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Njie C, Richman C, Rebhun J, Achalu S, Kamal AN, Otaki F, Leiman DA, Kathpalia P. Identification of gaps in the delivery of high-quality care of patients with eosinophilic esophagitis. Dis Esophagus 2024:doae055. [PMID: 39007698 DOI: 10.1093/dote/doae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 06/12/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024]
Abstract
Quality indicators (QIs) are standardized metrics that can be used to quantify health care delivery and identify important areas for practice improvement. Nine QIs pertaining to the diagnosis and management of eosinophilic esophagitis (EoE) were recently established. We therefore aimed to identify existing gaps in care using these QIs. This is a retrospective, multicenter study utilizing recently established EoE QIs to evaluate practice patterns among adult gastroenterologists in the diagnosis and management of EoE. Three patient cohorts of 30 patients each presenting with dysphagia, food impaction, and new diagnosis of EoE, respectively, were obtained, yielding 120 patients per site to assess for every QI. Summary statistics were reported across two main themes: diagnosis and management. Subsequent analysis of gaps in care was then performed. The domain of diagnosis of EoE (QI 1 and 2) had the most notable gap in care with only 55% of the presenting patients undergoing appropriate evaluation for EoE. The domain of management of EoE had overall higher QI fulfillment-however it also contained significant intra-category variation in care. Notably, while 79% of patients had clinical follow-up within 1 year from remission, only 54% underwent surveillance endoscopy within 2 years of remission. In contrast, 100% of patients with symptomatic strictures independent of histologic response underwent endoscopic dilation (QI 4). Management approaches for EoE are evolving and variation in care delivery exists. We identified significant gaps in both diagnosis of EoE especially amongst patients presenting with index food impaction and long term management of EoE, when retrospectively evaluating care patterns using newly established QIs. This is the first study of its kind to utilize these previously established QIs to objectively identify care gaps that exist in EoE amongst several institutions. These findings also highlight the importance of QIs and standardization of management of complex chronic diseases like EoE to help bridge these gaps and provide a framework to measure adherence to these best practices.
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Affiliation(s)
- Cheikh Njie
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, USA
| | | | | | | | - Afrin N Kamal
- Department of Medicine, Stanford University, Stanford, CA, USA
- Division of Gastroenterology and Hepatology, Stanford University, CA, USA
| | - Fouad Otaki
- Division of Gastroenterology, OHSU, Portland, OR, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Priya Kathpalia
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, USA
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2
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Reddy AT, Lee JP, Leiman DA. Measuring and improving quality in esophageal care and swallowing disorders. Dis Esophagus 2024; 37:doae013. [PMID: 38458618 DOI: 10.1093/dote/doae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024]
Abstract
Evaluating clinical care through quality-related metrics is increasingly common. There are now numerous quality statements and indicators related to the medical management of benign and pre-malignant esophageal diseases. Expert consensus leveraging evidence-based recommendations from published society guidelines has been the most frequently used basis for developing esophageal quality statements. While surgical care of patients with esophageal malignancies, including squamous cell carcinoma, has also been developed, those related to benign esophageal disease now include domains of diagnosis, treatment, and monitoring for gastroesophageal reflux disease, eosinophilic esophagitis (EoE), achalasia, and Barrett's esophagus (BE). Several recent studies evaluating adherence to quality metrics affirm substantial variation in practice patterns with opportunities for improvement in care across esophageal diseases. In particular, patient education regarding treatment options in achalasia, frequency of esophageal biopsies among patients with dysphagia to evaluate for EoE, and endoscopic evaluation within a BE segment are areas identified to have need for improvement. As the management of esophageal diseases becomes more complex and interdisciplinary, adherence to quality metrics may be a source of standardization and improvement in delivery and ultimately patient outcomes. Indeed, the development of national quality databases has resulted in a significant growth in the use of these metrics for quality improvement activities and may form the basis for future inclusion in quality reporting and payment programs.
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Affiliation(s)
| | - Joshua P Lee
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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3
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Collins K, Lu I, Ng JF, Stevenson C, Dowling D. Eosinophilic oesophagitis: a common cause of food bolus obstruction. Intern Med J 2024; 54:817-822. [PMID: 38149363 DOI: 10.1111/imj.16306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 11/16/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Eosinophilic oesophagitis (EOE) is a known cause of food bolus obstruction (FBO) with rising incidence and prevalence. AIMS To assess the rates of EOE in adult cases presenting with an FBO via prospective biopsy collection during index endoscopy. METHODS Oesophageal FBO cases requiring gastroscopy between February 2014 and January 2021 at a single institution with a unified policy to perform biopsies on FBO cases were analysed using medical records, endoscopy and histology. Statistical analysis was undertaken to compare those with and without EOE as their final diagnosis, including the timing of oesophageal biopsy and the season that cases presented. RESULTS One hundred ninety FBO presentations were analysed, 15 patients presented twice and one patient presented four times within the 7-year study period. Men represented 72% of cases. A total of 78% of cases had biopsies collected at an index or scheduled follow-up endoscopy. EOE was the cause of the FBO in 28% (53/190) of presentations. FBO secondary to EOE was more likely to occur in the spring and summer months (Australian September to March), with 39% (19 of 49) of cases presenting in spring attributable to EOE. CONCLUSION EOE affects a significant proportion of patients presenting with FBO (28%); a high biopsy rate of 78% in FBO cases provides an opportunity for prompt diagnosis and treatment.
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Affiliation(s)
- Kate Collins
- Department of Gastroenterology, Barwon Health, Geelong, Victoria, Australia
- Department of Gastroenterology and Hepatology, Austin Hospital, Melbourne, Victoria, Australia
| | - Irene Lu
- Department of Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Jer Fuu Ng
- Department of Gastroenterology, Western Health, Melbourne, Victoria, Australia
| | - Connor Stevenson
- School of Information and Physical Sciences, Newcastle University, Newcastle, New South Wales, Australia
| | - Damian Dowling
- Department of Gastroenterology, Barwon Health, Geelong, Victoria, Australia
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Redd WD, McCallen JD, Xue Z, Kiran A, Barlowe TS, Reed CC, Eluri S, Dellon ES. Association between time from esophageal food impaction to endoscopy and adverse events. Gastrointest Endosc 2024; 99:525-536.e3. [PMID: 37951280 PMCID: PMC10954388 DOI: 10.1016/j.gie.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND AND AIMS Guidelines recommend emergent or urgent EGD for esophageal food impaction (EFI), but data on how time to EGD impacts the risk of adverse events remain limited. We determined whether EFI-to-EGD time was associated with adverse events. METHODS In this retrospective cohort study of patients with endoscopically confirmed EFI, adverse events were classified as esophageal (mucosal tear, bleeding, perforation) or extraesophageal (aspiration, respiratory compromise, hypotension, arrhythmia). Esophageal perforation and extraesophageal adverse events requiring intensive care unit admission were classified as serious adverse events. Baseline characteristics, event details, and procedural details were compared between patients with and without adverse events. Multivariable logistic regression was performed to assess for an association between EFI-to-EGD time and adverse events. RESULTS Of 188 patients with EFI, 22 (12%) had any adverse event and 2 (1%) had a serious adverse event. Patients with adverse events were older and more likely to have an esophageal motility disorder, to tolerate secretions at presentation, and to have a higher American Society of Anesthesiologists score. EFI-to-EGD time was similar in those with and without adverse events. On multivariable analysis, EFI-to-EGD time was not associated with adverse events (odds ratio, 1.00 [95% confidence interval, .97-1.04] for 1-hour increments; odds ratio, 1.03 [95% confidence interval, .86-1.24] for 6-hour increments). Results were similar after stratifying by eosinophilic esophagitis status and after adjusting for possible confounders. CONCLUSIONS Because the time from EFI to EGD is not associated with adverse events, emergent EGD for EFI may be unnecessary, and other considerations may determine EGD timing.
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Affiliation(s)
- Walker D. Redd
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Justin D. McCallen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Zeyun Xue
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Akshatha Kiran
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Trevor S. Barlowe
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Craig C. Reed
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Swathi Eluri
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
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Banerjee AK, Narain MA. Apparent Increase in Eosinophilic Esophagitis Prevalence May Reflect Delayed Guideline Adoption. Clin Gastroenterol Hepatol 2024; 22:905. [PMID: 37544419 DOI: 10.1016/j.cgh.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Anjan K Banerjee
- Department of Gastroenterology, Bronglais General Hospital, Aberystwyth, Wales, United Kingdom
| | - Mark A Narain
- Department of Gastroenterology, Bronglais General Hospital, Aberystwyth, Wales, United Kingdom
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Guo H, Hamilton P, Enns E, Gupta M, Andrews CN, Nasser Y, Bredenoord AJ, Dellon ES, Ma C. Postendoscopy Care for Patients Presenting With Esophageal Food Bolus Impaction: A Population-Based Multicenter Cohort Study. Am J Gastroenterol 2023; 118:1787-1796. [PMID: 37410911 DOI: 10.14309/ajg.0000000000002392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/08/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Esophageal food bolus impactions (FBI) are a common gastrointestinal emergency. Appropriate management includes not only index endoscopy for disimpaction but also medical follow-up and treatment for the underlying esophageal pathology. We evaluated the appropriateness of postendoscopy care for patients with FBI and assessed patient-related, physician-related, and system-related factors that may contribute to loss to follow-up. METHODS We conducted a retrospective, population-based, multicenter cohort study of all adult patients undergoing endoscopy for FBI in the Calgary Health Zone, Canada, from 2016 to 2018. Appropriate postendoscopy care was defined by a composite of a clinical or endoscopic follow-up visit, appropriate investigations (e.g., manometry), or therapy (e.g., proton-pump inhibitors or endoscopic dilation). Predictors of inappropriate care were assessed using multivariable logistic regression. RESULTS A total of 519 patients underwent endoscopy for FBI: 25.2% (131/519) did not receive appropriate postendoscopy care. Half of the patients (55.3%, 287/519) underwent follow-up endoscopy or attended clinic, and among this group, 22.3% (64/287) had a change in their initial diagnosis after follow-up, including 3 new cases of esophageal cancer. Patients in whom a suspected underlying esophageal pathology was not identified at the index endoscopy were 7-fold (adjusted odds ratio 7.28, 95% confidence interval 4.49-11.78, P < 0.001) more likely to receive inappropriate postendoscopy follow-up and treatment, even after adjusting for age, sex, rural residence, timing of endoscopy, weekend presentation, and endoscopic interventions. DISCUSSION One-quarter of patients presenting with an FBI do not receive appropriate postendoscopy care. This is strongly associated with failure to identify a potential underlying pathology at index presentation.
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Affiliation(s)
- Howard Guo
- Division of Internal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Patrick Hamilton
- Division of Internal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Edwin Enns
- Department of Medicine, Alberta Health Services, Calgary, Alberta, Canada
| | - Milli Gupta
- Division of Gastroenterology & Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher N Andrews
- Division of Gastroenterology & Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yasmin Nasser
- Division of Gastroenterology & Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Christopher Ma
- Department of Medicine, Alberta Health Services, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Leiman DA, Kamal AN, Otaki F, Bredenoord AJ, Dellon ES, Falk GW, Fernandez-Becker NQ, Gonsalves N, Hirano I, Katzka DA, Peterson K, Yadlapati R, Kathpalia P. Quality Indicators for the Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol 2023; 118:1091-1095. [PMID: 36599135 PMCID: PMC10392038 DOI: 10.14309/ajg.0000000000002138] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/21/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Despite best practice recommendations for managing eosinophilic esophagitis (EoE), variation in care exists. METHODS We used established methodology for quality indicator development to identify metrics to define quality for the treatment of EoE. RESULTS Among 29 proposed quality indicator statements, 9 (31%) were adopted as highly valid across all categories. Two (22%) of these statements were identified as having existing or suspected quality gaps. DISCUSSION We identified highly valid EoE quality indicators for adult gastroenterologists, which can be used for quality improvement with resulting benefits for patient outcomes.
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Affiliation(s)
- David A. Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Afrin N. Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Albert J. Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania, USA
| | - Nielsen Q. Fernandez-Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David A. Katzka
- Division of Gastroenterology, Columbia University Medical Center, New York, New York, USA
| | | | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
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8
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Lee C, Sievers TJ, Vaughn BP. Diagnosis of Eosinophilic Esophagitis at the Time of Esophageal Food Impaction. J Clin Med 2023; 12:jcm12113768. [PMID: 37297963 DOI: 10.3390/jcm12113768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Esophageal food impactions (EFI) often precede a diagnosis of eosinophilic esophagitis (EOE). Current guidelines suggest obtaining esophageal biopsies upon suspicion of EOE, treating with proton pump inhibitor (PPI), and repeating esophagogastroduodenoscopy (EGD). This study was conducted to determine provider practice patterns with these mentioned recommendations at the time of EFI. METHODS In this retrospective study, key outcomes were the proportion of patients who had EOE mucosal biopsies, EOE diagnosis, PPI initiation, and recommendations and completions of repeat EGD. Differences in outcomes among age, sex, race, off-hours time of procedure, and trainee involvement were examined. EOE diagnosis predictors were explored with logistic regression. RESULTS Twenty-nine percent of the patients had esophageal biopsies taken at the time of index EGD (iEGD). Sixteen patients were diagnosed with EOE at the time of index EFI, while fourteen patients were diagnosed on subsequent EGDs. Among those diagnosed with EOE at iEGD, 94% were placed on PPI. Of patients with confirmed EOE on index biopsy, 63% of patients were recommended repeat EGD, of which 50% completed it within 90 days. Older age was protective of EOE diagnosis while no GERD history and endoscopist suspicion of EOE predicted diagnosis of EOE. CONCLUSIONS Endoscopists uncommonly take biopsies at the time of EFI, which may delay diagnosis and treatment of EOE.
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Affiliation(s)
- Christina Lee
- Department of Medicine, University of Minnesota, 420 Delaware St. SE, MMC 36, Minneapolis, MN 55455, USA
| | - Tyson J Sievers
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, 420 Delaware St. SE, MMC 36, Minneapolis, MN 55455, USA
| | - Byron P Vaughn
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, 420 Delaware St. SE, MMC 36, Minneapolis, MN 55455, USA
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9
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Hoversten P, Lomeli L, Broman AT, Gaumnitz E, Hillman L. Esophageal disease and loss to follow-up are common among patients who experience non-endoscopic resolution of food impaction. Dis Esophagus 2023; 36:6658242. [PMID: 35938855 DOI: 10.1093/dote/doac054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/30/2022] [Indexed: 12/11/2022]
Abstract
Many patients who experience esophageal food impaction (EFI) will have non-endoscopic resolution (NER) of their EFI, but this population is poorly defined. The purpose of this study is to describe the outcomes of patients with NER of EFI. A retrospective chart review from 2007 to 2017 was performed at a single tertiary care center. There were 593 patients who presented to the emergency department with EFI, defined as recent soft food ingestion and inability to tolerate oral secretions. Adequate follow-up was defined as a gastroenterology clinic visit or EGD within 6 months of EFI. Out of these, 149 patients (25.1%) had NER of their EFI. Patients with NER were less likely to have adequate follow-up than those with ER (45.0% vs. 59.5%, P = 0.003). Of those without established esophageal disease and NER, 92.5% had significant esophageal pathology on endoscopy, including stricture (34.0%), features of eosinophilic esophagitis (30.2%), and esophagitis (22.6%). Recurrent EFI occurred at a similar rate between patients with NER and ER (9.4% vs. 14.6%, P = 0.14). Patients with established esophageal disease (odds ratio [OR]: 1.51, P = 0.04) and recommendation to follow-up at time of EFI (OR: 6.06, P < 0.001) were most likely to follow up after EFI. Approximately, a quarter of patients with EFI will experience NER of their EFI. Virtually, all patients (92.5%) were found to have esophageal disease warranting longitudinal care. Importantly, follow-up rates are significantly lower in those with NER than their counterparts requiring EGD. Our study highlights the need to develop standardized protocols that improve follow-up for patients after NER of EFI.
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Affiliation(s)
- Patrick Hoversten
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Luis Lomeli
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Aimee Teo Broman
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Eric Gaumnitz
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Luke Hillman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Navarro P, Laserna-Mendieta EJ, Casabona S, Savarino E, Pérez-Fernández MT, Ghisa M, Pérez-Martínez I, Guagnozzi D, Perelló A, Guardiola-Arévalo A, Racca F, Betoré E, Blas-Jhon L, Krarup AL, Martín-Domínguez V, Maniero D, Suárez A, Llerena-Castro R, de la Peña-Negro L, Navacerrada AG, Pellegatta G, Alcedo J, de Hurtado Mendoza-Guena L, Feo-Ortega S, Barrio J, Gutiérrez-Junquera C, Fernández-Fernández S, De la Riva S, E Navés J, Carrión S, Ciriza de Los Ríos C, García-Morales N, Rodríguez-Oballe JA, Dainese R, Rodríguez-Sánchez A, Masiques-Mas ML, Palomeque MT, Santander C, Tamarit-Sebastián S, Arias Á, Lucendo AJ. Accurate and timely diagnosis of Eosinophilic Esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry. United European Gastroenterol J 2022; 10:507-517. [PMID: 35578565 PMCID: PMC9189464 DOI: 10.1002/ueg2.12240] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/24/2022] [Indexed: 12/29/2022] Open
Abstract
Background Poor adherence to clinical practice guidelines for eosinophilic esophagitis (EoE) has been described and the diagnostic delay of the disease continues to be unacceptable in many settings. Objective To analyze the impact of improved knowledge provided by the successive international clinical practice guidelines on reducing diagnostic delay and improving the diagnostic process for European patients with EoE. Methods Cross‐sectional analysis of the EoE CONNECT registry based on clinical practice. Time periods defined by the publication dates of four major sets of guidelines over 10 years were considered. Patients were grouped per time period according to date of symptom onset. Results Data from 1,132 patients was analyzed and median (IQR) diagnostic delay in the whole series was 2.1 (0.7‐6.2) years. This gradually decreased over time with subsequent release of new guidelines (p < 0.001), from 12.7 years up to 2007 to 0.7 years after 2017. The proportion of patients with stricturing of mixed phenotypes at the point of EoE diagnosis also decreased over time (41.3% vs. 16%; p < 0.001), as did EREFS scores. The fibrotic sub‐score decreased from a median (IQR) of 2 (1‐2) to 0 (0‐1) when patients whose symptoms started up to 2007 and after 2017 were compared (p < 0.001). In parallel, symptoms measured with the Dysphagia Symptoms Score reduced significantly when patients with symptoms starting before 2007 and after 2012 were compared. A reduction in the number of endoscopies patients underwent before the one that achieved an EoE diagnosis, and the use of allergy testing as part of the diagnostic workout of EoE, also reduced significantly over time (p = 0.010 and p < 0.001, respectively). Conclusion The diagnostic work‐up of EoE patients improved substantially over time at the European sites contributing to EoE CONNECT, with a dramatic reduction in diagnostic delay.
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Affiliation(s)
- Pilar Navarro
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain
| | - Sergio Casabona
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - María Teresa Pérez-Fernández
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Matteo Ghisa
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Viladecans, Viladecans, Spain
| | | | - Francesca Racca
- Personalized Medicine, Asthma and Allergy. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Elena Betoré
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Leonardo Blas-Jhon
- Department of Gastroenterology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Anne Lund Krarup
- Department of Medicine and Department of Clinical Medicine. The North Danish Regional Hospital, Hjoerring and Aalborg University, Aalborg, Denmark
| | - Verónica Martín-Domínguez
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Daria Maniero
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology Unit, Azienza Ospedaliera di Padova, Padova, Italy
| | - Adolfo Suárez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Diet, Microbiota and Health Group. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ronald Llerena-Castro
- Department of Gastroenterology, Hospital Universitario Valld'Hebrón, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Gaia Pellegatta
- Endoscopy Unit. IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Javier Alcedo
- Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Sara Feo-Ortega
- Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Pediatric Gastroenterology Unit. Hospital General de Tomelloso, Tomelloso, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Carolina Gutiérrez-Junquera
- Department of Pediatric Gastroenterology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Susana De la Riva
- Department of Gastroenterology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan E Navés
- Department of Gastroenterology, Parc de Salut Mar, Barcelona, Spain
| | - Silvia Carrión
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Department of Gastroenterology, Hospital de Mataró, Mataró, Spain
| | - Constanza Ciriza de Los Ríos
- Department of Gastroenterology. Hospital Clínico Universitario San Carlos, Instituto de Investigacion Sanitaria San Carlos (IdISSC), Madrid, Spain.,Universidad Complutense, Madrid, Spain
| | | | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology, Hospital Universitario Arnau de Vilanova & Hospital Universitario Santa María, Lérida, Spain
| | - Raffaela Dainese
- Department of Gastroenterology, Centre Hospitalier d'Antibes Juan-les-Pins, Antibes, France
| | | | | | | | - Cecilio Santander
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Sonsoles Tamarit-Sebastián
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Laboratory Medicine Department. Hospital Universitario de La Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.,Research Unit. Hospital General Mancha-Centro, Alcázar de San Juan, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
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11
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Guimarães P, Keller A, Fehlmann T, Lammert F, Casper M. Deep learning-based detection of eosinophilic esophagitis. Endoscopy 2022; 54:299-304. [PMID: 34058769 DOI: 10.1055/a-1520-8116] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND For eosinophilic esophagitis (EoE), a substantial diagnostic delay is still a clinically relevant phenomenon. Deep learning-based algorithms have demonstrated potential in medical image analysis. Here we establish a convolutional neuronal network (CNN)-based approach that can distinguish the appearance of EoE from normal findings and candida esophagitis. METHODS We trained and tested a CNN using 484 real-world endoscopic images from 134 subjects consisting of three classes (normal, EoE, and candidiasis). Images were split into two completely independent datasets. The proposed approach was evaluated against three trainee endoscopists using the test set. Model-explainability was enhanced by deep Taylor decomposition. RESULTS Global accuracy (0.915 [95 % confidence interval (CI) 0.880-0.940]), sensitivity (0.871 [95 %CI 0.819-0.910]), and specificity (0.936 [95 %CI 0.910-0.955]) were significantly higher than for the endoscopists on the test set. Global area under the receiver operating characteristic curve was 0.966 [95 %CI 0.954-0.975]. Results were highly reproducible. Explainability analysis found that the algorithm identified the characteristic signs also used by endoscopists. CONCLUSIONS Complex endoscopic classification tasks including more than two classes can be solved by CNN-based algorithms. Therefore, our algorithm may assist clinicians in making the diagnosis of EoE.
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Affiliation(s)
- Pedro Guimarães
- Department of Clinical Bioinformatics, Saarland University, Saarbrücken, Germany
| | - Andreas Keller
- Department of Clinical Bioinformatics, Saarland University, Saarbrücken, Germany.,Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford University, Stanford, California, USA
| | - Tobias Fehlmann
- Department of Clinical Bioinformatics, Saarland University, Saarbrücken, Germany
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany.,Hannover Health Sciences Campus, Hannover Medical School, Hannover, Germany
| | - Markus Casper
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
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12
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Hillman L, Donohue S, Broman AT, Hoversten P, Gaumnitz E, Lomeli L. Empiric proton pump inhibitor therapy after esophageal food impaction may mask eosinophilic esophagitis diagnosis at follow-up. Dis Esophagus 2021; 34:6274869. [PMID: 33987650 DOI: 10.1093/dote/doab030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/16/2021] [Accepted: 04/16/2021] [Indexed: 01/07/2023]
Abstract
Esophageal food impaction (EFI) is often the first presentation for patients with eosinophilic esophagitis (EoE); however, there is significant heterogeneity in the management of EFI. We aimed to study the impact of EFI management, particularly post-EFI medication prescriptions on EoE diagnosis, follow-up, and recurrence in patients with endoscopic features of EoE. In our retrospective study, adults presenting between 2007 and 2017 with EFI requiring endoscopic dis-impaction with endoscopic features of EoE (furrows, rings, and/or exudates) were included. We examined the impact of demographics and EFI management on EoE diagnosis, follow-up (esophagogastroduodenoscopy [EGD] or clinic visit within 6 months), and recurrence. We identified 164 cases of EFI due to suspected EoE. Biopsy was performed in 68 patients (41.5%), and 144 patients (87.8%) were placed on proton pump inhibitor (PPI) and/or swallow corticosteroids after EFI, including 88.5% of those not biopsied. PPI use at time of biopsy was negatively associated with EoE diagnosis (odds ratio: 0.39, confidence interval: 0.17-0.85). Sixty-one (37.4%) patients were lost to follow-up at 6 months. Recurrent EFI at 1 year occurred in 3.7% of patients. Medications, most commonly PPI, are frequently prescribed after EFI when the endoscopic features of EoE are present, which may mask the diagnosis of EoE on follow-up EGD. We estimated that for every five patients biopsied on PPI, one case of EoE is masked. As recurrent EFI within 1 year is uncommon, empiric therapy should be avoided until diagnostic biopsies are obtained. Further efforts to reduce loss to follow-up after EFI are also needed.
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Affiliation(s)
- Luke Hillman
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sarah Donohue
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Aimee Teo Broman
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Patrick Hoversten
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Eric Gaumnitz
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Luis Lomeli
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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13
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Rosenwald K, Pan Z, Andrews R, Menard-Katcher C. Follow-up and symptom persistence after esophageal food impaction. Dis Esophagus 2021; 34:6276257. [PMID: 33993222 DOI: 10.1093/dote/doab029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/18/2021] [Accepted: 04/16/2021] [Indexed: 12/11/2022]
Abstract
Esophageal food impactions (EFI) are associated with esophageal pathology, most commonly eosinophilic esophagitis (EoE). Obtaining biopsies provides opportunity for diagnosis, which is important since treatment of EoE decreases the risk for future EFI. Outpatient follow-up rates remain suboptimal and outcomes of patients without timely follow-up are unknown. We aimed to identify the factors associated with pediatric subspecialty follow-up post-EFI and to determine the symptom burden in patients without follow-up. We performed a retrospective review of patients presenting with EFI at a tertiary children's hospital between 2010 and 2018. Patients without subspecialty follow-up within 1 year of EFI were included in a prospective telephone survey investigating the barriers to care, outcomes, and symptoms. Clinical characteristics were compared between groups. Multivariate analysis was used to control for multiple variables. There were 127 EFI identified in 123 individuals (73% male, mean age: 12.2 years). Esophageal biopsies were collected in 76% of cases, and 49% of patients had follow-up. Individuals with follow-up were more likely (P ≤ 0.05) to have had biopsies. In a multivariate analysis, written recommendation for follow-up (Odds Ratio: 6.9 [2.4-19.5], P = 0.001) as well as atopic history and identified stricture were associated with a higher likelihood of follow-up. Those without follow-up had subsequent stricture (35%), dilation (44%), or EFI (39%), and 55% (12/22) described ongoing esophageal symptoms. Identification of treatable findings at time of EFI and ongoing symptom burden after EFI support an imperative for follow-up after EFI. Clear recommendations are a modifiable factor that may improve follow-up in this population.
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Affiliation(s)
- Kent Rosenwald
- Randall Children's Hospital at Legacy Emanuel Medical Center, Portland, OR, USA
| | - Zhaoxing Pan
- Biostatistics Core of Children's Hospital Colorado Research Institute, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rachel Andrews
- Digestive Health Institute, Children's Hospital Colorado,, Aurora, CO, USA
| | - Calies Menard-Katcher
- Digestive Health Institute, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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14
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Sharma A, Eluri S, Philpott H, Lemberg DA, Dellon ES. EoE Down Under Is Still EoE: Variability in Provider Practice Patterns in Australia and New Zealand Among Pediatric Gastroenterologists. Dig Dis Sci 2021; 66:2301-2310. [PMID: 32816214 DOI: 10.1007/s10620-020-06534-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is likely variation in approach and management of patient with EoE due to lack of standardized care and variation in guidelines. We aimed to identify current practices regarding diagnosis and treatment in children with eosinophillic esophagitis (EoE) in Australia and New Zealand (ANZ). METHODS Information on current diagnostic and management approaches for pediatric EoE was collected via an online survey sent to pediatric gastroenterologists (pGE) in ANZ. We performed a cross-sectional study of pGE using a 49-question instrument regarding evaluation, diagnostic, and therapeutic aspects of EoE between October 2019 and December 2019. RESULTS Eighty-five percent of the survey responders were from Australia, and 66% were academic. 30% pGE perform > 3 esophageal biopsies for diagnosis of EoE, 40% involve an allergist, 30% use a twice daily PPI trial, and 70% do not exclude other cause of esophageal eosinophilia. For management, only 3% use dietary elimination as an initial therapy, and 24% use less than the recommended doses of swallowed fluticasone. Forty-nine percent were likely to stop treatment in after remission is achieved for 12 months. The EoE endoscopic reference score (EREFS) was not routinely used (49%). Two-thirds of pGE are concerned about long-term effects of recurrent need of general anesthesia. CONCLUSIONS Diagnostic and management strategies for EoE differed widely among pGE in ANZ, including in diagnostic biopsies, assessing competing causes of esophageal eosinophilia, initials selection of treatments, and maintenance strategies. This variability likely reflects continued uncertainty regarding optimal management strategies and stresses the need for pediatric-specific ANZ guidelines to standardize EoE care.
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Affiliation(s)
- Ajay Sharma
- Department of Paediatrics, St John of God Hospital, Midland, Perth, Australia. .,Curtin Medical School, Curtin University, Perth, WA, Australia. .,Perth Paediatrics, 5/2 McCourt Street, West Leederville, Perth, WA, Australia.
| | - Swathi Eluri
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC, USA
| | - Hamish Philpott
- Northern Adelaide Local Health Network, Department of Gastroenterology, University of Adelaide, Adelaide, SA, Australia
| | - Daniel A Lemberg
- Department of Gastroenterology, Sydney Children's Hospital and School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC, USA
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15
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Begotka AM, Silverman AH, Goday P. A multidisciplinary approach to the management of phagophobia. CHILDRENS HEALTH CARE 2021. [DOI: 10.1080/02739615.2020.1870117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Andrea M. Begotka
- Division of Pediatrics, Psychiatry Department, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alan H. Silverman
- Division of Pediatrics, Gastroenterology Department, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Praveen Goday
- Division of Pediatrics, Gastroenterology Department, Medical College of Wisconsin, Milwaukee, WI, USA
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16
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Laserna-Mendieta EJ, Casabona S, Savarino E, Perelló A, Pérez-Martínez I, Guagnozzi D, Barrio J, Guardiola A, Asensio T, de la Riva S, Ruiz-Ponce M, Rodríguez-Oballe JA, Santander C, Arias Á, Lucendo AJ. Efficacy of Therapy for Eosinophilic Esophagitis in Real-World Practice. Clin Gastroenterol Hepatol 2020; 18:2903-2911.e4. [PMID: 31988045 DOI: 10.1016/j.cgh.2020.01.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/07/2020] [Accepted: 01/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Topical steroids, proton pump inhibitors (PPIs), and dietary interventions are recommended first- and second-line therapies for eosinophilic esophagitis (EoE). We investigated differences in their effectiveness in a real-world, clinical practice cohort of patients with EoE. METHODS We collected data on the efficacy of different therapies for EoE (ability to induce clinical and histologic remission) from the multicenter EoE CONNECT database-a database of patients with a confirmed diagnosis of EoE in Europe that began in 2016. We obtained data from 589 patients, treated at 11 centers, on sex, age, time of diagnosis, starting date of any therapy, response to therapy, treatment end dates, alternative treatments, and findings from endoscopy. The baseline endoscopy was used for diagnosis of EoE; second endoscopy was performed to evaluate response to first-line therapies. After changes in treatment, generally because lack of efficacy, a last endoscopy was performed. The time elapsed between endoscopies depended on the criteria of attending physicians. Clinical remission was defined by a decrease of more than 50% in Dysphagia Symptom Score; improvement in symptoms by less than 50% from baseline was considered as clinical response. Histologic remission was defined as a peak eosinophil count below 5 eosinophils/hpf. A peak eosinophil count between 5 and 14 eosinophils/hpf was considered histologic response. We identified factors associated with therapy selection and effectiveness using χ2 and multinomial logistic regression analyses RESULTS: PPIs were the first-line treatment for 76.4% of patients, followed by topical steroids (for 10.5%) and elimination diets (for 7.8%). Topical steroids were most effective in inducing clinical and histologic remission or response (in 67.7% of patients), followed by empiric elimination diets (in 52.0%), and PPIs (in 50.2%). Among the 344 patients who switched to a second-line therapy, dietary interventions were selected for 47.1% of patients, followed by PPIs (for 29.1%) and topical steroids (for 18.6%). Clinical and histologic remission or response was achieved by 80.7% of patients treated with topical steroids, 69.2% of patients given PPIs, and 41.7% of patients on empiric elimination diets. Multivariate analyses found the stricturing phenotype of EoE to be associated with selection of topical steroids over PPIs as the first-line therapy; lack of fibrotic features at initial endoscopy was associated with selection of elimination diets over topical steroids as a second-line therapy. The recruiting center was significantly associated with therapy choice; second-line treatment with topical steroids or PPIs were the only variables associated with clinical and histologic remission. CONCLUSIONS In an analysis of data from a large cohort of patients with EoE in Europe, we found topical steroids to be the most effective at inducing clinical and histologic remission, but PPIs to be the most frequently prescribed. Treatment approaches vary with institution and presence of fibrosis or strictures.
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Affiliation(s)
- Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain.
| | - Sergio Casabona
- Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, Università di Padova, Padova, Italy
| | - Antonia Perelló
- Department of Gastroenterology, Hospital de Villadecans, Barcelona, Spain
| | - Isabel Pérez-Martínez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Danila Guagnozzi
- Department of Gastroenterology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Jesús Barrio
- Department of Gastroenterology, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Antonio Guardiola
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain; Instituto de Investigación Sanitaria La Paz, Madrid, Spain
| | - Teresa Asensio
- Department of Allergy, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Miriam Ruiz-Ponce
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Juan Armando Rodríguez-Oballe
- Department of Gastroenterology, University Hospital Santa María - University Hospital Arnau de Vilanova, Lerida, Spain
| | - Cecilio Santander
- Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Department of Gastroenterology, Hospital Universitario La Princesa, Madrid, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Ángel Arias
- Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain.
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17
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Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome. Dig Dis Sci 2020; 65:3434-3447. [PMID: 33052498 PMCID: PMC7669680 DOI: 10.1007/s10620-020-06642-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/09/2022]
Abstract
Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of esophageal dysfunction, including dysphagia. While EoE is still considered a rare disease, in practice it seems that more and more cases are diagnosed every week, research in the field is exploding, and the pipeline for treatments contains multiple agents, some of which are quite far along the development pathway. After only scattered cases and small series were published in the late 1970s and 1980, Stephen Attwood, Thomas Smyrk, Tom DeMeester, and James Jones, published in Digestive Diseases and Sciences in 1993 a seminal report that described a clinicopathologic syndrome of esophageal eosinophilia with dysphagia. This review details the origins of this paper and compares and contrast what was observed then and what is known now about multiple aspects of EoE, including the clinical presentation, diagnosis, epidemiology, natural history, and treatments and outcomes. Moreover, it will highlight how the paper presaged a number of controversies in the field that have yet to be resolved, as well as foreshadowed the collaborative, multidisciplinary approach that has led to rapid advances.
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18
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Arias-González L, Rey-Iborra E, Ruiz-Ponce M, Laserna-Mendieta EJ, Arias Á, Lucendo AJ. Esophageal perforation in eosinophilic esophagitis: A systematic review on clinical presentation, management and outcomes. Dig Liver Dis 2020; 52:245-252. [PMID: 31836305 DOI: 10.1016/j.dld.2019.10.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 12/11/2022]
Abstract
There is evidence of an increased fragility in the inflamed esophagus of patients with eosinophilic esophagitis (EoE). We performed a systematic review on presentation, management and outcomes of and surgical interventions for esophageal perforation in these patients, by searching in the MEDLINE, Embase and Scopus databases. Of the 599 references identified, 41 full-papers and 9 abstract met the inclusion criteria. Overall, 76 esophageal perforation episodes in 70 individual patients aged between 9 and 65 years were reported. 51 patients had not been diagnosed with EoE at the time of perforation; 14 patients had an untreated disease and the remaining were non responsive to therapy. Acute or progressive pain after long-lasting dysphagia and food impaction was the most common symptom leading to diagnosis in 42 patients who presented with Boerhaave syndrome. Pushing impacted food into the stomach led to perforation in 5 cases. Eight episodes appeared after dilation. CT scans demonstrated perforation in 82.4% of patients. Conservative management (including esophageal stenting) was used in 67.1% patients. The 25 remaining patients underwent surgery. Recovery was uneventful in the vast majority of patients. No death was reported. Active inflammation due to undiagnosed or untreated EoE was present in most cases of esophageal perforation. Conservative treatment of perforation should always be considered in EoE.
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Affiliation(s)
- Laura Arias-González
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - Esther Rey-Iborra
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Miriam Ruiz-Ponce
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - Emilio J Laserna-Mendieta
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - Ángel Arias
- Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Instituto de Investigación Sanitaria Princesa, Madrid, Spain.
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19
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Sharma A, Philpott H. Recognising eosinophilic oesophagitis. Frontline Gastroenterol 2020; 11:3-4. [PMID: 31886773 PMCID: PMC6914289 DOI: 10.1136/flgastro-2019-101245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ajay Sharma
- St John of God Midland Hospital, Perth, Western Australia, Australia
| | - Hamish Philpott
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
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20
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May Maestas M, Perry KD, Smith K, Firszt R, Allen‐Brady K, Robson J, Joy E, Peterson K. Food impactions in Eosinophilic esophagitis and acute exposures to fine particulate pollution. Allergy 2019; 74:2529-2530. [PMID: 31144728 DOI: 10.1111/all.13932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Melissa May Maestas
- Earth Lab, Cooperative Institute for Research in Environmental Sciences, Earth Lab University of Colorado Boulder Denver Colorado
- Department of Atmospheric Science University of Utah Salt Lake City Utah
| | - Kevin D. Perry
- Department of Atmospheric Science University of Utah Salt Lake City Utah
| | - Ken Smith
- Utah Pedigree and Population Resource, Department of Family and Consumer Studies, Huntsman Cancer Institute University of Utah Salt Lake City Utah
| | - Rafael Firszt
- Division of Allergy and Immunology Tanner Memorial Clinic Salt Lake City Utah
| | - Kristina Allen‐Brady
- Genetic Epidemiology, Department of Internal Medicine University of Utah Salt Lake City Utah
| | - Jacob Robson
- Department of Pediatrics, Division of Pediatric Gastroenterology University of Utah Salt Lake City Utah
| | | | - Kathryn Peterson
- Division of Gastroenterology, Department of Internal Medicine University of Utah Salt Lake City Utah
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21
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Dellon ES, Gupta SK. A Conceptual Approach to Understanding Treatment Response in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2019; 17:2149-2160. [PMID: 30710696 PMCID: PMC6667323 DOI: 10.1016/j.cgh.2019.01.030] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/15/2019] [Accepted: 01/20/2019] [Indexed: 02/07/2023]
Abstract
While the diagnosis and initial treatment of eosinophilic esophagitis are becoming more standardized, there are still major gaps in knowledge related to measuring treatment response. One such question centers on how to measure treatment response and what treatment endpoints should be. This impacts not only patient care and engagement in decision-making, but also the field of drug development. In addition, studies so far have use a myriad of treatment endpoints including over a dozen histologic endpoint criteria. This review will discuss the various stakeholders involved in assessment of treatment endpoints of a complex condition, including patients, practitioners and regulatory agencies, and the care settings in which treatment response is assessed, including routine clinical care, clinical trials, and observational studies. Potential parameters or treatment endpoints such as histology, symptoms, patient-reported outcomes, endoscopy, and biomarkers are discussed along with associated challenges and opportunities. A framework on how to define treatment outcomes is discussed and a conceptual approach treatment response is proposed. This takes into account histology, symptoms, and endoscopic findings and harnesses existing, validated tools. It includes definitions of nonresponse, complete normalization, and a graded response category between these 2 extremes, and also permits flexibility and latitude for modifications as newer knowledge emerges. In addition, ways to position the pediatric population in these endeavors are discussed as are future research directions.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, University of Illinois College of Medicine, Peoria, IL
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22
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Chang JW, Olson S, Kim JY, Dolan R, Greenson J, Sanders G, Rubenstein JH. Loss to follow-up after food impaction among patients with and without eosinophilic esophagitis. Dis Esophagus 2019; 32:5512617. [PMID: 31175359 PMCID: PMC9115375 DOI: 10.1093/dote/doz056] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Indexed: 12/11/2022]
Abstract
Symptoms of esophageal dysfunction such as food impaction are consistent with, but not diagnostic for eosinophilic esophagitis (EoE) without obtaining histology. We conducted a retrospective study to characterize patients with food impaction at a tertiary center. We hypothesized that many patients with food impaction may be lost to follow-up and that many have features suggestive of EoE. Adult patients presenting to the emergency department with esophageal food impaction were identified from an endoscopic database. Electronic medical records were manually abstracted. We examined associations between demographics, comorbid conditions, and follow-up with biopsy findings. Of 220 patients who presented to the emergency department for food impaction, 74.1% were men. Adequate follow-up was not documented in 120 (54.5%). Those lost to follow-up did not differ significantly by gender, age at symptom onset, or distance from hospital compared to those with follow-up. Esophageal biopsies were obtained in 158 (71.8%), and those with ≥15 eos/HPF were more likely to be lost to follow-up than those with <15 eos/HPF (52.8% vs. 34.8%, P < 0.05). Of those never biopsied, 79.0% were lost to follow-up and had intermediate proportions of males, food allergy, and asthma when compared to those with and without eosinophilic inflammation. Patients with food impaction commonly have EoE but are often lost to follow-up. Among those never biopsied, demographic and clinical features suggest that many may have undiagnosed EoE. Strategies for increasing use of biopsies in patients with food impaction and improving follow-up are needed to diagnose and manage EoE.
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Affiliation(s)
- Joy W Chang
- Address correspondence to: Joy W. Chang, MD, MS, Clinical Lecturer, Division of Gastroenterology, Department of Internal Medicine, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109.
| | - Samuel Olson
- Division of Gastroenterology, Department of Internal Medicine
| | | | | | | | - Georgiana Sanders
- Division of Allergy & Immunology, Department of Internal Medicine, University of Michigan
| | - Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA,Division of Gastroenterology, Department of Internal Medicine
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23
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Ntuli Y, Bough I, Wilson M. Recognising eosinophilic oesophagitis as a cause of food bolus obstruction. Frontline Gastroenterol 2019; 11:11-15. [PMID: 31886777 PMCID: PMC6914293 DOI: 10.1136/flgastro-2019-101176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/25/2019] [Accepted: 04/07/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Eosinophilic oesophagitis (EoE) is a chronic, inflammatory condition of the oesophagus, characterised by intermittent dysphagia, food bolus obstruction (FBO) and histologically proven, eosinophil-mediated inflammation. EoE is identified in up to 50% of FBO presentations. OBJECTIVE To evaluate the management of patients presenting with FBO to our centre against current clinical guidelines. DESIGN A retrospective analysis of acute FBO was performed between January 2008 and August 2014. Patients were identified using the ICD 10 code T18.1, 'foreign body in oesophagus' in their electronic discharge document. Data were collected on admitting specialty, previous FBO, endoscopy findings, biopsy sites and findings, eosinophil count and diagnosis of EoE. RESULTS 310 acute episodes of FBO were included in the final study cohort. 202 (65.2%) flexible oesophagogastroduodenoscopies (OGDs) were performed, with 50 (34.5%) of those occurring in those admitted under ENT (n=145), versus 28 (93.3%) and 124 (91.9%) in general medicine (n=30) and surgery (n=135), respectively. 80 (39.6%) had oesophageal biopsies taken, and 21 novel diagnoses of EoE were made (26.3% biopsy-proven rate). Five (23.8%) of the novel diagnoses had a formal eosinophil count included in the histopathology report, and eight (38.1%) had up to three previous OGDs that had not diagnosed their condition of EoE. CONCLUSION Our study highlights wide variation in adherence to the guidelines for the management of FBO depending on admitting specialty. We advocate an FBO protocol involving single specialty management, flexible OGD, ≥6 biopsies from the upper and lower oesophagus, and standardisation of oesophageal biopsy reports with a formal eosinophil count.
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Affiliation(s)
- Yevedzo Ntuli
- University of Dundee School of Medicine, University of Dundee, Dundee, UK,Royal London Hospital, London, London, UK
| | - Isabelle Bough
- University of Dundee School of Medicine, University of Dundee, Dundee, UK,Glasgow Royal Infirmary, Glasgow, Glasgow, UK
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24
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Schupack DA, Lenz CJ, Geno DM, Tholen CJ, Leggett CL, Katzka DA, Alexander JA. The evolution of treatment and complications of esophageal food impaction. United European Gastroenterol J 2019; 7:548-556. [PMID: 31065372 DOI: 10.1177/2050640619836052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/29/2019] [Indexed: 12/14/2022] Open
Abstract
Background Esophageal food impaction is relatively common and increasing over time. Treatment ranges from medications to invasive endoscopic therapies. The endoscopic push technique has been advised against in favor of endoscopic retrieval for safety concerns. We sought to assess use patterns and safety of treatments for food impaction in a population-based retrospective review. Methods A database of recorded esophageal food impactions in Olmsted County, MN, USA, from 1975-2011 was reviewed for patient demographics, treatment, and complications. Results A total of 645 impactions occurred, with increasing incidence over time, peaking at 23.2 per year (2000-2004). Medications (almost exclusively glucagon) were successful in relieving impactions 34.5% of the time when trialed. Urgent endoscopy was common (74.0%), as was the need for endoscopic therapy (67.1%). Endoscopic therapy increased over time, with the endoscopic push technique becoming most common. Esophageal complications (deep mucosal injury or perforation) increased over time but remained rare (peak 11%). There was no difference in complications between push and retrieval techniques. Conclusions The endoscopic push technique is safe in comparison to endoscopic retrieval in esophageal food impactions. While complications surrounding impaction have increased, they remain rare. Medication trials are reasonable, as long as they do not delay endoscopy, and may prevent the need for emergent endoscopy in one-third of cases.
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Affiliation(s)
- Daniel A Schupack
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Charles J Lenz
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Debra M Geno
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Crystal J Tholen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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25
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Food Bolus Impaction in the Era of Increased EoE Recognition: Push and Pull, Biopsy and Dilate Before It Is Too Late. Dig Dis Sci 2018; 63:1371-1373. [PMID: 29651583 DOI: 10.1007/s10620-018-5057-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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