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To the Editors, We read with interest the excellent review by Fass et al.1 regarding proton pump inhibitors (PPIs) failure in gastro-oesophageal reflux disease (GERD). In our experience 10 patients were evaluated (M:F 5:5, mean age 45.1 years, range 21–61 years) for refractory heartburn to double-dose PPIs (symptoms of any severity for at least 2 days/week during the last 30 days). Using standard forceps, all patients had three biopsy specimens taken from the proximal and distal parts of the oesophagus, the body and the antrum of the stomach, and the duodenum.

Four males (40%) (mean age 32.1 years, range 21–38 years) presented evidence of eosinophilic oesophagitis (EO) with more than 20 eosinophils/high power field (HPF) on oesophageal biopsies. The mean number of eosinophils/HPF on specimens from the upper and lower oesophagus was 31 (range 21–42) and 44.8 (range 29–67) respectively. Three of these patients reported an allergic history, two patients had peripheral eosinophilia and one patient had an increase in IgE. The patients were advised to spray betamethasone via metered dose inhalers into the mouth without inhaling and were asked to swallow the medication. In this case series, heartburn resolved in all. Improvement occurred within 1 week and continued for up to 2 months.

In conclusion, we think that in cases of refractory heartburn to PPIs, physicians should always consider the possibility of EO. To date, no absolute diagnostic criteria for EO exist, but the presence of more than 15–20 eosinophils/HPF on biopsies from distal and proximal oesophagus whilst mucosal eosinophilia is absent in the gastric and duodenal tissues, is considered diagnostic of EO.2 Endoscopists should keep in mind the importance of tissue sampling since approximately 10% of cases present with normal endoscopy.3 Early diagnosis and initiation of appropriate treatment may avert or delay stricture formation.4

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