Esophageal foreign-body impactions: epidemiology, time trends, and the impact of the increasing prevalence of eosinophilic esophagitis

Timing of Endoscopic Intervention for Esophageal Food Impaction and Its Impact on Patient Outcomes

INTRODUCTION

Esophageal food impaction (EFI) is a common complaint of patients presenting to the emergency department. EFI requires urgent evaluation by the gastroenterology service and often necessitates esophagogastroduodenoscopy (EGD) for management. Timing of EGD in patients with EFI that does not improve with medical management remains a point of contention. We aim to evaluate outcomes of EFI in the context of time to intervention.

METHODS

A retrospective cohort study was performed among patients who presented to a multicenter health system with EFI between 2018 and 2022. Patients with EFI that did not resolve after medical management and required EGD were included. Outcome analysis evaluated rates of complications and hospitalizations.

RESULTS

Two hundred eighty sis unique patient presentations were included. 175 (61.2%) of patients underwent EGD within six hours of presentation, 59 (20.6%) underwent EGD six to twelve hours after presentation, and 52 (18.2%) underwent EGD beyond twelve hours after presentation. Complication rates did not differ between patients depending on timing of EGD (p = 1.000). Admission rates were higher among patients in whom EGD was performed longer after presentation (p = 0.003). Complication rates were higher among patients with advanced age (p = 0.037), prior impaction (p = 0.004), and those who have not received glucagon (p = 0.007).

CONCLUSION

Timing of EGD after presentation in patients with EFI was not associated with a difference in complication rates. Delayed intervention was associated with a higher rate of hospitalization which should be taken into consideration when assessing the cost of EFI to the healthcare system.

Quality of Life in Children With Eosinophilic Esophagitis in Saudi Arabia

INTRODUCTION

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus that can adversely affect the quality of life (QOL) in children. We aim to investigate the burden of EoE on the QOL in children aged 2-18 years and identify factors that influence their QOL.

METHOD

A multicenter cross-sectional study was conducted in six Saudi pediatric hospitals. Pediatric Quality of Life 3.0 EoE Module was used to measure the QOL of children with EoE.

RESULTS

Thirty-six families (36 parents and 33 children) were enrolled. The most reported symptoms were vomiting (50%), dysphagia (44.4%), and food impaction (36.1%). The mean total score of the parent-proxy report of the Pediatric Quality of Life EoE was 82.9 ± 10.3 versus the children's self-reported score of 77.28 ± 13.6 (p = .043).

DISCUSSION

Recurrent emergency department visits were associated with a lower QOL, and a positive family history of EoE was associated with a better QOL.

The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis - Definition, Clinical Presentation and Diagnosis

Eosinophilic esophagitis (EoE) is a chronic type 2-mediated inflammatory disease of the esophagus that represents the most common eosinophilic gastrointestinal disease. Experts in the field of EoE across Italy (i.e., EoETALY Consensus Group) including gastroenterologists, endoscopists, allergologists/immunologists, and paediatricians conducted a Delphi process to develop updated consensus statements for the management of patients with EoE and update the previous position paper of the Italian Society of Gastroenterology (SIGE) in light of recent evidence. Grading of the strength and quality of the evidence of the recommendations was performed using accepted GRADE criteria. The guideline is divided in two documents: Part 1 includes three chapters, namely 1) definition, epidemiology, and pathogenesis; 2) clinical presentation and natural history, and 3) diagnosis, while Part 2 includes two chapters: 4) treatment and 5) monitoring and follow-up. This document has received the endorsement of three Italian national societies including the SIGE, the Italian Society of Neurogastroenterology and Motility (SINGEM), and the Italian Society of Allergology, Asthma, and Clinical Immunology (SIAAIC). With regards to patients' involvement, these guidelines involved the contribution of members of ESEO Italia, the Italian Association of Families Against EoE.

Clinical Evaluation of the Adult with Eosinophilic Esophagitis

Adult patients with eosinophilic esophagitis (EoE) typically present with a history of dysphagia for solids, sometimes with additional reflux-like pain and a history of prior food impactions. In contrast to these alarming symptoms, the general appearance and physical examination of adult patients with EoE is in line with apparently healthy individuals. Therefore, the diagnosis is based on a history of solid-food dysphagia and eosinophilic tissue infiltration. Importantly, the increasing prevalence of EoE variants, that is, typical EoE symptoms in the absence of a relevant eosinophilia, and several studies with eosinophil-targeting drugs, call the pathogenic role of eosinophils into question.

Association between time from esophageal food impaction to endoscopy and adverse events

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.

Endoscopic Management of a Long-Duration Esophageal Food Impaction: A Case Report

Foreign object ingestion (FOI) is a potentially life-threatening pathology that affects all ages, from children to older adults. The classification includes true FOI and esophageal food impaction (EFI), and each presents unique challenges. Endoscopic intervention is often required to prevent complications. Flexible endoscopes are the preferred management tool, ensuring a high success rate and safety. The following text presents a case of a 48-year-old male with a 5-day undiagnosed esophageal food impaction and the approach taken.

Pediatric Patients with Eosinophilic Esophagitis and Their Parents Identify Symptoms as the Most Important Treatment Outcome

INTRODUCTION

Given the lack of data, we aimed to explore which therapeutic endpoints pediatric patients with eosinophilic esophagitis (EoE) and their parents consider to be relevant.

METHODS

We created an educational brochure on EoE and a questionnaire, both of which were content-validated by pediatric patients and parents. Validated documents were sent to 112 patients and parents. They ranked the importance (5 levels) of short (during next 3 months) and long-term (≥1 year) treatment effect on symptoms, quality of life, endoscopic inflammation, stricture formation, histological inflammation, and fibrosis.

RESULTS

A total of 45 parents and 30 pediatric patients ≥11 years completed the questionnaires. Pediatric patients identified improvement in the following domains as most important in the short- and long-term, respectively: symptoms (73% vs. 77%), QoL (53% vs. 57%), histologic inflammation (47% vs. 50%), histologic fibrosis (40% vs. 33%), endoscopic inflammation (47% vs. 40%), and strictures (33% vs. 40%). Parents of children ≥11 years old classified improvement in the following domains as most important in the short- and long-term, respectively: symptoms (70% vs. 83%), QoL (63% vs. 80%), histologic inflammation (67% vs. 77%), histologic fibrosis (47% vs. 63%), endoscopic inflammation (77% vs. 80%), and strictures (40% vs. 53%). Agreement between caregiver and children on the short-term importance of treatment outcomes was as follows: symptoms (77%), QoL (40%), histologic inflammation and fibrosis (47% and 43%), endoscopic inflammation and strictures (50% and 40%).

CONCLUSION

Pediatric patients and parents attributed most importance to improvement in symptoms and QoL. Agreement between parents and patients regarding therapy goals is limited.

A Case Report of Food Impaction Relieved by Warm Water Drinking Therapy

BACKGROUND

Emergency department (ED) management of esophageal food impaction without high-grade obstruction is highly variable, without definitive and validated interventions being supported in medical literature.

CASE REPORT

We discuss a 34-year-old male patient with diagnosis of eosinophilic esophagitis and history of multiple food impactions presenting to the ED with a food impaction. Based on a known esophageal history with repeated failure of pharmacologic interventions, the patient was submitted to a new conservative treatment of warm water drinking. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report suggests warm water ingestion as a novel, safe, and successful treatment method in the management of esophageal food bolus impaction. As a conservative treatment not deviating greatly from current ED treatment options, it can reduce patient length of stay and decrease exposure to potential morbidity via invasive endoscopic or surgical intervention. It should be further investigated and validated with a large cohort study.

Forty years of Helicobacter pylori infection and changes in findings at esophagogastroduodenoscopy

BACKGROUND

It is 40 years since the discovery of Helicobacter pylori infection. Over that time major changes have occurred in esophagogastroduodenoscopy (EGD) findings. The aim of this review is to describe these changes, and the important role H. pylori infection has played in their evolution.

METHODS

References were identified through searches of PubMed using the search terms-endoscopy time trends, peptic ulcer disease, gastroesophageal reflux disease, upper gastrointestinal cancer, gastric polyps, H. pylori, eosinophilic gastrointestinal disorders, and celiac disease, from 1970 through December 2021.

RESULTS

The prevalence of H. pylori infection has fallen and consequently, H. pylori-positive peptic ulcer disease has become rare. Gastroesophageal reflux disease is now the commonest disorder diagnosed at EGD, and Barrett's esophagus has increased in parallel. Cancer of the distal stomach has fallen while esophageal adenocarcinoma and reflux-related cardia cancer have risen. Gastric polyps have changed from hyperplastic and adenomas to sporadic fundic gland polyps. Antimicrobial resistance has made H. pylori infection more difficult to eradicate. Eosinophilic gastrointestinal disorders, particularly eosinophilic esophagitis, have emerged as important new allergic disorders. Celiac disease has changed and increased.

CONCLUSIONS

EGD findings appear to have changed from features suggesting a H. pylori-positive "phenotype" 40 years ago to a H. pylori-negative "phenotype" today. These changes have major implications for the management of gastrointestinal disorders.

Epidemiologic Burden and Projections for Eosinophilic Esophagitis-Associated Emergency Department Visits in the United States: 2009-2030

BACKGROUND & AIMS

Patients with poorly controlled eosinophilic esophagitis (EoE) may require unplanned emergency department (ED) visits for the management of dysphagia or food impactions. We evaluated the epidemiologic burden of EoE on ED utilization in the United States.

METHODS

Data from the US Nationwide Emergency Department Sample were used to estimate weighted annual EoE-associated ED visits from 2009 to 2019. Temporal trends in population-adjusted rates of EoE visits were assessed using joinpoint regression. Autoregressive integrated moving average models were used to project EoE-associated ED visits to 2030. We also evaluated endoscopic utilization, requirement for hospitalization, and ED-related charges in patients with EoE presenting to the ED.

RESULTS

A total of 11,125 unweighted (49,507 weighted) ED visits for EoE were included (69.0% male; mean age, 32.4 y). The annual volume of EoE-associated ED visits increased from 2934 (95% CI, 2437-3431) in 2009 to 8765 (95% CI, 7514-10,015) in 2019, and is projected to reach 15,445 (95% prediction interval, 14,672-16,218) by 2030. From 2009 to 2019, the number of EoE-associated ED visits increased by an average of 11.5% per year (95% CI, 10.3%-12.7%). The proportion of patients admitted to the hospital from the ED decreased from 25.6% in 2009 to 2011 to 14.0% in 2017 to 2019. Half of EoE patients presenting to the ED required an endoscopy, and nearly 40% required an esophageal foreign body removal. Total mean inflation-adjusted charges for an EoE-associated ED visit were $9025 US dollars in 2019.

CONCLUSIONS

The volume of EoE-associated ED visits tripled between 2009 and 2019 and is projected to further double by 2030. This represents a substantial burden of unanticipated health care resource utilization and highlights a potential opportunity to optimize outpatient EoE care.

Postendoscopy Care for Patients Presenting With Esophageal Food Bolus Impaction: A Population-Based Multicenter Cohort Study

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.

Time trends and endoscopic management of foreign body ingestion in the upper GI tract: a retrospective analysis of 1,152 cases in China

OBJECTIVES

foreign body ingestions are encountered in the clinical practice and sometimes require endoscopic management. However, time trends and epidemiology of these cases have not been fully clarified. Whether seasons and festivals have an effect on the occurrence has been poorly described.

METHOD

from 2009 to 2020, 1,152 consecutive foreign body ingestion cases were enrolled in our endoscopic center. Case records were reviewed for demographic data, foreign body type and location, outpatient or hospitalization, adverse events and dates. Annual time trends and seasonal variation were analyzed as well as the influence of Chinese legal festivals on the incidence. The impact of SARS-CoV-2 pandemic on the potential delay for clinical consultation of these cases was preliminarily explored. Clinical features of these cases were demonstrated.

RESULTS

the overall success rate was 99.7 % and the adverse events rate was 2.4 %. There was an uptrend in the annual frequency of food foreign body ingestion endoscopic extraction from 0.65 in 2009 to 8.86 in 2020 per 1,000 esophagogastroduodenoscopy patients (r = 0.902, p < 0.001). Furthermore, the frequency of endoscopic extraction significantly increased in winter (p < 0.001) and during Chinese New Year celebratory season (p = 0.003). The duration of hospitalization may be longer in the pandemic period (p = 0.0049).

CONCLUSION

considering the uptrend of the annual frequency of food related foreign body endoscopic extraction, the publicity about the danger of foreign body ingestion should be enhanced. Arrangement of endoscopic physicians and assistants during the high-incidence season should be emphasized.

Novel corticosteroid formulations in the treatment of eosinophilic esophagitis: what is the evidence?

Background and study aims

Eosinophilic esophagitis (EoE) is a food allergen-induced disease of the esophagus. Chronic, eosinophil-predominant inflammation eventually leads to fibrosis, esophageal dysfunction and severe morbidity. Swallowed topical corticosteroids (STCs) are a mainstay of anti-inflammatory therapy in the treatment of active EoE. Data on the efficacy of novel corticosteroid formulations, developed specifically for esophageal delivery, have recently become available.

Methods

A comprehensive review was performed aiming to summarize evidence on the role of STCs in the treatment of EoE. Two biomedical bibliographic databases (PubMED, EMBASE) were searched for articles providing original information on the efficacy and safety of STCs in adult EoE patients.

Results

Budesonide orodispersible tablet (BOT) and budesonide oral suspension (BOS) both surpassed placebo formulations regarding the efficacy of inducing and maintaining histologic, symptomatic and endoscopic remission. Overall, BOT displayed the highest grade of efficacy with clinico-histologic remission rates up to 75% after 1 year. Fluticasone propionate (APT-1011) achieved and maintained histologic and endoscopic responses in the majority of patients, whereas only a positive trend was demonstrated for symptomatic improvement. Mometasone and ciclesonide were studied in a limited number of smaller-scale trials and placebo-controlled data are required to substantiate the promising findings. All STCs displayed a similar side effects profile and were generally considered safe and well-tolerated.

Conclusions

Current evidence supports long-term treatment with novel corticosteroid formulations, challenging the established treatment paradigm of EoE. BOT appears to be the most effective steroid therapy, although head-to-head comparative trials between STCs are needed.

Impact of anxiety and depression on the swallowing process among patients with neurological disorders and head and neck neoplasia: systemic review

Background

Dysphagia is associated with depression and anxiety due to the severity, impact of symptoms itself or secondary to the underlying cause. This is more recognizable to brain diseases that has consequences common to the neural supply of the swallowing act and the cognition and behavior. Limited data are available to explore, quantitate and monitor these neurological outcomes. Our aim of this research to review the literature pertinent to depressive disorders, anxiety, and/or the quality of life (QoL) and psychological well-being. Search of Medline and Google Scholar databases for relevant articles had revealed a total of 1568 citations; 30 articles met the inclusion and exclusion criteria.

Results

Data about the direct effect of dysphagia on psychiatric aspects are limited. Studies of the relationship between severity of dysphagia and depressive symptoms demonstrated that several evaluation tools are available for objective and subjective assessment. The severity and progression of dysphagia was significantly associated with increased depressive symptoms.

Conclusion

Dysphagia is associated with and positively correlated to depression and anxiety scores observed in Parkinson disease (PD), multiple sclerosis (MS) and stroke. Similar association is observed in patients with head and neck cancer, tongue cancer and oral cancer. A bidirectional positive correlation exists with a vicious circle that loops between dysphagia and psychological disease. Moreover, the severity of dysphagia shows correlation with depression and/or anxiety scores (Fig. 1, Graphical abstract).

Graphical Abstract

Diagnosis of Eosinophilic Esophagitis at the Time of Esophageal Food Impaction

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.

Navigating the Esophagus: Effective Strategies for Foreign Body Removal

Foreign body ingestion is a common medical emergency that can affect individuals of all ages and can be caused by various factors, including accidental ingestion, psychiatric disorders, intellectual disabilities, and substance abuse. The most common site for foreign body lodgment is the upper esophagus, followed by the middle esophagus, stomach, pharynx, lower esophagus, and duodenum. This article provides a case report of a 43-year-old male patient with a history of schizoaffective disorder and an indwelling suprapubic catheter who presented to the hospital due to foreign body ingestion. After examination, a metal clip from his Foley catheter was found lodged in his esophagus. The patient was intubated for the procedure, and an emergent endoscopic removal was performed to remove the metallic Foley component. No postoperative complications were observed, and the patient was successfully discharged. This case highlights the importance of considering foreign body ingestion in patients with chest pain, dysphagia, and vomiting. Prompt diagnosis and treatment are crucial to prevent potential complications such as perforation or gastrointestinal tract obstruction. The article also emphasizes the need for healthcare providers to know the different risk factors, variations, and common sites for foreign body lodgment to optimize patient care. Furthermore, the article highlights the importance of multidisciplinary care involving psychiatry and surgery to provide comprehensive care to patients with psychiatric disorders who may be at higher risk for foreign body ingestion. In conclusion, foreign body ingestion is a typical medical emergency that requires prompt diagnosis and treatment to prevent complications. This case report highlights the successful management of a patient with foreign body ingestion and emphasizes the importance of multidisciplinary care to optimize patient outcomes.

Esophageal disease and loss to follow-up are common among patients who experience non-endoscopic resolution of food impaction

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.

Endoscopic Diagnosis of Eosinophilic Esophagitis: Basics and Recent Advances

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease, characterized by esophageal dysfunction and intense eosinophil infiltration localized in the esophagus. In recent decades, EoE has become a growing concern as a major cause of dysphagia and food impaction in adolescents and adults. EoE is a clinicopathological disease for which the histological demonstration of esophageal eosinophilia is essential for diagnosis. Therefore, the recognition of the characteristic endoscopic features with subsequent biopsy are critical for early definitive diagnosis and treatment, in order to prevent complications. Accumulating reports have revealed that EoE has several non-specific characteristic endoscopic findings, such as rings, furrows, white exudates, stricture/narrowing, edema, and crepe-paper esophagus. These findings were recently unified under the EoE endoscopic reference score (EREFS), which has been widely used as an objective, standard measurement for endoscopic EoE assessment. However, the diagnostic consistency of those findings among endoscopists is still inadequate, leading to underdiagnosis or misdiagnosis. Some endoscopic findings suggestive of EoE, such as multiple polypoid lesions, caterpillar sign, ankylosaurus back sign, and tug sign/pull sign, will aid the diagnosis. In addition, image-enhanced endoscopy represented by narrow band imaging, endocytoscopy, and artificial intelligence are expected to render endoscopic diagnosis more efficient and less invasive. This review focuses on suggestions for endoscopic assessment and biopsy, including recent advances in optical technology which may improve the diagnosis of EoE.

Clinical presentation and endoscopic findings in adult patients with eosinophilic esophagitis

Background/Aim: The frequency of eosinophilic esophagitis has been rising over the last decades. It is diagnosed primarily based on symptoms and endoscopic and histopathological examination findings. Although eosinophilic esophagitis is not associated with malignancy, it remains an important condition affecting both children and adults, as it is associated with morbidity such as dysphagia, food impaction, and esophageal strictures. This study aimed to define clinical and endoscopic characteristics of adult patients diagnosed with eosinophilic esophagitis based on recently recommended histopathological criteria. Methods: This retrospective cross-sectional descriptive study included 54 adult patients (mean age: 33.6 yr, range: 16–61 yr) who underwent upper gastrointestinal system endoscopy for dyspeptic complaints (epigastric pain, reflux, dysphagia, or food impaction) and diagnosed with eosinophilic esophagitis based on the latest histopathological criteria (≥15 eosinophils per high-power field). Patients with a history of malignancy were excluded. Patients’ clinical, endoscopic, and histopathological data were examined. Results: In patients diagnosed with eosinophilic esophagitis, the most common presenting complaint was dysphagia (61.1%), followed by dyspepsia (24.0%), regurgitation (16.6%), chest pain (16.6%), epigastric pain (12.9%), food impaction (11.1%), and halitosis (3.7%), without any age predilection for the complaints. White papules and linear furrow were the most frequent findings on endoscopic examination (35.1% each), followed by circular rings (24.0%), paleness (22.2%), normal endoscopic finding (20.3%), and small-caliber esophagus (11.1%). Conclusion: The diagnosis of eosinophilic esophagitis remains challenging due to considerable variations in definitions and in the relative frequencies of endoscopic findings. Therefore, we recommend combining clinical, endoscopic, and histologic criteria to establish diagnosis. The identification of standards for diagnosis in future studies is warranted.

Management of eosinophilic esophagitis associated food impaction in Europe and the United States

Eosinophilic esophagitis (EoE) is the most common cause of esophageal food impaction (EFI). Approaches to management of EFI due to EoE have not been well characterized. We conducted a web-based survey to understand approaches to management of EFI due to EoE among endoscopists. Questions focused on management of patients from presentation to post-endoscopy follow-up. The survey was administered to a list of eligible candidates provided by societies of gastroenterology. A total of 308 endoscopists completed the questionnaire. The majority (83%) practiced in Europe and treated adults (78%). Most agreed patients should be advised to seek emergency care (66%) within 1 to 2 hours (41% agreement). There was agreement that medications to induce vomiting should be avoided (84%) and that blood tests or imaging studies were usually not required before endoscopy. By contrast, there was more variability in the type of sedation recommended and the need for endotracheal intubation, especially when comparing more experienced with less experienced EoE-endoscopists. Overall, fewer than half (43%) respondents recommended obtaining esophageal biopsies during the initial endoscopy. However, there were significant differences in the proportion who recommended biopsies based on level of EoE-experience (25, 52, 77%, P < 0.001; less vs. moderate vs. very experienced) and comparing pediatric and adult endoscopists (32, vs. 79%, P < 0.001; adult vs. pediatric). There exists heterogeneity among endoscopists in recommendations to manage EFI in patients with EoE. These findings support development of clinical guidelines and new studies to clarify the rationale for best practices. Key summary: Established knowledge-The optimal management of patients with esophageal food impaction due to eosinophilic esophagitis from presentation at the emergency department to postendoscopy care is unclear. New findings-Considerable recommendation variation exists in the management of EFI in patients with EoE. Our findings provide a rationale for the creation of consensus practice guidelines and further study into best practices.

British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults

BACKGROUND

Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE.

METHODS

The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance.

RESULTS

Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research.

CONCLUSIONS

These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.

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.

Incidence and evolution of foreign body impaction in the upper gastrointestinal tract and its relationship with eosionophilic oesophagitis

BACKGROUND

Foreign body impaction is a frequent indication of urgent endoscopy. One of the reasons for impaction is eosinophilic oesophagitis (EE). To analyse characteristics of oesophageal foreign body impactions and their relationship with eosinophilic oesophagitis.

METHODS

In this retrospective study, urgent endoscopies in a tertiary care centre were analysed. We included all urgent endoscopies due to bolus and foreign body impactions performed between September 1^st 2018 and September 1^st 2020. We reviewed clinical data of all patients who were diagnosed with EE and compared it to impactions that were due to other motives. The mean follow-up time was 18.7 months.

RESULTS

693 urgent endoscopy procedures were performed. 239 (34%) of these were due to foreign body ingestion. Mean age of the patients was 63 years old and 135 (63%) were men. EE was diagnosed in 36 (17%) patients. The factors associated with EE were age, to be younger than 50 years (OR, 7.3; 95% CI, 1.1-48.4; P=0.04), asthma/rhinitis/atopic dermatitis (OR, 8.9; 95% CI, 2.3-35.3; P= 0.002), findings in the endoscopy as trachealization (OR, 9.7; 95% CI, 1.3-70.9; P= 0.03) and psychotropic/ calcium channel blocker drugs (OR, 0.09; 95% CI, 0.009-0.9; P= 0.04). 15 (7%) patients died. In 6 of them death was impaction-related. None patients with EE died.

CONCLUSIONS

Foreign body impaction in the upper gastrointestinal tract due to EE is a frequent cause of urgent endoscopy. Being under 50 years of age, having asthma/rhinitis/atopic dermatitis, trachealization on the esophagus and not taking psychotropic/calcium channel blocker drugs are factors associated with the diagnosis of EE. Mortality in the follow-up of patients without EE is important.

Eosinophilic esophagitis induced by sublingual immunotherapy with cedar pollen: a case report

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease associated with eosinophilic infiltration of the esophageal mucosa mostly due to exposure to allergens. However, the causes and pathogenesis of EoE are not fully understood. We encountered a case of EoE that was triggered by sublingual immunotherapy (SLIT) for cedar pollen allergy. A 40-year-old man who was treated with Japanese cedar pollen tablet SLIT for cedar pollen allergy developed heartburn 3 weeks after the initiation of the treatment. He took vonoprazan for the heartburn, but the heartburn did not improve. Then, esophagogastroduodenoscopy was performed; it revealed longitudinal furrows and white spots on the esophageal mucosa, decreased vascular permeability, and erosions. Consequently, the patient was diagnosed with EoE. Heartburn and chest discomfort disappeared 1 week after the discontinuation of Japanese cedar pollen tablet SLIT, and the patient tested positive for drug allergy to Japanese cedar pollen tablet SLIT. In this study, we found that if heartburn persists during SLIT for cedar pollen allergy, and does not improve on administration of vonoprazan or proton pump inhibitors, EoE should be suspected. In addition, the occurrence of EoE due to drug allergy is indicated.

Empiric proton pump inhibitor therapy after esophageal food impaction may mask eosinophilic esophagitis diagnosis at follow-up

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.

Association of eosinophil-mediated inflammatory biomarkers with the presence of the Schatzki ring

PURPOSE

The study aimed to assess the level of inflammatory biomarkers related to eosinophilia: interleukins 5 (IL-5) and 13 (IL-13), eotaxin 3, major basic protein (MBP) and transforming growth factor β1 (TGF-β1) in patients with dysphagia and Schatzki ring (SR), as well as the characteristics of this group of patients in terms of the features differentiating gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE).

PATIENTS AND METHODS

We analyzed 42 patients with dysphagia, each of whom underwent panendoscopy with an assessment of the occurrence of SR, retrospectively assessed EoE Endoscopic Reference Score (EREFS) total, inflammatory and fibrostenotic and serum concentrations of IL-5 and 13, TGF-β1, eotaxin 3 and MBP. All of them completed a symptom and comorbid questionnaire. Patients diagnosed with SR constituted the SR group (n ​= ​8), the rest - the non-SR group. The quantification of the biomarkers was performed by enzyme immunoassay (ELISA). In the data analysis, p ​≤ ​0.05 was considered statistically significant.

RESULTS

We demonstrated a significant increase in terms of exceeding the reference values of TGF-β1 (37.5% vs 8.8%) and MBP (75% vs 35.3%) in patients with SR compared to the non-SR group (qualitative analysis). There was also a statistically significant increase in the concentration of each of the determined biomarkers (quantitative analysis) in the SR group.

CONCLUSIONS

The increase in TGF-β1 and MBP concentrations indicates the inflammatory and probably fibrostenotic pathogenesis of SR. Obtained results do not allow for an unequivocal classification of SR as a complication typical only for GERD or EoE.

Medication Adherence Aligns with Age and a Behavioral Checklist but Not Symptoms or Quality of Life for Patients with Eosinophilic Esophagitis

OBJECTIVE

To measure adherence rates to swallowed topical steroids in children with eosinophilic esophagitis (EoE), describe factors related to adherence, and determine the association between adherence, symptoms, perceived disease severity, and quality of life in children with EoE.

STUDY DESIGN

Subjects in this cross-sectional study of 117 children between 5 and 18 years old with EoE completed the Pediatric Eosinophilic Esophagitis Symptoms Score V2.0 (PEESS), Pediatric Quality of Life Inventory Eosinophilic Esophagitis Module (PedsQL EoE), a Medication-Taking Checklist (MTC), and a demographics questionnaire. Adherence rate was calculated based on reported number of missed doses/prescribed doses in the last week. Parent-reported measures were used for children aged 5-12 years and self-report was used for children aged 13-18 years.

RESULTS

Adolescents had lower adherence rates than younger children (76.2 ± 24.5% vs 88.6 ± 16.7%, P = .002). Adherence rates were not associated with disease history, PEESS, or PedsQL EoE scores but instead correlated with MTC scores (Pearson r of 0.65, P < .001 for child-report and Pearson r of 0.74, P < .001 for parent-report). Symptomatology was associated with worse quality of life (PEESS Frequency: r = -0.7, P < .001; PEESS Severity: r = -0.71, P < .001 for children 5-12 years old; PEESS Frequency: r = -0.61, P < .001; PEESS Severity: r = -.5, P < .001 for adolescents).

CONCLUSIONS

Unrelated to their clinical history, demographic factors, symptoms, and quality of life, adolescents with EoE have lower medication adherence rates. The MTC may serve as a clinical tool to discuss adherence and provide targeted educational counseling regarding adherence interventions.

Similarity and difference in the characteristics of eosinophilic esophagitis between Western countries and Japan

Over the past two decades, the incidence and prevalence of eosinophilic esophagitis (EoE) have risen rapidly, especially in Western countries, with cases in Japan also showing a gradual increase in recent years. However, similarities and differences regarding the characteristics of EoE between Western countries and Japan remain to be clearly elucidated. The current clinical guidelines for diagnosis include symptoms related to esophageal dysfunction and dense eosinophilic infiltration in the esophageal epithelium. Most affected patients in Japan are diagnosed incidentally during a medical health check-up and asymptomatic cases with typical endoscopic findings suggestive of EoE are frequently encountered. Clinical characteristics of EoE in Japanese are similar to those seen in Western populations. The predominant symptom is dysphagia, with food impaction extremely rare in Japanese cases. Linear furrows are the most frequently reported characteristic endoscopic finding, while an esophageal stricture or narrow caliber is rarely observed. Treatment strategies for EoE include drugs, dietary restrictions, and endoscopic dilation when the disease is advanced with stricture formation. Although single therapy using a proton-pump inhibitor has been shown to achieve symptomatic and histological response in the majority of patients in Japan, no prospective randomized control studies that evaluated drug or elimination diet therapy have been presented. Overall, EoE has similar clinical characteristics between Japanese and Western populations, while disease severity seems to be milder in Japan. Additional studies are necessary to determine genetic factors, natural history of the disease, and treatment efficacy of drugs and elimination diet as compared to Western populations.

Esophageal Food Impaction: A Retrospective Chart Review

Background

Esophageal food impaction (EFI) is the third most common non-biliary emergency in gastroenterology, with an annual incidence rate of 13 episodes per 100,000 person-years and 1,500 deaths per year. Patients presenting with food impaction often have underlying esophageal pathology. We evaluated the possible risk factors for EFI in our study.

Methods

We performed a retrospective chart review of 455 patients at Staten Island University Hospital (SIUH) that presented with symptoms of food impaction from 1999 to 2017. We analyzed relevant clinical data such as age, risk factors, type of food bolus, location, administration of glucagon, endoscopic technique and complications.

Results

Overall, 174 patients had endoscopically confirmed EFI. The majority were males 102/174 (58.6%). Esophageal pathological findings included esophagitis in 58/174 (33.3%), strictures in 43/174 (24.7%), hiatal hernias in 29/174 (16.6%) and Schatzki’s rings in 15/174 (8.6%). Thirty-two out of 174 (18.3%) had normal endoscopic findings. Diabetes mellitus (DM) was reported in 20/174 (11.4%) patients. The type of food impacted was mostly meat in 73/174 (41.9%) cases. The location of EFI was mainly in the lower one-third of the esophagus in 94/174 (54%). The endoscopic push technique was used in 95/174 (54.5%) patients and the pull technique in 83/174 (47.7%) cases. The endoscopic therapeutic intervention was successful as a first attempt in 165/175 (94.8%) patients. Complications were reported in only 5/174 (2.8%), and these mostly comprised of perforations and tears. Glucagon was given to 74/174 (42.5%) patients. The median door-to-scope time (time of presentation at the emergency department to endoscopic intervention) was 7 h (range 1.5 - 24 h) in patients who had received glucagon as opposed to 7 h (range 1 - 24 h) in patients who did not receive it.

Conclusion

EFI is more common in males. Esophageal strictures and hiatal hernias were the most common pathologies found in endoscopy. Esophagitis was evident in 33.3% of patients, but if it was the cause or consequence of EFI is not clearly understood. DM was associated with food impaction in only 11.4% of patients, but more studies are needed to determine if DM has a stronger association with EFI. The door-to-scope time was shorter in patients who had received glucagon. Endoscopy is a safe and effective therapeutic intervention for EFI, and complications reported were minimal.

[Approach of Dysphagia]

Dysphagia has been reported to be relatively common and seems to be increased in Korea. Dysphagia can be classified as oropharyngeal dysphagia or esophageal dysphagia. In patients with swallowing difficulties, it is important to determine whether the dysphagia is oropharyngeal or esophageal. Patients with orophayngeal dysphagia are likely to develop aspiration and aspiration pneumonia, so accurate diagnosis should be made in the early stages of complaining of swallowing difficulties. Patients with orophayngeal dysphagia complained difficulty initiating a swallow. Swallowing may be accompanied by coughing, choking, nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx. Patients with esophageal dysphagia complained difficulty swallowing several seconds after initiating a swallow and a sensation of food getting stuck in the esophagus. Esophageal dysphagia should be characterized by analyzing whether foods that cause swallowing difficulties are solid, liquids or both, whether symptoms are progressive or intermittent, how severe, and associated symptoms, such as weight loss, heartburn, or regurgitation. The approach to diagnostic testing to determine the cause of esophageal dysphagia is based upon the medical history. If esophageal motility disorder is suspected, barium esophagogram is performed first, and upper endoscopy is performed first if structural abnormalities are suspected. If an upper endoscopy shows normal findings, but the esophagus is still suspected of mechanical obstruction, a barium esophagogram is performed. Esophageal manometry should be performed in patients with swallowing difficulties who are suspected of esophageal motility disorder or have normal findings in upper endoscopy.

Complication rates in emergent endoscopy for foreign bodies under different sedation modalities: A large single-center retrospective review

BACKGROUND

Foreign object ingestion (FOI) and food bolus impaction (FBI) are common causes of emergent endoscopic intervention. The choice of sedation used is often dictated by physician experience. Many endoscopists frequently prefer to use monitored anesthesia care (MAC) and general anesthesia (GA) as opposed to conscious sedation (CS) due to the concern for inadequate airway protection. However, there is insufficient data examining the safety of different sedation modalities in emergent endoscopic management of FOI and FBI.

AIM

To investigate the complication rates of emergent endoscopic extraction performed under different sedation modalities.

METHODS

We conducted a retrospective chart review of patients presenting with acute FBI and FOI between 2010 and 2018 in two hospitals. A standardized questionnaire was utilized to collect data on demographics, endoscopic details, sedation practices, hospital stay and adverse events. Complications recognized during and within 24 h of the procedure were considered early, whereas patients presenting with a procedure-related adverse event within two weeks of the index event were considered delayed complications. Complication rates of patients who underwent emergent endoscopic retrieval were compared based on sedation types, namely CS, MAC and GA. Chi-square analysis and multiple logistic regression were used to compare complication rate based on sedation type.

RESULTS

Among the 929 procedures analyzed, 353 procedures (38.0%) were performed under CS, 278 procedures (29.9%) under MAC and the rest (32.1%) under GA. The median age of the subjects was 52 years old, with 57.4% being male. The majority of the procedures (64.3%) were FBI with the rest being FOI (35.7%). A total of 132 subjects (14.2%) had chronic comorbidities while 29.0% had psychiatric disorders. The most commonly observed early complications were mucosal laceration (3.8%) and bleeding (2.6%). The most common delayed complication was aspiration pneumonia (1.8%). A total of 20 patients (5.6%) could not adequately be sedated with CS and had to be converted to MAC or GA. Patient sedated with MAC and GA were more likely to require hospitalization, P < 0.0001. Analysis revealed no statistically significant difference in the complication rate between patients sedated under CS (14.7%), MAC (14.7%) and GA (19.5%), P = 0.19.

CONCLUSION

For patients who present with FOI or FBI and undergo emergent endoscopic treatment, there is no significant difference in adverse event rates between CS, MAC and GA.

Eosinophilic esophagitis: novel concepts regarding pathogenesis and clinical manifestations

Eosinophilic esophagitis is a chronic disease whose incidence and prevalence are increasing, based on a genetic-driven interaction between environment and immune system. Several gene loci involved in the development of the disease have been identified. A two-step mechanism has been hypothesized: a thymic stromal lymphopoietin-induced allergic sensitization followed by upregulation of CAPN14-related esophageal-specific pathways. Environment seems to have a larger effect than genetic variants. Factors that could play a role are allergens, drugs, colonizing bacteria and possibly Helicobacter Pylori infection. Acting on these modifiable risk factors may be a tool to prevent the disease. EoE is characterized by a typical eosinophilic infiltrate limited to the esophageal epithelium, supported by a Th2-mediated immune response, found in other atopic conditions. The key of the pathogenesis is the disfunction of the epithelial barrier which allow the interaction between allergens and inflammatory cells. Eosinophilic-predominant inflammation leads to the typical wall remodeling, histologically characterized by epithelial and smooth muscle hyperplasia, lamina propria fibrosis and neo-angiogenesis. These alterations find their clinical expression in the pattern of symptoms: dysphagia, food impaction, chest pain, heartburn.

[Diagnostic and treatment of foreign bodies of the upper digestive tract]

OBJECTIVE

To evaluate the results of diagnosis and treatment of foreign bodies of the upper gastrointestinal tract.

MATERIAL AND METHODS

There were 1187 patients aged 15-99 years with suspected foreign body of the upper gastrointestinal tract. In 536 patients (266 men, 270 women), foreign bodies were detected. Ingestion of a foreign body was more common in patients aged 46-65 years. In 516 patients, foreign bodies were detected in the esophagus (pharyngo-esophageal junction - 25, upper third of the esophagus - 426, middle third of the esophagus - 34, lower third of the esophagus - 21, esophageal-gastric junction - 10). Four patients admitted with esophageal wall perforation. In 3 cases, foreign bodies were localized in the throat, 15 patients - in the stomach, 2 patients - in the duodenum.

RESULTS

In most cases, foreign bodies were organic (n=506). Removal was successful in 530 cases. In 4 patients with esophageal wall perforation and mediastinitis, removal was performed intraoperatively. Flexible endoscope was used in 500 cases. In 86 patients, foreign bode was displaced in the stomach using flexible endoscopy. Foreign body removing wasn't successful in 4 cases. In 2 patients, extraction was followed by esophageal wall damage. In 4 patients, esophagotomy was applied to extract foreign body. Suturing the esophageal wall defect was carried out in 2 cases. Abrasion and erosive esophagitis were the most common injuries of esophageal mucosa. Esophageal diseases were detected in 75 cases after foreign body removal (67 cases - benign esophageal diseases). One patient died from bedsore of innominate artery complicated by acute hemorrhage.

CONCLUSION

Foreign bodies of the upper gastrointestinal tract are observed in 45% of patients at admission. Neck and chest X-ray examination is obligatory before endoscopy. Flexible endoscopy is a gold standard for diagnosis and extraction of foreign bodies. Repeated endoscopy after foreign body extraction should be mandatory. It is necessary to visualize complications associated with foreign body and identify esophageal diseases.

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.

Budesonide Orodispersible Tablets Maintain Remission in a Randomized, Placebo-Controlled Trial of Patients With Eosinophilic Esophagitis

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder. Swallowed topical-acting corticosteroids are effective in bringing active EoE into remission. However, it is not clear whether these drugs are effective for long-term maintenance of remission.

METHODS

We performed a double-blind trial to compare the efficacy and safety of 2 dosages of a budesonide orodispersible tablet (BOT) vs placebo in maintaining remission of EoE. Maintenance of remission was defined as absence of clinical and histologic relapse and no premature withdrawal for any reason. Two hundred and four adults with EoE in clinical and histologic remission, from 29 European study sites, were randomly assigned to groups given BOT 0.5 mg twice daily (n = 68), BOT 1.0 mg twice daily (n = 68), or placebo twice daily (n = 68) for up to 48 weeks.

RESULTS

At end of treatment, 73.5% of patients receiving BOT 0.5 mg twice daily and 75% receiving BOT 1.0 mg twice daily were in persistent remission compared with 4.4% of patients in the placebo group (P < .001 for both comparisons of BOT with placebo). Median time to relapse in the placebo group was 87 days. The frequency of adverse events was similar in the BOT and placebo groups. Morning serum levels of cortisol were in the normal range at baseline and did not significantly change during treatment. Four patients receiving BOT developed asymptomatic, low serum levels of cortisol. Clinically manifested candidiasis was suspected in 16.2% of patients in the BOT 0.5 mg group and in 11.8% of patients in the BOT 1.0 mg group; all infections resolved with treatment.

CONCLUSIONS

In a phase 3 trial, up to 48 weeks of treatment with BOT (0.5 mg or 1.0 mg twice daily) was superior to placebo in maintaining remission of EoE. Both dosages were equally effective and well tolerated. EudraCT number; 2014-001485-99; ClinicalTrials.gov number, NCT02434029.

Esophageal emergencies: another important cause of acute chest pain

A variety of esophageal pathologies can present emergently with a chief complaint of acute chest pain. Computed tomography (CT) is often the first line of imaging in esophageal emergencies and provides useful information-even without an initial suspicion-when used in conjunction with other imaging modalities such as esophagography and direct visualization. We review various urgent and emergent esophageal disease entities which may manifest as acute chest pain, with an emphasis on CT and ancillary imaging appearances, while discussing management according to their emergency. Radiologists should be familiar with the imaging findings of these esophageal emergencies in order to provide an accurate diagnosis and recommend timely and appropriate management.

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.

Esophageal foreign bodies: observational cohort study and factors associated with recurrent impaction

BACKGROUND AND AIM

Esophageal foreign bodies, including food bolus impaction, represent a common clinical problem. The prevalence of underlying esophageal disease depends on study design and degree of suspicion of a structural or functional esophageal abnormality. Aim of this study was to analyze factors associated with recurrent impaction.

METHODS

The prospectively collected database at a University Hospital and Swallowing Center was reviewed from January 2012 to June 2019 to identify all patients admitted for esophageal foreign bodies. Patients who underwent an emergency endoscopic procedure represented the final study sample. Patient characteristics, including history of previous esophageal foreign bodies, and type of endoscopic procedure were collected.

RESULTS

Sixty-five patients, 41 males and 24 females with a median age of 59 years, underwent emergency endoscopy for esophageal foreign bodies during the study period. Food bolus was the most common foreign body (n = 43, 66%). Flexible endoscopy was successful in retrieving or pushing the foreign bodies in the stomach in 91% of patients. In 54% of patients, impaction was secondary to an underlying esophageal disorder, which was previously unrecognized in half of them. Recurrent impaction was more common in patients with esophageal disease (P < 0.011). Surgical therapy was required in 4 patients (6.1%).

CONCLUSIONS

Food bolus impaction is a common sentinel event in patients with underlying esophageal disease and is associated with recurrent impaction. Diagnostic endoscopy with biopsies should possibly be performed at the first episode of impaction. Patients with negative biopsies should undergo barium swallow study and high-resolution esophageal manometry.

Eosinophilic esophagitis with a severe stenosis: report of a Japanese case

A 49 years old male, who had had postprandial dysphagia during the preceding 10 years, was referred to our hospital. Esophagogastroduodenoscopy (EGD) revealed longitudinal furrows and concentric rings in the mid to lower esophagus and stenosis in the lower esophagus. Histologic findings from esophageal biopsies showed eosinophilic infiltration (> 15 per high-power field). Under a diagnosis of eosinophilic esophagitis, an endoscopic bougie was performed, which resulted in symptomatic relief. Follow-up EGD revealed that the stenosis had improved, but histologic findings of eosinophilic esophagitis were remaining. Our case suggests that although rare, esophageal stenosis occurs in Japanese patients with EoE, and that the complication may be a consequence of prolonged disease. Other risks and the appropriate treatment for the prevention of stenosis need to be elucidated further.

National trends in healthcare outcomes and utilization of endoscopic and surgical interventions in patients hospitalized with esophageal foreign body and food impaction

The incidence and number of emergency room visits for esophageal foreign body and food impaction (EFB) are on the rise. However, its impact on the rate of inpatient admissions, utilization of endoscopic and surgical interventions, and healthcare outcomes is poorly understood. We conducted a study to analyze these outcomes using the national inpatient sample (NIS) database. Data on all adult patients (≥18 years) admitted with EFB was extracted from the NIS database from 1998 to 2013. The temporal trends in discharge rates as well as in length of stay (LOS), hospital charges, and in-hospital mortality rates were assessed by linear and polynomial regression. Average age, gender, and race of inpatients with EFB were not significantly different between 1998 and 2013. The rate of EFB admissions increased significantly from 1998 to 2005 followed by a decline thereafter (p = 0.01). LOS and hospital charges significantly increased by 0.02 days/year (p = 0.015) and $1,547/year (p < 0.001), respectively. There was a trend towards less utilization of overall esophagogastroduodenoscopy (EGD) over the last decade with significant lower use of EGD within 24 hours in 2013 as compared to 1998 (p = 0.026). The rates of surgical intervention and inpatient mortality did not change significantly over the study period. The rate of inpatient admissions for EFB is on the decline in recent years, suggesting the modern-day practice of cost-effective medicine. Hospitalization costs for EFB have increased, whereas rates of surgical intervention and inpatient mortality have not changed significantly over the study period.

Outcome, complication and follow-up of patients with esophageal foreign body impaction: an academic institute's 15 years of experience

Esophageal foreign body impaction (EFBI) is a gastrointestinal emergency, mostly requiring endoscopic management. The aim of this study is to evaluate the epidemiology, adverse events, and outcomes of patients following the episode of EFBI. All esophagogastroduodenoscopy (EGD) reports of admitted patients for EFBI at the University of Kansas Medical Center between 2003 and 2018 were retrospectively reviewed. Of 204 patients, who met the inclusion criteria, 60% were male and the mean age was 54.7 ± 17.7 years. The encounter was the first episode of EFBI in 76% of cases. EGD in less than 24 hours of patients' admission was required in 79% of cases. The distal esophagus was the most common site of impaction (44%). Push and pull techniques were used in 38 and 35.2% of cases, respectively, while 11% were managed by a combination of both techniques. Structural causes were the most common etiologic findings including benign strictures and stenosis in 21.5% of patients, followed by Schatzki's ring (7.8%) and hiatal hernia (6.9%). Of all cases, 45% did follow-up in up to 1 year, and biopsy was done in 34% of cases. Out of 43 patients who had endoscopic findings suspicious for eosinophilic esophagitis (EoE), the diagnosis was confirmed by pathology in 37. The rate of recurrence EFBI was significantly higher in patients with EoE (P < 0.001). EFBI-related esophageal adverse events (AEs) occurred in 4.9% of cases. Cardiovascular and pulmonary AEs occurred in 1.5 and 2.9%, respectively. Logistic regression did not find any predictor for AEs occurrence. EFBI managed very well with endoscopic treatments. Despite the emerging data about the safety of the push technique, there are still concerns regarding its adverse events especially the risk of perforations. Our study shows no significant difference in adverse events between different types of techniques.

Outcomes of delayed endoscopic management for esophageal soft food impactions

BACKGROUND AND AIMS

Food impactions are a common reason for emergent upper endoscopy. Current guidelines call for urgent upper endoscopy (within 24 hours) for food impactions without complete esophageal obstruction and emergent endoscopy (within 6 hours) for those with complete esophageal obstruction. Multiple adverse events can arise from esophageal foreign bodies. Cases with longer delays from symptom onset to presentation have been associated with higher rates of surgical intervention. However, data on esophageal soft food impactions are scant. We set out to determine differences in outcomes for food impactions undergoing intervention within 12 hours versus over 12 hours of symptom onset.

METHODS

A retrospective review of medical records was conducted to identify patients who presented to our hospital with an esophageal soft food impaction and underwent an EGD between January 2010 and January 2018. Patients were divided into 2 groups based on the timing from symptom onset to EGD. An EGD within 12 hours was considered an early intervention and over 12 hours was considered a delayed intervention. Patients who had ingested bones or hard objects were not included. Primary outcomes studied were rates of aspiration, admission, local esophageal adverse events, and 30-day all-cause mortality.

RESULTS

We identified 110 patients with a soft food impaction who underwent an EGD. Forty- two patients had an early intervention and 68 a delayed intervention. There were no differences in basic demographics and comorbidities. Additionally, there were no differences in rates of local esophageal adverse events, aspiration, admission, or 30-day mortality. Multivariate analysis revealed endoscopic accessory use was associated with increased odds of local esophageal adverse events (odds ratio, 6.37; P = .01).

CONCLUSIONS

The overall rates of serious adverse events in esophageal soft food impactions are low. Delayed intervention is not associated with increased adverse events or 30-day mortality compared with early intervention. However, accessory use is associated with higher adverse event rates.

Distal esophagus is the most commonly involved site for strictures in patients with eosinophilic esophagitis

While strictures are common in eosinophilic esophagitis (EoE), there are few data on stricture distribution and characteristics. Our primary aim was to characterize strictures by location in the esophagus in EoE and associated clinical, endoscopic, and histologic features. This was a retrospective study from the UNC EoE Clinicopathologic Database of subjects with esophageal strictures or narrowing from 2002 to 2017. Strictures were categorized as distal esophagus/gastroesophageal junction, mid-esophagus, proximal esophagus, or diffusely narrowed. Stricture location was assessed and compared with clinical, endoscopic, and histologic features, and also with treatment response to diet or topical steroids. Efficacy of combination therapy with dilation and intralesional steroid injection was assessed in a sub-group of patients with strictures. Of 776 EoE cases, 219 (28%) had strictures, 45% of which were distal, 30% were proximal, 5% were mid-esophageal, and 20% had diffuse narrowing. Those with mid-esophageal strictures were younger (P = 0.02) and had shorter symptom duration (P < 0.01). Those with diffuse esophageal narrowing were more likely to be women (57%) and have abdominal pain (25%). There was no association between other clinical, endoscopic, and histologic findings and treatment response based on stricture location. Fourteen patients (8%) received intralesional triamcinolone injection and subsequently achieved a higher mean dilation diameter after injection (13.7 vs. 15.5 mm; P < 0.01). In conclusion, almost half of strictures in EoE patients were in the distal esophagus. Therefore, EoE should be a diagnostic consideration in patients with focal distal strictures and not presumed to be secondary to gastroesophageal reflux disease.

Immediate dilation in esophageal food impaction is safe and effective but performed infrequently: observations from a large Midwest US cohort

This study aimed to determine the rate and safety of immediate esophageal dilation for esophageal food bolus impaction (EFBI) and evaluate its impact on early recurrence (i.e. prior to interval esophageal dilation) from a large Midwest US cohort. We also report practice patterns among community and academic gastroenterologists practicing in similar settings. We identified adult patients with a primary discharge diagnosis for EFBI from January 2012 to June 2018 using our institutional database. Pregnant patients, incarcerated patients, and patients with esophageal neoplasm were excluded. The primary outcome measured was rate of complications with immediate esophageal dilation after disimpaction of EFBI. Secondary outcomes were recurrence of food bolus impaction prior to scheduled interval endoscopy for dilation, practice patterns between academic and private gastroenterologists, and adherence to follow-up endoscopy. Two-hundred and fifty-six patients met our inclusion criteria. Esophageal dilation was performed in 46 patients (18%) at the time of disimpaction. A total of 45 gastroenterologists performed endoscopies for EFBI in our cohort. Twenty-five (62%) did not perform immediate esophageal dilation, and only 5 (11%) performed immediate dilation on greater than 50% of cases. Academic gastroenterologists performed disimpaction of EFBI for 102 patients, immediate dilation as performed in 20 patients and interval dilation was recommended in 82 patients. Of these 82, only 31 patients (38%) did not return for interval dilation. Four patients who did not undergo immediate dilation, presented with recurrent EFBI prior to interval dilation, within 3 months. None of the patients had complications. Complications with immediate esophageal dilation after disimpaction of EFBI are infrequent but are rarely performed. Failure of immediate dilation increases the risk of EFBI recurrence. Given poor patient adherence to interval dilation, immediate dilation is recommended.