Esophageal dilation in eosinophilic esophagitis: safety and predictors of clinical response and complications

Mechanisms and clinical management of eosinophilic oesophagitis: an overview

Since the first description of eosinophilic oesophagitis (EoE) less than three decades ago, we have observed a striking increase in the number of patients diagnosed with EoE and the understanding of its clinical and immunopathogenic background. Nonetheless, a plethora of open questions await elucidation. In this Review, we discuss the current state of knowledge regarding the underlying mechanisms, particularly environmental factors and their interaction with genetic susceptibility. Subsequently, we discuss how to translate these factors into the diagnostic and therapeutic management of this chronic, immune-mediated disorder. Finally, we dissect the still long list of unmet needs, such as reasons for and handling refractory EoE and atypical clinical presentations. These open questions can guide us through future research steps and potentially foster reconsideration of the diagnostic guidelines of EoE.

Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference

Endoscopy plays a critical role in caring for and evaluating the patient with eosinophilic esophagitis (EoE). Endoscopy is essential for diagnosis, assessment of response to therapy, treatment of esophageal strictures, and ongoing monitoring of patients in histologic remission. To date, less-invasive testing for identifying or grading EoE severity has not been established, whereas diagnostic endoscopy as integral to both remains the criterion standard. Therapeutic endoscopy in patients with adverse events of EoE may also be required. In particular, dilation may be essential to treat and attenuate progression of the disease in select patients to minimize further fibrosis and stricture formation. Using a modified Delphi consensus process, a group of 20 expert clinicians and investigators in EoE were assembled to provide guidance for the use of endoscopy in EoE. Through an iterative process, the group achieved consensus on 20 statements yielding comprehensive advice on tissue-sampling standards, gross assessment of disease activity, use and performance of endoscopic dilation, and monitoring of disease, despite an absence of high-quality evidence. Key areas of controversy were identified when discussions yielded an inability to reach agreement on the merit of a statement. We expect that with ongoing research, higher-quality evidence will be obtained to enable creation of a guideline for these issues. We further anticipate that forthcoming expert-generated and agreed-on statements will provide valuable practice advice on the role and use of endoscopy in patients with EoE.

Refractory eosinophilic esophagitis: what to do when the patient has not responded to proton pump inhibitors, steroids and diet

PURPOSE OF REVIEW

Management for patients with refractory eosinophilic esophagitis (EoE) remains a clinical challenge. This review aims to define refractory EoE, explore rates and reasons for nonresponse, and discuss the evidence that informs the approach to these patients.

RECENT FINDINGS

Many patients will fail first-line therapies for EoE. Longer duration of therapy can increase response rates, and initial nonresponders may respond to alternative first-line therapies. There are ongoing clinical trials evaluating novel therapeutics that hold promise for the future of EoE management. Increasingly, there is recognition of the contribution of oesophageal hypervigilance, symptom-specific anxiety, abnormal motility and oesophageal remodelling to ongoing clinical symptoms in patients with EoE.

SUMMARY

For refractory EoE, clinicians should first assess for adherence to treatment, adequate dosing and correct administration. Extending initial trials of therapy or switching to an alternative first-line therapy can increase rates of remission. Patients who are refractory to first-line therapy can consider elemental diets, combination therapy or clinical trials of new therapeutic agents. Patients with histologic remission but ongoing symptoms should be evaluated for fibrostenotic disease with EGD, barium esophagram or the functional luminal imaging probe (FLIP) and should be assessed for the possibility of oesophageal hypervigilance.

Pathophysiology of Dysphagia in Eosinophilic Esophagitis: Causes, Consequences, and Management

Eosinophilic esophagitis (EoE) is a leading cause of food bolus impaction in children and adults. The mechanism of dysphagia in EoE, particularly non-obstructive dysphagia, remains incompletely understood. While fibrostenotic processes appear to be critical in the development of dysphagia, somatosensory dysfunction and dysmotility also contribute. This review considers potential mechanisms of dysphagia and evaluates the utility of current and future treatment strategies in this context.

Immunogenetic, Molecular and Microbiotic Determinants of Eosinophilic Esophagitis and Clinical Practice-A New Perspective of an Old Disease

Eosinophilic oesophagitis (EoE) is a chronic, allergic disease associated with a T-lymphocyte response inducing esophageal eosinophilic infiltration in the esophagus. Inflammation and tissue fibrosis are responsible for the main clinical symptoms such as food impaction and dysphagia. The etiopathogenesis is multifactorial in which genetic and environmental factors coexist. The most common trigger is a non-IgE-mediated food allergy to milk, wheat, egg, soybean, nuts, fish, and seafood. The second factor we focus on is the contribution of genetic variation to the risk of EoE, describing the expression profile of selected genes associated with eosinophilic oesophagitis. We raise the topic of treatment, aiming to eliminate inflammation through an elimination diet and/or use of pharmacologic therapy with the use of proton pump inhibitors or steroids and endoscopic procedures to dilate the esophagus. We demonstrate that early diagnosis and effective treatment prevent the development of food impaction and decreased quality of life. The increasing presence of EoE requires bigger awareness among medical specialists concerning clinical features, the course of EoE, diagnostic tools, and management strategies.

Effect of Maintenance Therapy for Eosinophilic Esophagitis on Need for Recurrent Dilation

BACKGROUND

Eosinophilic esophagitis is an inflammatory condition in which eosinophil infiltration leads to esophageal remodeling and stricturing, with dilation therapy often needed. Achieving histologic remission reduces the need for repeat dilation, although little is known about the effects of long-term maintenance therapy.

AIMS

To further assess the relationship between short-term histologic remission and maintenance therapy on need for repeat dilation in eosinophilic esophagitis.

METHODS

A total of 77 patients with eosinophilic esophagitis (59.7% male; mean age 41.6 years) seen at a single medical center from June 2000 to August 2017 were included. Information on history of dilation and therapy [proton pump inhibitors (PPIs), steroids, elimination diet] was collected. Mean follow-up was 164 weeks. Fifty-one patients achieved histologic remission and 42 of these remained on maintenance therapy (23 PPIs, 14 topical steroids, and 5 dietary therapy). Standard phone interview was completed in cases with lack of follow-up. Only patients who underwent esophageal dilation to ≥ 17 mm were included.

RESULTS

A significantly lower proportion of patients on maintenance therapy required repeat dilation (12/42) compared with patients not on maintenance therapy (8/9) (hazard ratio 0.12; p < 0.001). Of patients who received maintenance therapy, 9.1% required re-dilation. The difference in need for repeat dilation in patients who achieved histologic remission on therapy (14/26) versus those who did not (20/51) was not significant (hazard ratio 1.34; p = 0.45).

CONCLUSION

In a retrospective analysis of patients with eosinophilic esophagitis, we found that a significantly lower proportion who received maintenance therapy (PPIs, steroids, or dietary exclusions) required repeat dilation.

Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome

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.

Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence

The role of endoscopic procedures, in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly. In this context, endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently. This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding. Thus, there is now greater importance on optimal pre, peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding, without increasing the risk of a thromboembolic event as a consequence of therapy interruption. Currently, there are position statements and guidelines from the major gastroenterology societies. These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures, to ensure optimal patient safety. However, since the publication of these guidelines, there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices. Most notably and divergent from current position statements, is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding, suggestive that this practice should be avoided. In addition, there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps (< 10 mm).

Management of Eosinophilic Esophagitis: Dietary and Nondietary Approaches

Eosinophilic esophagitis (EoE) is an allergen-driven chronic inflammatory condition, characterized by symptoms related to esophageal dysfunction and confirmed histologically by esophageal mucosal eosinophilia. Since its first description in the 1990s, the incidence and prevalence of EoE have been on the rise. It is known to affect all ages of various ethnic backgrounds and both sexes; however, it is most seen in White males. Children with EoE often present with abdominal pain, nausea, vomiting, and failure to thrive, whereas adults with EoE typically present with dysphagia and food impaction. Diagnosis of EoE requires histologic confirmation of elevated esophageal eosinophils in a symptomatic patient, and only after secondary causes have been excluded. Because EoE is a chronic and progressively fibrostenotic disease, treatment goals include resolution of symptoms, induction and maintenance of disease remission, and prevention and possibly reversal of fibrostenotic complications, while minimizing treatment-related adverse effects and improving quality of life. Treatment strategies include the "3 D's"-drugs, diet, and dilation. Standard drug therapies include proton-pump inhibitors and topical corticosteroids. Dietary therapies include elemental diet, allergy testing-directed elimination diet, and empiric elimination diets. Endoscopic esophageal dilation for EoE strictures can alleviate esophageal symptoms but has no effect on mucosal inflammation. Recent progress in EoE research has made possible evidence-based clinical guidelines. Ongoing pharmacologic trials show promise for novel biologic agents in the treatment of refractory EoE.

Dysphagia as an Initial Manifestation of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a clinicopathological condition characterized clinically by symptoms of esophageal dysfunction, with typical endoscopic findings and intra-epithelial eosinophilia on biopsy. This case report focuses on the historical aspect of EoE, clinical manifestations, and correlation with immune disorders, medical management, and interventional management of EoE. We present a 20-year-old patient presenting with tightness in throat and odynophagia after the ingestion of certain foods. These symptoms resolve in two or three hours. Endoscopic examination of the upper gastrointestinal tract visualizes esophageal stenosis, and histological examination of the biopsy specimen reveals increased eosinophils in the esophageal mucosa. The patient was treated with fluticasone inhaler and has shown improvement in symptoms. EoE is a chronic esophageal disorder that is increasing in incidence and prevalence in both pediatric and adult age groups. This case report accentuates the complications of EoE, and delays in diagnosis lead to strictures, and fibro-stenotic disease and punctual recognition can govern the course of the disease.

Challenges and updates in the management of eosinophilic esophagitis

Eosinophilic esophagitis (EE) is a chronic T helper cell-2 mediated inflammatory condition and is considered as a primary cause of dysphagia and foregut symptoms. There are many challenges regarding the treatment options of EE. Different therapeutic approaches are best at meeting different endpoints. There are unresolved questions such as whether the goal for treatment should be to control esophageal eosinophilia and inflammation or to achieve symptomatic improvement. Still, proton pump inhibitors are used in differential diagnosis, along with their anti-inflammatory and anti-acid properties. Conducted trials continue to recommend the use of topical corticosteroids and empiric food elimination diets as first-line therapeutic modalities. The growing knowledge on the pathogenesis of EE has allowed further progression of encouraging targeted biologic therapies. However, the guidelines for EE management should be updated accordingly in the coming years, including fast evolving data on non-invasive diagnostic strategies, new treatment modalities, and the long-term prognosis of the disease.

Advancing patient care through the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR)

Recent advances in rare disease research are accelerated by the work of consortia that have been supported by the National Institutes of Health. Development of such consortia rely on multidisciplinary relationships and engagement with patient advocacy groups, as well as the National Institutes of Health and industry and academic partners. In this rostrum we present the development of such a process that focuses on eosinophilic gastrointestinal diseases. Principal investigators, patient advocacy groups, research assistants, and trainees work together to perform natural history studies that promote clinical trial readiness tools, conduct clinical trials, train a new generation of investigators, and perform innovative pilot studies.

Rare Co-occurrence of Eosinophilic Esophagitis and Type 2B von Willebrand Disease: Implications for Endoscopic Surveillance and Esophageal Dilation

Eosinophilic esophagitis (EoE) and type 2B von Willebrand disease (vWD) are both rare diseases, and the co-occurrence is unlikely. Patients with EoE often need recurrent endoscopic dilations and esophageal biopsies, and the safety of these procedures in the setting of bleeding disorders is not well described in the literature. We describe successful management strategies in a patient with co-existing EoE and type 2B vWD who required multiple dilations and biopsies. This approach might be used for patients with other esophageal disorders and type 2B vWD as well.

Factors associated with complications during endoscopic esophageal dilation

BACKGROUND

endoscopic dilation is considered as the treatment of choice for esophageal strictures. However, there are no studies in our region that have assessed the safety of the procedure.

OBJECTIVE

to assess the safety of esophageal dilation and the factors associated with the development of complications.

MATERIALS AND METHODS

a retrospective cohort was studied. All patients referred for esophageal dilation between January 2015 and June 2017 were included in the study. A complication rate was obtained and the association between nonadherence to the "rule of 3" and the development of complications was determined. Other predictive factors associated with complication development were also analyzed.

RESULTS

a total of 164 patients that underwent 474 dilations were included in the study. Surgical anastomosis stricture was the most prevalent etiology. A total of six complications occurred, including three perforations (0.63%), two bleeding events (0.42%) and one episode of significant pain that required post-procedure observation (0.21%). Endoscopic esophageal dilation without adherence to the "rule of 3" was not associated with a higher risk of complications. Balloon dilation was the only predictive factor for complications.

CONCLUSIONS

esophageal dilation is a safe procedure. Nonadherence to the "rule of 3" does not appear to be associated with a higher risk of complications, including esophageal perforation.

Successful Esophageal Dilation of Eosinophilic Esophagitis (EoE) Patients With a Previous Postdilation Complication: Start Low and Go Slow

INTRODUCTION

Esophageal dilation is an effective and safe treatment option for fibrostenotic eosinophilic esophagitis (EoE). Despite the safety, adverse events occur, yet there is scarce literature on the best treatment postcomplications.

METHODS

Patients with diagnosis of EoE (≥15 eosinophils per high-power field) from 2011 to 2015 treated at our center were included. Thirty patients with fibrostenotic disease had records available regarding serial dilation therapy. Eight patients previously experienced complications by outside providers. Groups were created based on history of complication before our dilation versus a group without. Mean difference and odds ratio with 95% confidence interval (CI) were calculated.

RESULTS

There were 8 complications, 7 occurred during dilation and 1 during passage of the endoscope. Esophageal diameter at initial dilation was lower in patients with prior complications 9.0±1.51 versus 11.73±2.98 mm (95% CI: -4.44, -1.02; P=0.003). However, end-esophageal diameter was similar across both groups 15.8±1.8 versus 16.1±2.0 mm. Total number of dilation sessions: 4.0±1.8 versus 2.32±1.0 (95% CI: 0.17, 3.19; P=0.03), as well as sessions to reach 17 mm diameter 3.8±1.0 versus 2.3±1.0 (95% CI: -0.08, 2.89; P=0.04), were higher in the patients with complications. The length of time in months to reach an esophageal diameter of 17 mm was longer in patients with complications, but the difference was not statistically significant 3.50±0.6 versus 2.3±2.3 months (P=0.09).

CONCLUSIONS

Esophageal dilation is a safe and effective modality to treat severe fibrostenotic EoE in patients with prior history of complications. The keys to success are: (1) start with lower diameter bougies and (2) dilate slowly over a longer time course to reach targeted diameter and symptom resolution.

Eosinophilic Esophagitis and the Eosinophilic Gastrointestinal Diseases: Approach to Diagnosis and Management

The eosinophilic gastrointestinal diseases (EGIDs) represent disorders of the gastrointestinal (GI) tract that result from the local infiltration and aberrant activity of eosinophils and other immune cells. Eosinophilic esophagitis (EoE) is the most well-characterized EGID and is defined by the presence of intraepithelial eosinophils in the esophagus (≥15 eosinophils per high-powered field) and clinical symptoms associated with esophageal dysfunction. The other EGIDs are rare and lack strong data regarding pathogenesis and management. The incidence and prevalence of EoE are increasing, and EoE is now a major cause of upper GI morbidity. Management is multidisciplinary, with collaboration between gastroenterologists, allergists, pathologists, and dieticians, and is aimed at amelioration of symptoms and prevention of long-term complications such as esophageal stricture. Treatment options for EoE include proton pump inhibitors, swallowed topical corticosteroids, and elimination diets. Esophageal dilation is used when esophageal strictures or fibrostenotic changes are present. Additional therapies targeting eosinophils and other mediators of Th2 inflammation are under development and are promising. Treatment options for other EGIDs typically involve corticosteroids or dietary elimination.

Esophageal dilation in eosinophilic esophagitis: risks, benefits, and when to do it

PURPOSE OF REVIEW

For patients with eosinophilic esophagitis (EoE), endoscopic dilation has been used primarily to provide immediate symptomatic relief of dysphagia. This report reviews the current position of esophageal dilation in the therapeutic algorithm for EoE, including effectiveness and safety issues.

RECENT FINDINGS

Esophageal strictures in EoE develop as a consequence of long-lasting esophageal eosinophilia, with patient age and diagnostic delay as well established risk factors. Endoscopic dilation leads to immediate symptomatic improvement in 95% of EoE patients who have strictures or narrow caliber esophagus. As dilation has no effect on the underlying eosinophil inflammation, repeated procedures are usually needed to maintain symptoms in remission. Adding an effective drug or dietary-based EoE therapy reduces the need of further dilation. The high rate of severe complications from dilation reported in early literature has not been reproduced in most recent series, with mild postprocedural chest pain as the most common side effect. Current data suggest that the risk of esophageal perforation is less than 1%. Mucosal tears after dilation should no longer be considered a complication, but rather a marker of procedural success.

SUMMARY

Esophageal dilation should be considered in EoE patients with esophageal strictures or narrow caliber esophagus who have persistent dysphagia/food impaction despite an effective anti-inflammatory treatment.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

Endoscopic Treatment of Eosinophilic Esophagitis

In eosinophilic esophagitis, the main cause of solid-food dysphagia is tissue remodeling resulting in strictures and narrowed esophagus. Endoscopy and biopsies help to identify the degree of inflammation but often miss the fibrosis. Although initially considered dangerous, esophageal dilation has evolved into an extremely effective and safe treatment in fibrostenotic disease. The key is starting low with small-diameter bougies or balloons, and gradually dilating the esophagus and strictures to 16 to 18 mm. Results in more than 1000 adults and children have shown low rates of complications, especially perforations, and no deaths, but postprocedure chest pain is common.

The role of endoscopy in eosinophilic esophagitis: from diagnosis to therapy

Eosinophilic esophagitis (EoE) has arisen as a common disorder in current clinical and endoscopic gastroenterology practice. Areas covered: A comprehensive review of the literature to summarize and update different aspects related with the use of endoscopy in the diagnostic workout and treatment of pediatric and adult EoE patients is conducted. Expert commentary: Endoscopic features in EoE are frequently subtle, so were inadverted in some initial reports of the disease. Literature has described a wide number of EoE-associated features, systematized in the EREFS classification, which standardized the grade and severity of exudates, rings, edema, furrows, and strictures. The insufficient reliability of these features to predict eosinophilic inflammation still makes biopsies essential in diagnosing or monitoring EoE. EoE causes half of the food impactions requiring endoscopy; food impaction leads to EoE diagnosis in up to half of cases. Long term consequences of EoE include esophageal remodeling leading to strictures and narrowing, thus impairing symptoms and needs dilation. Recognizing the risks from dilation in EoE required carrying out a safe technique to avoid the high complication rate reported in the early literature. Endoscopic dilation should be considered in patients with esophageal narrowing and dysphagia/food impaction unresponsive to diet or drugs-based anti-inflammatory treatment.

Causes and Outcomes of Esophageal Perforation in Eosinophilic Esophagitis

GOALS

To characterize patients who suffer perforation in the context of eosinophilic esophagitis (EoE) and to identify predictors of perforation.

BACKGROUND

Esophageal perforation is a serious complication of EoE.

MATERIALS AND METHODS

We conducted a retrospective cohort study of the University of North Carolina EoE clinicopathologic database from 2001 to 2014. Subjects were included if they had an incident diagnosis of EoE and met consensus guidelines, including nonresponse to a PPI trial. Patients with EoE who had suffered perforation at any point during their course were identified, and compared with EoE cases without perforation. Multiple logistic regression was performed to determine predictors of perforation.

RESULTS

Out of 511 subjects with EoE, 10 (2.0%) had experienced an esophageal perforation. Although those who perforated tended to have a longer duration of symptoms before diagnosis (11.4 vs. 7.0 y, P=0.13), a history of food impaction (odds ratio, 14.9; 95% confidence interval, 1.7-129.2) and the presence of a focal stricture (odds ratio, 4.6; 95% confidence interval, 1.1-19.7) were the only factors independently associated with perforation. Most perforations (80%) occurred after a prolonged food bolus impaction, and only half of individuals (5/10) carried a diagnosis of EoE at the time of perforation; none occurred after dilation. Six patients (60%) were treated with nonoperative management, and 4 (40%) required surgical repair.

CONCLUSIONS

Esophageal perforation is a rare but serious complication of eosinophilic esophagitis, occurring in ∼2% of cases. Most episodes are due to food bolus impaction or strictures, suggesting that patients with fibrostenotic disease due to longer duration of symptoms are at increased risk.

Esophageal dilation with either bougie or balloon technique as a treatment for eosinophilic esophagitis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Esophageal dilation is a now recognized to be an important therapeutic modality in eosinophilic esophagitis (EoE). We aimed to evaluate the safety of esophageal dilation in EoE, especially regarding perforation risk, and to examine perforation risk by dilator type.

METHODS

We conducted a systematic review of the published literature from January 1, 1950 to June 30, 2016 using PubMed, EMBASE, and Web of Science. Studies were included if they described patients with EoE who underwent elective esophageal dilation and also reported the presence or absence of at least 1 adverse event (eg, perforation, bleeding, pain, or hospitalization). We used random-effects meta-analysis to estimate the frequency of each adverse event.

RESULTS

Of 923 identified articles, 37 met inclusion criteria and represented 2034 dilations in 977 patients. On meta-analysis, postprocedure hospitalization occurred in .689% of dilations (95% confidence interval [CI], 0%-1.42%), clinically significant GI hemorrhage in .028% (95% CI, 0%-.217%), and clinically significant chest pain in 3.64% (95% CI, 1.73%-5.55%). Nine perforations were documented, at a rate of .033% (95% CI, 0%-.226%) per procedure after meta-analysis. None of the perforations resulted in surgical intervention or mortality. Most (5/9) were reported before 2009 (rate, .41% [95% CI, 0%-2.75%]); from 2009 forward the rate was .030% (95% CI, 0%-.225%). Dilation method was described in 30 studies (1957 dilations), in which 4 perforations were detected. The estimated perforation rate for bougies was .022% (95% CI, 0%-.347%) and for balloons was .059% (95% CI, 0%-.374%).

CONCLUSIONS

Perforation from esophageal dilation in EoE is rare, and there is no evidence of a significant difference in perforation risk related to dilator type. Esophageal dilation should be considered a safe procedure in EoE.

Management of Eosinophilic Esophagitis Based on Pathophysiological Evidence

Over the past decades eosinophilic esophagitis (EoE) has been increasingly diagnosed, and significant progress has been made in our understanding of its pathophysiology. As EoE cannot be cured yet, treatment goals are suppression of disease activity and symptoms as well as the prevention of progression to a more severe disease phenotype. Disease-modifying treatment options can be divided into dietary therapy and immunosuppressive medications, of which topical steroids have been most investigated, yet are still prescribed off-label. In this review, we will summarize recent advances in our understanding of EoE and discuss the mechanisms of action of current treatment options, with emphasis on the role of the esophageal epithelial barrier and the effects of proton-pump inhibitors in the management of patients with EoE.

Management of refractory eosinophilic oesophagitis

The goal of this Review is to discuss the clinical approach to patients who do not respond to treatment for eosinophilic oesophagitis (EoE). Refractory EoE is challenging to manage as there are limited data to guide decision-making. In this Review, refractory EoE is defined as persistent eosinophilia in the setting of incomplete resolution of the primary presenting symptoms and incomplete resolution of endoscopic findings following a PPI trial, and after treatment with either topical steroids or dietary elimination. However, this definition is controversial. This Review will examine these controversies, explore how frequently non-response is observed, and highlight potential explanations and predictors of non-response. Non-response is common and affects a large proportion of patients with EoE. It is important to systematically assess multiple possible causes of non-response, as well as consider treatment complications and an incorrect diagnosis of EoE. If non-response is confirmed, second-line treatments are required. Although the overall response rate for second-line therapy is disappointing, with only half of patients eventually responding, there are several promising agents that are currently under investigation, and the future is bright for new treatment modalities for refractory EoE.

Targeting granulocyte-macrophage colony-stimulating factor in epithelial and vascular remodeling in experimental eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic antigen-mediated clinicopathologic disease of the esophagus characterized by an eosinophil-predominant inflammatory infiltrate. A clinical hallmark is extensive tissue remodeling including basal zone hyperplasia, fibrosis, and angiogenesis. However, the cellular mechanisms responsible for these processes are not fully defined. We hypothesized that targeting granulocyte-macrophage colony-stimulating factor (GM-CSF; an agonist cytokine linked with eosinophil survival and activation) would be protective in a preclinical model of EoE.

METHODS

Eosinophilic esophagitis-like esophageal inflammation was induced in the L2-IL5^OXA EoE mouse model, and GM-CSF production was assessed by mRNA and protein analyses. Granulocyte-macrophage colony-stimulating factor-receptor-alpha expression patterns were examined by flow cytometric and immunofluorescence analysis. L2-IL5^OXA EoE mice were treated with anti-GM-CSF neutralizing antibody or isotype control and assessed for histopathological indices of eosinophilia, epithelial hyperplasia, and angiogenesis by immunohistochemistry and RT-PCR.

RESULTS

Significantly increased levels of esophageal GM-CSF expression was detected in the L2-IL5^OXA mouse EoE model during active inflammation. Granulocyte-macrophage colony-stimulating factor-receptor-alpha was predominantly expressed on esophageal eosinophils during EoE, in addition to select cells within the lamina propria. Anti-GM-CSF neutralization in L2-IL5^OXA EoE mice resulted in a significant diminution of epithelial eosinophilia in addition to basal cell hyperplasia and vascular remodeling. This treatment response was independent of effects on esophageal eosinophil maturation or activation.

CONCLUSION

Granulocyte-macrophage colony-stimulating factor is a potential therapeutic target to reduce esophageal eosinophilia and remodeling.

Control of inflammation decreases the need for subsequent esophageal dilation in patients with eosinophilic esophagitis

It is unknown if successful control of esophageal inflammation in eosinophilic esophagitis (EoE) decreases the need for subsequent esophageal dilation. We aimed to determine whether histologic response to topical steroid treatment decreases the likelihood and frequency of subsequent esophageal dilation. We conducted a retrospective cohort study. Patients with an incident diagnosis of EoE were included if they had an initial esophageal dilation, received topical steroids, and had a subsequent endoscopy with biopsies. The number of dilations performed in each group was determined, and histologic responders (<15 eos/hpf) were compared to nonresponders. The 55 EoE patients included (27 responders and 28 nonresponders) underwent a mean of 3.0 dilations over a median follow-up of 19 months. Responders required fewer dilations than nonresponders (1.6 vs. 4.6, P = 0.03), after adjusting for potential confounders. Despite undergoing significantly fewer dilations, responders achieved a similar increase in esophageal diameter with dilation (4.9 vs. 5.0 mm; P = 0.92). In EoE patients undergoing esophageal dilation at baseline, control of inflammation with topical steroids was associated with a 65% decrease in the number of subsequent dilations to maintain the same esophageal caliber. This suggests that inflammation control is an important goal in patients with fibrostenotic changes of EoE.

Systematic review with meta-analysis: endoscopic dilation is highly effective and safe in children and adults with eosinophilic oesophagitis

BACKGROUND

Oesophageal dilation is frequently used as an adjunct treatment to alleviate symptoms that develop from fibrostenotic remodelling in eosinophilic oesophagitis (EoE). Earlier reports described an increased risk of complications associated with dilation.

AIM

Perform a systematic review and meta-analysis to assess the efficacy and safety of endoscopic dilation in children and adults with EoE.

METHODS

Professional librarians searched MEDLINE, EMBASE, the Cochrane library, Scopus, and Web of Science for articles in any language describing studies of dilation in EoE through December 2016. Studies were selected and data were abstracted independently and in duplicate. Random effects modelling was used to generate summary estimates for clinical improvement and complications (haemorrhage, perforation, hospitalisation, and death).

RESULTS

The search resulted in 3495 references, of which 27 studies were included in the final analysis. The studies described 845 EoE patients, including 87 paediatric patients, who underwent a total of 1820 oesophageal dilations. The median number of dilations was 3 (range: 1-35). Clinical improvement occurred in 95% of patients (95% CI: 90%-98%, I² : 10%, 17 studies). Perforation occurred in 0.38% (95% CI: 0.18%-0.85%, I² : 0%, 27 studies), haemorrhage in 0.05% (95% CI: 0%-0.3%, I² : 0%, 18 studies), and hospitalisation in 0.67% (95% CI: 0.3%-1.1%, I² : 44%, 24 studies). No deaths occurred (95% CI: 0%-0.2% I² : 0%, 25 studies).

CONCLUSIONS

Endoscopic dilation is consistently effective in children and adults with EoE, resulting in improvement in 95% of patients with very low rates (<1%) of major complications.

Cost Utility Analysis of Topical Steroids Compared With Dietary Elimination for Treatment of Eosinophilic Esophagitis

BACKGROUND & AIMS

Topical corticosteroids or dietary elimination are recommended as first-line therapies for eosinophilic esophagitis, but data to directly compare these therapies are scant. We performed a cost utility comparison of topical corticosteroids and the 6-food elimination diet (SFED) in treatment of eosinophilic esophagitis, from the payer perspective.

METHODS

We used a modified Markov model based on current clinical guidelines, in which transition between states depended on histologic response simulated at the individual cohort-member level. Simulation parameters were defined by systematic review and meta-analysis to determine the base-case estimates and bounds of uncertainty for sensitivity analysis. Meta-regression models included adjustment for differences in study and cohort characteristics.

RESULTS

In the base-case scenario, topical fluticasone was about as effective as SFED but more expensive at a 5-year time horizon ($9261.58 vs $5719.72 per person). SFED was more effective and less expensive than topical fluticasone and topical budesonide in the base-case scenario. Probabilistic sensitivity analysis revealed little uncertainty in relative treatment effectiveness. There was somewhat greater uncertainty in the relative cost of treatments; most simulations found SFED to be less expensive.

CONCLUSIONS

In a cost utility analysis comparing topical corticosteroids and SFED for first-line treatment of eosinophilic esophagitis, the therapies were similar in effectiveness. SFED was on average less expensive, and more cost effective in most simulations, than topical budesonide and topical fluticasone, from a payer perspective and not accounting for patient-level costs or quality of life.

Dilation of Pediatric Eosinophilic Esophagitis: Adverse Events and Short-term Outcomes

OBJECTIVES

Although several studies report on the experience with adult eosinophilic esophagitis (EoE)-related stricture, outcomes for pediatric patients with EoE-associated fibrostenosis and stricture is more limited. To address this, we aim to identify the adverse event (AE) rate and short-term outcomes of the largest reported cohort of children with EoE to undergo esophageal dilation for management of symptomatic esophageal narrowing.

METHODS

A retrospective assessment of all children, 18 years and younger, who underwent esophageal dilation at an academic children's hospital during a 5-year period was conducted. Clinical, endoscopic, histologic, and outcomes of dilation were extracted from the medical record. AEs were captured within a standardized endoscopic AE database. Grade 2 AEs (requiring unanticipated medical intervention) were termed significant. Dilation-related events were compared between patients with EoE, without EoE, and those undergoing standard upper endoscopy.

RESULTS

Of the 451 total dilations, 68 dilations were performed in 40 EoE patients (mean age 13.8 years, standard deviation 3.3 years [4.6-18.9 years]). Forty-three percent (17/40) had repeat dilation during the study period. Dilation-related grade 2 AE rates in EoE and in non-EoE patients were 2.9% and 3.1%, respectively (P > 0.5). Chest pain (any grade AE) was reported in 14.7% of EoE dilations. No significant associations were found between postprocedural pain and dilation method, final dilator size, medical therapy, or esophageal eosinophilia. No perforations or significant hemorrhage were reported.

CONCLUSIONS

We conclude that dilation can be performed safely in children with EoE. In the appropriate clinical setting, cautious dilation may be considered in the management of fibrostenotic EoE.

Role of endoscopic esophageal dilation in managing eosinophilic esophagitis: A systematic review and meta-analysis

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disorder of the esophagus characterized by mucosal eosinophilic infiltration. Topical glucocorticoids are considered standard line of treatment, whereas endoscopic dilations are performed for patients presenting with treatment-resistant disease or manifestations of dysphagia and/or food impactions. Efficacy and safety of esophageal dilation in these patients are currently unclear.

AIMS

Primary outcomes were to evaluate the efficacy, adverse events, and mortality rates of endoscopic esophageal dilation in patients with EoE.

METHODS

STUDY SELECTION CRITERIA:: Studies that reported the use of esophageal dilation in EoE patients were included in this meta-analysis.

DATA COLLECTION AND EXTRACTION

Articles were searched in Medline, Pubmed, and Ovid journals. Two authors independently searched and extracted data. The study design was written in accordance to PRISMA statement. Clinical improvement was defined as patient-reported symptom relief noted by the authors of individual studies. The symptoms were assessed on various nonstandardized, however, relevant questionnaires that were deemed appropriate by the senior authors of individual studies.

STATISTICAL METHOD

Pooled proportions were calculated using fixed- and random-effects model. I statistic was used to assess heterogeneity among studies.

RESULTS

Initial search identified 491 reference articles, in which 39 articles were selected and reviewed. Data were extracted from 14 studies (N = 1607) using esophageal dilation for EoE management, which met the inclusion criterion. Mean age of patients was 41years. Pooled patients included 75% males. The pooled proportion of patients that showed clinical improvement with esophageal dilations, after the median follow-up period of 12 months, was 84.95%. No procedure-related deaths were noted. The pooled proportion of patients with post procedural esophageal perforation, chest pain, hospitalization, deep mucosal tear (involving muscularis propria), small mucosal tear, and hemorrhage were 0.61%, 0.06%, 0.74%, 4.04%, 22.32%, and 0.38% respectively. I (inconsistency) was 0% (95% confidence interval [CI] = 0-49.8) and Egger: bias was 0.06 (95% CI = -0.30 to 0.42).

CONCLUSIONS

In patients with conformed diagnosis of EoE, endoscopic esophageal dilation seems to be an effective and safe treatment option. Majority patients with chest pain and deep mucosal tears did not require hospitalization and symptoms were self-limiting.

Eosinophilic esophagitis: Update in diagnosis and management. Position paper by the Italian Society of Gastroenterology and Gastrointestinal Endoscopy (SIGE)

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease of the esophagus characterized by symptoms related to esophageal dysfunction, as well as significant esophageal eosinophilia. The entity exists worldwide but has been most extensively studied in Western countries. However, a wide range of symptoms has been noticed such as chest pain or gastro-esophageal reflux disease-like symptoms. Upper gastro-intestinal endoscopy and esophageal biopsies are crucial for the diagnosis. Endoscopy might be normal or reveal typical patterns such as rings, furrows, exudates, edema, and stricture. Two to four biopsies should be performed both in the distal and in the proximal esophagus, and 15 eosinophils per high power field within the esophageal epithelium are the minimal threshold to diagnose eosinophilic esophagitis. Allergy testing is recommended, although its impact to orient treatment remains to be demonstrated. Eosinophilic esophagitis treatment includes medical treatment, diet and endoscopic dilation. Proton pump inhibitors are the first-line therapy as up to 50% of patients respond well to proton pump inhibitors irrespective of objective evidence of GERD. Topical viscous corticosteroids or elimination diet are the treatment of choice in case of unresponsiveness to proton pump inhibitors.

Non-adherence to the rule of 3 does not increase the risk of adverse events in esophageal dilation

BACKGROUND AND AIMS

Although the rule of 3 is recommended to minimize the risk of perforation when esophageal dilation is performed using bougie dilators, there are no data to validate its use. Our aim was to investigate the association between the rule of 3 and adverse events (AEs) in esophageal dilation.

METHODS

A retrospective chart review in patients who underwent esophageal bougie or balloon dilation between December 1991 and February 2013 at a tertiary hospital was performed. Data collection included patient demographics, stricture and procedural characteristics, AEs, and follow-up. Univariate logistic regression models were used to assess the risk of AEs and perforations.

RESULTS

A total of 297 patients (median age, 63 years; 60% men) underwent 2216 esophageal bougie or balloon dilations. Major AEs occurred in 22 (1%) dilation sessions, including 11 (0.5%) perforations, 4 (0.2%) fistulas, 3 (0.1%) hospitalizations for pain management, 2 (0.09%) clinically significant hemorrhages, 1 (0.04%) fever, and 1 (0.04%) tracheoesophageal voice prosthesis leak. Mean duration of treatment was 43.2 months (standard deviation, 47.7 months). Most strictures were benign (n = 275; 93%) and complex in nature (n = 198; 67%). Non-adherence to the rule of 3 occurred in 190 (13%) dilations with bougie dilators. Non-adherence was not associated with a higher rate of major AEs (1/190, 0.5% vs 15/953, 1.6%; P = .18) and perforations (0/190, 0% vs 7/952, 0.7%; P = .18). Gender, complex strictures, location of the stricture, type of dilator, and additional interventions were also not associated with major AEs or perforations. However, malignant strictures were associated with an increased risk of major AEs (odds ratio, 3.5; 95% confidence interval, 1.1-12.0) and perforations (odds ratio, 8.3; 95% confidence interval, 2.2-31.9).

CONCLUSIONS

Non-adherence to the rule of 3 does not appear to increase the risk of AEs, particularly perforation, after esophageal dilation using bougie dilators. Caution is needed with the dilation of malignant strictures, as there is an increased risk of perforations and AEs. However, large prospective studies are needed to verify the results of this study.

Randomized controlled trial comparing esophageal dilation to no dilation among adults with esophageal eosinophilia and dysphagia

The role of esophageal dilation in patients with esophageal eosinophilia with dysphagia remains unknown. The practice of dilation is currently based on center preferences and expert opinion. The aim of this study is to determine if, and to what extent, dysphagia improves in response to initial esophageal dilation followed by standard medical therapies. We conducted a randomized, blinded, controlled trial evaluating adult patients with dysphagia and newly diagnosed esophageal eosinophilia from 2008 to 2013. Patients were randomized to dilation or no dilation at time of endoscopy and blinded to dilation status. Endoscopic features were graded as major and minor. Subsequent to randomization and endoscopy, all patients received fluticasone and dexlansoprazole for 2 months. The primary study outcome was reduction in overall dysphagia score, assessed at 30 and 60 days post-intervention. Patients with severe strictures (less than 7-mm esophageal diameter) were excluded from the study. Thirty-one patients were randomized and completed the protocol: 17 randomized to dilation and 14 to no dilation. Both groups were similar with regard to gender, age, eosinophil density, endoscopic score, and baseline dysphagia score. The population exhibited moderate to severe dysphagia and moderate esophageal stricturing at baseline. Overall, there was a significant (P < 0.001) but similar reduction in mean dysphagia score at 30 and 60 days post-randomization compared with baseline in both groups. No significant difference in dysphagia scores between treatment groups after 30 (P = 0.93) or 60 (P = 0.21) days post-intervention was observed. Esophageal dilation did not result in additional improvement in dysphagia score compared with treatment with proton pump inhibitor and fluticasone alone. In patients with symptomatic esophageal eosinophilia without severe stricture, dilation does not appear to be a necessary initial treatment strategy.

Managing eosinophilic esophagitis: challenges and solutions

Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated condition defined by symptoms of esophageal dysfunction and dense eosinophilic infiltration of the esophageal mucosa. Therapies consist of anti-eosinophilic medications and specialized diets aimed to decrease the progression of EoE and alleviate its symptoms, namely, dysphagia and food impaction. Assessing response to therapy remains challenging, as treatment end points are not well defined and currently consist of clinical, histologic, and endoscopic features. Newer validated measures may help standardize treatment end points. Emerging data support the use of maintenance therapy, which may reduce disease progression. Optimal dosages, delivery techniques, and duration of treatment need to be determined. When features of fibrostenosis develop, esophageal dilation is a safe and effective adjunctive strategy for improving symptoms. In EoE cases refractory to conventional treatments, newer therapies targeting inflammatory mediators and cytokines are on the horizon.

Diagnosis and Treatment of Eosinophilic Esophagitis in Adults

Eosinophilic esophagitis is a relatively recently discovered disease of increasing incidence and prevalence and is a common cause of dysphagia and food bolus impaction. The definition of eosinophilic esophagitis continues to evolve, most recently with the characterization of proton pump inhibitor-responsive esophageal eosinophilia. The number of high-quality prospective, controlled trials guiding therapeutic decisions in eosinophilic esophagitis has increased steadily over the past several years. Treatment options at present focus on dietary therapy, particularly implementation of a 6-food elimination diet, and medical therapy, primarily the use of swallowed, topical corticosteroids. Proton pump inhibitors play an important role in current management. Conservative esophageal dilation is effective at ameliorating dysphagia in symptomatic patients with esophageal strictures. We conducted an evidence-based review of the diagnosis and treatment options in adults with eosinophilic esophagitis. The understanding of eosinophilic esophagitis continues to be refined. Continued validation of appropriate endpoints, however, is essential to establish the efficacy of existing and novel therapeutic approaches.

An Overview of the Diagnosis and Management of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by symptoms of esophageal dysfunction and eosinophilic infiltration of the esophageal mucosa. The diagnosis requires esophageal biopsies demonstrating at least 15 eosinophils per high-powered field following a course of high-dose proton pump inhibitors. Management of EoE consists of the three Ds: drugs, dietary therapy, and esophageal dilation. In this review, we discuss the epidemiology, pathogenesis, diagnosis, and treatment of EoE to include the role of emerging therapies.

Eosinophilic Esophagitis Dilation in the Community--Try It--You will Like It--But Start Low and Go Slow

The saga of esophageal dilation for patients with eosinophilic esophagitis and strictures reads like a historical novel. Currently, data from over 500 eosinophilic esophagitis (EoE) patients now convincingly prove that esophageal dilation is effective for prolonged relief and safe. It can easily be performed in the gastroenterologists community but follow the basic tenets of starting low with small diameter bougies/balloons and progressing slowly as you gradually dilate these strictures to 16-18 mm. Table 1 outlines my approach.

Impact of Diagnostic Delay and Other Risk Factors on Eosinophilic Esophagitis Phenotype and Esophageal Diameter

GOALS

Endoscopic features of eosinophilic esophagitis (EoE) are variable with at least 2 phenotypes. The goal of this study was to classify adult EoE patients based on esophageal phenotype and diameter, and assess an association between demographical and clinical histories to define EoE phenotypes and overall disease progression.

METHODS

All consecutive patients with a confirmed diagnosis of EoE from 1988 to 2013 treated at University of South Florida were included. Patients were grouped into inflammatory or fibrostenotic phenotype, and further characterized by esophageal diameter: group 1 (6 to 9.9 mm), group 2 (10 to 16.9 mm), and group 3 (>17 mm-control). Significance level was set at 5%.

RESULTS

Sixty-four adult patients met inclusion criteria. Sixty-one percent of patients (39/64) were defined as fibrostenotic and 39% (25/64) as inflammatory phenotype. There was a significant difference in mean time of delayed diagnosis in patients with <10 mm esophageal diameter (14.8 y) and patients with a diameter of 10 to 16.9 mm (11.1 y) compared with patients with an esophageal diameter of ≥17 mm (5 y); P=0.002 and 0.006, respectively. Patients on aspirin with delayed diagnosis (>7 y) were significantly more likely to present with strictures (<10 mm) compared with nonaspirin users [odds ratio (OR=7.0; 95% confidence interval (CI), 7.2-31.3; P=0.008]. Similar results were found with non-steroid anti-inflammatory drugs, smoking, and alcohol (OR=6.4; 95% CI, 1.6-26.4; P=0.01, OR=5.2; 95% CI, 1.4-20.1; P=0.02, and OR=6.4; 95% CI, 1.6-26.0; P=0.009), respectively.

CONCLUSIONS

In our US population, a delay in diagnosis was shown to be associated with stricture formation in EoE confirming the Swiss experience. The results show the importance of reducing the diagnostic delay in EoE as there appears to be progression to fibrosis over time, aggravated by common medications and social habits.

Outcomes of Esophageal Dilation in Eosinophilic Esophagitis: Safety, Efficacy, and Persistence of the Fibrostenotic Phenotype

OBJECTIVES

Esophageal dilation is commonly performed in eosinophilic esophagitis (EoE), but there are few long-term data. The aims of this study were to assess the safety and long-term efficacy of esophageal dilation in a large cohort of EoE cases, and to determine the frequency and predictors of requiring multiple dilations.

METHODS

We conducted a retrospective cohort study in the University of North Carolina EoE Clinicopathological Database from 2002 to 2014. Included subjects met consensus diagnostic criteria for EoE. Clinical, endoscopic, and histologic features were extracted, as were dilation characteristics (dilator type, change in esophageal caliber, and total number of dilations) and complications. Patients with EoE who had undergone dilation were compared with those who did not and also stratified by whether they required single or multiple dilations.

RESULTS

Of 509 EoE patients, 164 were dilated a total of 486 times. Those who underwent dilation had a longer duration of symptoms before diagnosis (11.1 vs. 5.4 years, P<0.001). Ninety-five patients (58%) required >1 dilation (417 dilations total, mean of 4.4±4.3 per patient). The only predictor of requiring multiple dilations was a smaller baseline esophageal diameter. Dilation was tolerated well, with no major bleeds, perforations, or deaths. The overall complication rate was 5%, primarily due to post-procedural pain. Of 164 individuals dilated, a majority (58% or 95/164) required a second dilation. Of these individuals, 75% required repeat dilation within 1 year.

CONCLUSIONS

Dilation in EoE is well-tolerated, with a very low risk of serious complications. Patients with long-standing symptoms before diagnosis are likely to require dilation. More than half of those dilated will require multiple dilations, often needing a second procedure within 1 year. These findings can be used to counsel patients with fibrostenotic complications of EoE.

Current Management of Eosinophilic Esophagitis 2015

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition characterized by esophageal dysfunction and eosinophilic infiltrate (≥15/hpf) in the esophageal epithelium and the absence of other potential causes of eosinophilia. The prevalence is increasing and is the most common cause of solid food dysphagia in children and young adults. This article will review the diagnosis and management of EoE based on consensus conferences, systematic reviews, and meta-analysis and highlights seminal studies in our evolving treatment of this disease. However, all answers are not available and I will remark about the lessons learned in my clinical practice seeing EoE patients over the last 25 years. The complicated etiology of the complaint of dysphagia in EoE patients will be reviewed. The importance of utilizing endoscopy, biopsies, and barium esophagram to help define the 2 phenotypes (inflammatory, fibrostenosis) of EoE will be highlighted. The controversy about PPI-responsive esophageal eosinophilia will be discussed and contrasted with idiopathic EoE. Finally, the 3 treatment options for EoE (drugs, diet, dilation) will be reviewed in detail and a useful clinical management algorithm presented.

Esophageal dilation in eosinophilic esophagitis

Tissue remodeling with scaring is common in adult EoE patients with long standing disease. This is the major factor contributing to their complaints of solid food dysphagia and recurrent food impactions. The best tests to define the degree of remodeling are barium esophagram, high resolution manometry and endoscopy. Many physicians are fearful to dilate EoE patients because of concerns about mucosal tears and perforations. However, multiple recent case series attest to the safety of esophageal dilation and its efficacy with many patients having symptom relief for an average of two years. This chapter will review the sordid history of esophageal dilation in EoE patients and outline how to perform this procedure safely. The key is graduated dilation over one to several sessions to a diameter of 15-18 mm. Postprocedural pain is to be expected and mucosal tears are a sign of successful dilation, not complications. In some healthy adults, occasional dilation may be preferred to regular use of medications or restricted diets. This approach is now supported by recent EoE consensus statements and societal guidelines.

Management of proton pump inhibitor responsive-esophageal eosinophilia and eosinophilic esophagitis: controversies in treatment approaches

Eosinophilic esophagitis (EoE) is a chronic immune-mediated clinicopathologic disease. The prevalence of EoE is approximately 1/2000 persons, EoE is now the most common cause of food impactions, with healthcare expenditures approaching US$ 1 billion annually. This article will discuss challenges related to proton pump inhibitor responsive esophageal eosinophilia, including distinguishing this condition from EoE and understanding the mechanisms behind the PPI response. For EoE, we will review multiple ongoing debates about treatment and monitoring strategies, including selecting treatment outcomes, optimizing medication formulations, approaching the steroid-refractory patient, conducting dietary elimination, prescribing long-term maintenance therapy and performing esophageal dilation.