

Dunngalvin

et al.

Parents report better health-related quality of life for their food-allergic children than children themselves. Clin Exp Allergy 2011; 41: 1431–1439.

19.

Testa

. Current concepts: Assessment of quality-of-life outcomes. N Eng J Med 1996; 334: 835–840.

20.

Liacouras

Furuta

Hirano

et al.

Eosinophilic esophagitis: Updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128: 3–20.

21.

Taft

Kern

Kwiatek

et al.

The Adult Eosinophilic Oesophagitis Quality of Life questionnaire: A new measure of health-related quality of life. Aliment Pharmacol Ther 2011; 34: 790–798.

22.

Bajaj

Taft

Keefer

et al.

Validity, usability, and acceptability of the Eosinophilic Esophagitis Quality of Life scale for adults (EoE-QOL-A). Gastroenterology 2012; 142(Suppl 1): S–434.

23.

Lucendo

Sánchez-Cazalilla

Molina-Infante

et al.

Transcultural adaptation and validation of the “Adult Eosinophilic Esophagitis Quality of Life Questionnaire” into Spanish. Rev Esp Enferm Dig 2014; 106: 386–394.

24.

Ramírez-Cervantes

Remes-Troche

Del Pilar Milke-García

et al.

Characteristics and factors related to quality of life in Mexican Mestizo patients with celiac disease. BMC Gastroenterol 2015; 15: 4–4.

25.

Paarlahti

Kurppa

Ukkola

et al.

Predictors of persistent symptoms and reduced quality of life in treated coeliac disease patients: A large cross-sectional study. BMC Gastroenterol 2013; 13: 75–75.

26.

Franciosi

Hommel

Bendo

et al.

PedsQL eosinophilic esophagitis module: Feasibility, reliability, and validity. J Pediatr Gastroenterol Nutr 2013; 57: 57–66.

27.

Greenhawt

. Food allergy quality of life and living with food allergy. Curr Opin Allergy Clin Immunol 2016; 16: 284–290.

28.

Birdi

Cooke

Knibb

. Quality of life, stress, and mental health in parents of children with parentally diagnosed food allergy compared to medically diagnosed and healthy controls. J Allergy 2016; 2016: 1497375–1497375.

29.

Cummings

Knibb

Erlewyn-Lajeunesse

et al.

Management of nut allergy influences quality of life and anxiety in children and their mothers. Pediatr Allergy Immunol 2010; 21(4 Pt 1): 586–594.

30.

Rodríguez Almagro

Hernández Martínez

Lucendo

et al.

Health-related quality of life and determinant factors in celiac disease. A population-based analysis of adult patients in Spain. Rev Esp Enferm Dig 2015; 108: 181–189.

31.

Nachman

Mauriño

Vázquez

et al.

Quality of life in celiac disease patients: Prospective analysis on the importance of clinical severity at diagnosis and the impact of treatment. Dig Liver Dis 2009; 41: 15–25.

32.

Johnston

Rodgers

Watson

. Quality of life in screen-detected and typical coeliac disease and the effect of excluding dietary gluten. Eur J Gastroenterol Hepatol 2004; 16: 1281–1286.

33.

Wagner

Berger

Sinnreich

et al.

Quality of life in adolescents with treated coeliac disease: Influence of compliance and age at diagnosis. J Pediatr Gastroenterol Nutr 2008; 47: 555–561.

34.

Arias

González-Cervera

Tenias

et al.

Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: A systematic review and meta-analysis. Gastroenterology 2014; 146: 1639–1648.

35.

Mroczek

Kurpas

Urban

et al.

The influence of asthma exacerbations on health-related quality of life. Adv Exp Med Biol 2015; 873: 65–77.

36.

Laforest

Bousquet

Neukirch

et al.

Influence of sociodemographic factors on quality of life during pollen season in seasonal allergic rhinitis patients. Ann Allergy Asthma Immunol 2005; 95: 26–32.

37.

Selinger

Lal

Eaden

et al.

Better disease specific patient knowledge is associated with greater anxiety in inflammatory bowel disease. J Crohns Colitis 2013; 7: e214–e218.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.10 MB

0.12 MB

Determinant factors of quality of life in adult patients with eosinophilic esophagitis

Abstract

Background

Objective

Methods

Results

Conclusion

Keywords

Introduction

Materials and methods

Study population and procedures

QoL measures

Statistical methods

Results

Study participants

HRQoL levels

HRQoL determinants

Discussion

Footnotes

Acknowledgments

Declaration of conflicting interests

Funding

Ethics approval

Informed consent

References

Supplementary Material