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Rabinowitz SS, Candava R, Kady B, Arostegui D, Grossman E. Utilizing a balloon sheath and miniprobe for diagnostic endoscopic ultrasound in eosinophilic esophagitis: a case series. Ultrasound J 2024; 16:40. [PMID: 39167277 PMCID: PMC11339230 DOI: 10.1186/s13089-024-00380-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/16/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is a unique example of POCUS, which allows the gastroenterologist to discuss subepithelial pathology immediately after an endoscopy. The challenges that are encountered to create an acoustic interface by adding free water during the endoscopy may be curtailing the full utilization of EUS during endoscopic procedures. Eosinophilic esophagitis (EoE) is a progressive inflammatory condition whose morbidity is related to esophageal wall remodeling. However, in clinical practice, in clinical guidelines, and in many trials, EoE outcomes are based on esophageal eosinophilia and symptoms. Hence, a method to identify and quantitate the thickening of the esophageal wall, could contribute to the management of this disease. RESULTS A modification of the approach employed to perform EUS during bronchoscopy was developed. An EUS miniprobe was positioned inside of a water filled balloon sheath. This technique permitted rapid and reproducible images acquisition of the total esophageal wall and its sublayers (mucosa, and submucosa + submucosa, which permitted derivation of the muscle layer). The presented series describes the results from 22 consecutive EoE patients. A full set of measurements from both the mid and distal esophagus were achieved in all EoE patients in an average time of less than 10 minutes. CONCLUSIONS This pilot study supports further investigations evaluating this economical, convenient, and safe technique to follow EoE patients. In addition, this approach could be potentially employed in all patients who are found to have subepithelial gastrointestinal pathology during routine endoscopic procedures.
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Affiliation(s)
- Simon S Rabinowitz
- Pediatric Gastroenterology Division, Downstate Health Sciences University, 450 Clarkson Ave, Box 49, Brooklyn, NY, 11203, USA.
| | - Rheu Candava
- Pediatric Gastroenterology Division, Downstate Health Sciences University, 450 Clarkson Ave, Box 49, Brooklyn, NY, 11203, USA
| | - Blair Kady
- Pediatric Gastroenterology Division, Downstate Health Sciences University, 450 Clarkson Ave, Box 49, Brooklyn, NY, 11203, USA
| | - Dalia Arostegui
- Pediatric Gastroenterology Division, Downstate Health Sciences University, 450 Clarkson Ave, Box 49, Brooklyn, NY, 11203, USA
| | - Evan Grossman
- Division of Gastroenterology and Hepatology, Department of Medicine, Downstate Health Sciences University, 450 Clarkson Ave, Box 49, Brooklyn, NY, 11203, USA
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Pomenti SF, Bailey DD, Katzka DA. Monitoring and modulating the trajectory of eosinophilic esophagitis. J Allergy Clin Immunol 2024; 153:1465-1471. [PMID: 38570041 DOI: 10.1016/j.jaci.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/09/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024]
Abstract
Current treatments of eosinophilic esophagitis (EoE) aim to eliminate esophageal mucosal inflammation and attenuate, stabilize, or reverse stricture formation. However, our ability to study the long-term course of esophageal strictures in patients with EoE is hampered by the short-term existence of this disease. It is unclear to what degree of control of inflammation is needed to prevent stricture formation. Additionally, identified phenotypes of EoE may ultimately dictate different levels of concern and time intervals for developing fibrosis. Currently, multiple methods are used to monitor patients' disease progression to fibrosis, as symptoms alone do not correlate with disease activity. Endoscopic findings and mucosal histology are used to monitor disease activity, but these focus on improvements in inflammation with inconsistent evaluation of underlying fibrosis. The use of functional lumen impedance planimetry, barium esophagraphy, and endoscopic ultrasound continues to expand in EoE. The rapid advancements in EoE have led to an armamentarium of measuring tools and therapies that holistically characterize disease severity and response to therapy. Nevertheless, our ability to evaluate gross esophageal fibrosis and stricture formation from a transmural rather than mucosal view should be a focus of future investigations because it is essential to monitoring and modulating the trajectory of EoE.
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Affiliation(s)
- Sydney F Pomenti
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY
| | - Dominique D Bailey
- Division of Pediatric Gastroenterology and Hepatology, Columbia University Medical Center, New York, NY
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY.
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Cohen WG, Mchugh M, Giordano T, Jacobs IN. Anatomic Considerations of esophageal button battery ingestion for outcomes and imaging. Int J Pediatr Otorhinolaryngol 2024; 176:111803. [PMID: 38043185 DOI: 10.1016/j.ijporl.2023.111803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 11/05/2023] [Accepted: 11/21/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION Button batteries (BB) are a source of significant morbidity and mortality in young children. Little data is available regarding associations between esophageal impaction location and outcomes or need for surveillance imaging. METHODS All patients treated at a single institution following BB ingestion between 2018 and 2022 were included for retrospective chart review. RESULTS Twenty patients were treated at our institution BBs were located, or most significant damage observed, in the cervical esophagus (n = 10, 50 %), followed by thoracic esophagus (n = 6, 30 %), and abdominal esophagus (n = 4, 20 %). Patients with cervical esophageal impaction were younger (482 [370-866] days), than those with thoracic (1395 [871-2369] days) or abdominal esophageal impaction (2021.5 [1230.5-3419.5] days) (p = 0.003). Zargar Mucosal Injury Grade was significantly more severe in patients with cervical button battery impaction; 8/10 (80 %) had a ≥Grade IIIB injury, compared to 2/6 (33.3 %) thoracic impactions and 0/4 (0 %) abdominal impactions (p = 0.002). All patients who developed persistent esophageal stenosis (n = 6) had cervical battery impactions (6, 60 %, p = 0.015). Both TEFs (2/2) had anterior facing anode, while both (2/2) esophageal perforations had posterior. Only 1/20 (5 %) patients, and 1/7 (14.3 %) with serious complications, had a serious complication detected on routine, rather than clinically indicated follow-up surveillance. CONCLUSIONS In our population, cervical BB impaction occurred more frequently in younger children, was associated with more severe mucosal injury, and had higher risk of stenosis. Nearly all complications were detected on clinically indicated rather than postoperative surveillance imaging.
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Affiliation(s)
- William G Cohen
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Moira Mchugh
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Terri Giordano
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Ian N Jacobs
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Ferrelli RS, Machado RS, Ogata SK. Oesophageal wall thickness assessment at endoscopic ultrasound in children and adolescents with eosinophilic oesophagitis: a case-control study. J Ultrasound 2023; 26:785-791. [PMID: 36574193 PMCID: PMC10632350 DOI: 10.1007/s40477-022-00742-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/06/2022] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Eosinophilic oesophagitis (EoE) is a chronic immune-mediated disease, and an endosonographic evaluation may help the diagnosis. The main objectives of this study were to measure the thickness of the oesophageal wall using a radial endoscopic ultrasound (EUS), mucosa/submucosa (MSM), muscularis propria (MP) and mucosa to muscularis propria (MMP); to compare these measurements between patients with and without EoE; to correlate them with the Endoscopic Reference Score (EREFS); and to evaluate the diagnostic accuracy of these measurements. METHODS Children and adolescents (aging from 4 to 17 years) were evaluated in this prospective cross-sectional study. A radial EUS at 12 MHz frequency was used, and EREFS was employed to grade macroscopic findings. Accuracy of the measurements for the diagnosis of EoE was assessed by receiver operating characteristics (ROC) curve. RESULTS Twenty-six (19 M/7 F) patients (median age 10.83 years, range 5.65-17.46) were evaluated. EoE was diagnosed in 6 patients. The mean (and SD) oesophageal wall thicknesses in the distal oesophagus in millimetres in groups with and without EoE, respectively, were: MSM 1.07 (0.44) and 1.11 (0.33); MP 0.67 (0.25) and 0.60 (0.19); and MMP 1.73 (0.46) and 1.72 (0.32). Mid-oesophagus: MSM 1.16 (0.34) and 1.15 (0.34); MP 0.63 (0.16) and 0.60 (0.2); and MMP 1.79 (0.41) and 1.74 (0.34). In the ROC curve, the distal MP layer thickness presented better discriminative performance, with an area under the curve of 0.61 (95% CI 0.28-0.93) at 0.73 mm cut-off (66.67% sensitivity, 80% specificity, likelihood ratios of 3.33 for positive and 0.42 for negative test). CONCLUSION The evaluation of oesophageal thickness measurements by EUS is not useful for diagnosing EoE.
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Affiliation(s)
- Regis Schander Ferrelli
- Pediatric Gastroenterology Division, Department of Pediatrics, Escola Paulista de Medicina/Universidade Federal de São Paulo, Rua dos Otonis 839, Vila Clementino, São Paulo, 04025-002, Brazil.
| | - Rodrigo Strehl Machado
- Pediatric Gastroenterology Division, Department of Pediatrics, Escola Paulista de Medicina/Universidade Federal de São Paulo, Rua dos Otonis 839, Vila Clementino, São Paulo, 04025-002, Brazil
| | - Silvio Kazuo Ogata
- Pediatric Gastroenterology Division, Department of Pediatrics, Escola Paulista de Medicina/Universidade Federal de São Paulo, Rua dos Otonis 839, Vila Clementino, São Paulo, 04025-002, Brazil
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Sabe R, Hiremath G, Ng K. Endoscopy in Pediatric Eosinophilic Esophagitis. Gastrointest Endosc Clin N Am 2023; 33:323-339. [PMID: 36948749 DOI: 10.1016/j.giec.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergen-mediated clinicopathologic condition that currently requires esophagogastroduodenoscopy with biopsies and histologic evaluation to diagnose and monitor its progress. This state-of-the art review outlines the pathophysiology of EoE, reviews the application of endoscopy as a diagnostic and therapeutic tool, and discusses potential complications related to therapeutic endoscopic interventions. It also introduces recent innovations that can enhance the endoscopist's ability to diagnose and monitor EoE with minimally invasive procedures and perform therapeutic maneuvers more safely and effectively.
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Affiliation(s)
- Ramy Sabe
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Rainbow Babies and Children's Hospitals, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 11226, 2200 Children's Way, Nashville, TN 37232, USA
| | - Kenneth Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, 600 North Wolfe Street, CMSC 2-116, Baltimore, MD 21287, USA.
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Zhang B, Zhang Y, Wang Y, Yang F, Sheng S, Wang Z, Chang X, Wei J, Guo J, Sun S. Acellular Dermal Matrix Prevents Esophageal Stricture After Full Circumferential Endoscopic Submucosal Dissection in a Porcine Model. Front Bioeng Biotechnol 2022; 10:884502. [PMID: 35586551 PMCID: PMC9108161 DOI: 10.3389/fbioe.2022.884502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/14/2022] [Indexed: 11/17/2022] Open
Abstract
Esophageal stricture is a common complication after endoscopic submucosal dissection (ESD), especially in full circumferential ESD. This study investigated fully covered self-expanding metal stent (FCSEMS) placement with an acellular dermal matrix (ADM) for preventing post-ESD esophageal stricture. Twelve Bama minipigs were randomly divided into two groups, which underwent full circumferential ESD in the distal esophagus. In group A, an FCSEMS with ADM was placed at the mucosal defect, whereas group B underwent standard FCSEMS placement. The stent was removed during gastroscopy 2 weeks after the ESD procedure. At the fourth week, gastroscopy was repeated to evaluate local healing and stenosis. The animals were sacrificed, esophageal specimens were obtained for macroscopic and histological evaluation, and serum C-reactive protein (CRP) levels were quantified. Four weeks post ESD, dysphagia occurrence was lesser in group A than in group B. Group A demonstrated lesser esophageal stricture on macroscopic evaluation (21.02 ± 16.65% vs. 57.41 ± 8.48%, p = 0.001) in the form of enhanced re-epithelization (99.13 ± 0.98% vs. 96.63 ± 1.64%, p = 0.009), diminished submucosal fibrosis (1117.53 ± 188.83 um vs. 1834.69 ± 421.99 um, p = 0.003), and attenuated inflammatory infiltration (121.00 ± 30.66 vs. 188.17 ± 64.92, p = 0.045). The increase in the serum CRP level was lower in group A than in group B at 4 weeks post-ESD. FCSEMS combined with ADM can enhance re-epithelization in the process of wound healing and significantly reduce the degree of esophageal stenosis after circumferential ESD. This study provided important preclinical findings for subsequent clinical trials.
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Affiliation(s)
- Baozhen Zhang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yue Zhang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yidan Wang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Fan Yang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shiyun Sheng
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhe Wang
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaoying Chang
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jianyu Wei
- Medical Transformation Department, Micro-Tech (Nanjing) Co. Ltd., Nanjing, China
| | - Jintao Guo
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Jintao Guo, ; Siyu Sun,
| | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Jintao Guo, ; Siyu Sun,
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Endoscopic Ultrasonography in Children with Eosinophilic Esophagitis-A Review. Pediatr Rep 2022; 14:13-19. [PMID: 35076585 PMCID: PMC8788551 DOI: 10.3390/pediatric14010003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 01/27/2023] Open
Abstract
Endoscopic ultrasonography (EUS) is a diagnostic endoscopy of the upper gastrointestinal tract, during which ultrasound of nearby organs is also performed. It is also possible to perform a fine needle aspiration biopsy. Currently, EUS is performed more frequently in adults. Despite some limitations, this diagnostic method is also more and more often performed in pediatric patients. Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus, which also occurs in children, and leads to irreversible fibrosis of the esophagus wall, if left untreated. Traditional methods of diagnosing and monitoring EoE treatment have significant limitations, and the use of EUS and total esophageal wall thickness (TWT) assessment may bring measurable benefits. Several studies have shown an increased thickening of TWT in EoE in children compared to pediatric patients with gastroesophageal reflux disease, and a decrease in TWT in adults who responded to EoE treatment. These results suggest that EUS and TWT measurement may become an important test in diagnostics, monitoring the effectiveness of therapy, assessing disease progression, and in individualizing the method and duration of EoE treatment also in children.
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Affiliation(s)
- Simon S Rabinowitz
- Division of Pediatric Gastroenterology, Children's Hospital at Brooklyn, New York, USA
| | - Evan Grossman
- Division of Gastroenterology & Hepatology, Department of Medicine, SUNY Downstate College of Medicine, Brooklyn, New York, USA
| | - Frank Gress
- Division of Gastroenterology, Mount Sinai Hospital, New York, USA
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