Proton pump inhibitor failure in gastro-oesophagel reflux disease – what about eosinophilic oesophagitis? Authors’ reply S IRS , We would like to thank Doctors Sgouros and Mantides for their insight- ful comments about our systematic review paper on proton pump inhibitor (PPI) failure in patients with gastro-oesophageal reflux disease (GERD). 1 When patients who failed PPI therapy are evaluated, we hope that other oesophageal disorders that may mimic GERD such as eosinophilic oesophagitis, achalasia, pill-induced oesophagitis, etc. have been already excluded. However, Drs Sgo- uros and Mantides’ point is well taken primarily because eosinophilic oesopha- gitis is presently an under-recognized disorder and thus some of these patients may end up within the PPI failure group. However, prior to making a sweeping recommendation to endoscope all those who failed PPI to rule out eosinophilic oesophagitis, we need to answer three pivotal questions. The first, how common is eosinophilic oesophagitis within the PPI failure group? Currently, we are lacking any data addressing the prevalence of these patients among those who failed PPI and thus any further recommendations about an invasive and costly procedure such as endoscopy should be halted until further information is obtained. In fact, the anecdotal endoscopic experi- ences of Drs Sgouros and Mantides in PPI failure patients support the need for future studies. The second question is how common is heartburn as the sole manifestation of eosinophilic oesophagitis? In children, 57% of 381 subjects with eosinophi- lic oesophagitis reported epigastric pain, heartburn and water brash. 2 This study and others suggest that GERD-related symptoms are not uncommon in children with eosinophilic oesophagitis. However, in adults, GERD-related symptoms are much less common (see Table 1), affecting 0–43% of the sub- jects with eosinophilic oesophagitis. 3–7 In many cases, patients also report dys- phagia or have a history of food impaction. Both should serve as alarm symptoms and the impetus for an immediate upper endoscopy. The last question is what is the relationship between GERD and eosinophilic oesophagitis? If the two are not related, can they coincide within the same subject? The answer to the last question remains to be elucidated. However, this is an important clinical dilemma. We have already seen in our practice a few patients with GERD-related symptoms, eosinophilic oesophagitis on biopsy and markedly abnormal oesophageal pH testing. The extent of overlap between the two disorders should be definitely evaluated. Potentially, the presence of Table 1. Prevalence of gastro-oesophageal reflux disease (GERD)-related symptoms in patients with eosinophilic oesophagitis Author Patients (n) GERD-related symptoms (%) Dysphagia (%) Others (%) Remedios et al. 3 26 0.0 100 53 Straumann et al. 4 30 6.7 100 0 Croese et al. 5 31 16 68 16 Potter et al. 6 29 28 72 0 Zimmerman et al. 7 14 43 93 – R. F ASS & M. S HAPIRO The Neuro-Enteric Clinical Research Group, Southern Arizona VA Health Care System and University of Arizona Health Sciences Center, Tucson, AZ, USA E-mail: ronnie.fass@med.va.gov doi: 10.1111/j.1365-2036.2006.02864.x 1282 LETTERS TO THE EDITORS ª 2006 The Authors, Aliment Pharmacol Ther 23, 1273–1286 Journal compilation ª 2006 Blackwell Publishing Ltd