Hello, everyone. Welcome back to our afternoon session for our virtual esophagology. We had an excellent morning on GERD and achalasia, and it is my pleasure to co-moderate our section on eosinophilic esophagitis with Amitabh Chowk from Cleveland, Ohio, and I'll turn it over to him. Thanks, Bonnie. Looking forward to this afternoon session after lunch. Without further ado, let me introduce the first speaker. Shivangi Kothari is Associate Professor at University of Rochester. She's also the Associate Director of Endoscopy, and she'll be talking to us about eosinophilic esophagitis during endoscopy diagnosis and dilation. Shivangi? Welcome, everyone, to the ASG esophagology course. I'm Shivangi Kothari, and I will be talking about thinking about eosinophilic esophagitis during your EGD diagnosis and dilation. I would like to thank the course directors, Dr. Pratik Sharma and Dr. Vani Konda for giving me the opportunity to give this talk, and thank you to ASG for giving me this opportunity. These are my disclosures. In this talk, I will be reviewing the diagnostic criteria for eosinophilic esophagitis, the characteristic endoscopic findings, and the tips and tricks for dilation of eosinophilic esophagitis structures. Eosinophilic esophagitis is defined as a chronic immune antigen-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophilic predominant inflammation. The diagnostic criteria for eosinophilic esophagitis from the recent updated international consensus from the AGREE conference are presence of symptoms of esophageal dysfunction, greater than 15 eosinophils per high-power field on esophageal biopsy and eosinophilic infiltration isolated to the esophagus, and assessment of non-eosinophilic esophagitis disorders that cause or potentially contribute to esophageal eosinophilia. Since about 30% to 50% of patients with eosinophilic esophagitis are PPI responsive, a trial of PPI is no longer recommended prior to the diagnosis as that was recommended by the older guidelines. Eosinophilic esophagitis is three times more common in men. The classic scenario is a male with atopy. It can occur at any age and is more commonly seen in whites. The prevalence of EOE has been estimated to range between 43 to 52 per 100,000 in the general population. Studies have reported that more than 6% of patients undergoing upper endoscopy for any reason and more than 15% having the procedure for an indication of dysphagia will be diagnosed with eosinophilic esophagitis. Having a high clinical suspicion and a detailed history are very important steps in eosinophilic esophagitis evaluation prior to endoscopy. The classic presentation is usually dysphagia for years with gradual increase in frequency and intensity, especially to dry fruits such as meats and breads. However, many times patients don't have the classic presentation and thus inquiring about their eating habits and coping strategies can give clues such as prolonged mastication, use of ample amount of liquids with dry foods, and prolonged mealtimes can suggest underlying esophageal dysfunction. Eosinophilic esophagitis is strongly associated with atopic diseases such as asthma, allergic rhinitis, sinusitis, atopic dermatitis, and food allergies and thus inquiring about this can help impact management and treatment. Sometimes patients may have non-cardiac chest pain, food impactions, and 1-8% of patients with PPI refractory reflux symptoms could have eosinophilic esophagitis and inquiring about these is essential. So coming to the most important step in diagnosis of eosinophilic esophagitis, esophageal biopsies are required for the diagnosis. 2-4 biopsies are recommended from the proximal and distal esophagus given the patchy nature of the esophageal involvement by EOE. Since GERD can also cause eosinophilic infiltrates, in patients with mainly reflux symptoms, I usually sample the proximal and distal esophagus and send the specimen in separate jars. Targeting endoscopic lesions like exudates and furrows can also help increase the diagnostic yield. At the time of diagnosis, biopsies should be obtained from antrum and duodenum to rule out other causes of esophageal eosinophilia in all children and adults with gastric or small intestinal symptoms or endoscopic abnormalities. So on endoscopic evaluation, the esophagus can appear normal in about 10-25% of patients with eosinophilic esophagitis. Some of the classic findings on endoscopy are the presence of fixed esophageal rings previously called as trachealization. The rings can vary in severity from subtle ridges to tight fibrotic bands and full insufflation of the esophagus is required to appreciate their extent. There can be transient rings also called as felonization. Other furrows are fissures that run parallel to the axis of the esophagus, whitish plaques or exudates which are eosinophilic microabscesses and these can be confused with candida esophagitis. Esophageal narrowing. Presence of frank esophageal strictures. Also you can see there is a mucosal edema and decreased vascularity which can be a very subtle finding. Crepe paper mucosa which is a mucosal tear that can occur with the passage of just the endoscope. So while advancing the endoscope if you feel any resistance, make sure to back up and check that the scope is not causing any tears in the proximal esophagus as you are advancing the scope. These findings can occur in isolation, however, they are routinely seen in combination with a significant overlap in patients with eosinophilic esophagitis. Here you can see on an EGD that was reportedly normal in a patient with persistent dysphagia. Subtle mucosal edema, felonization and whitish exudates were seen and biopsies revealed greater than 15 eosinophils and patient was diagnosed with eosinophilic esophagitis. In 2013 Hirano et al proposed the Endoscopic Reference Score Classification System as a way for standardization and reporting the endoscopic signs of eosinophilic esophagitis in adults. This classification has demonstrated good inter-observer and intra-observer concurrence. The proposed system incorporated the grading of four major esophageal features, rings, furrows, exudates and edema and the presence of additional features of narrow-caliber esophagus, feline esophagus, stricture and crepe paper esophagus. This helps with having a standardized reporting of EOE findings and also for follow-up assessment for treatment and subsequent comparison to baseline findings. In a study prospectively evaluating the eosinophilic esophagitis endoscopic reference scoring system comparing patients with EOE to controls, the scoring system successfully identified patients with EOE with an area under the curve of 0.934. The mean score decreased with treatment from 3.88 to 2.01 and histologic responders had significantly lower scores than non-responders. Recently narrow-band imaging has been employed for diagnosis of eosinophilic esophagitis. The presence of base mucosa, dot-shaped intraepithelial papillary-capillary loop and absent kind vessels correlated strongly with the presence of eosinophilic esophagitis and lymphocytic esophagitis with absent kind vessels carrying the highest sensitivity and specificity to make this differentiation. The histologic hallmark of eosinophilic esophagitis is presence of increased number of eosinophils in the esophageal epithelium. The diagnostic criteria recommend greater than 15 eosinophils per high-power field. Presence of eosinophilic microabscesses, which is defined as clusters of at least 4 eosinophils, dilated intercellular spaces, basal layer hyperplasia, papillary lengthening, and lamina propria fibrosis. Alternative etiologies to eosinophilic esophagitis should be excluded with the most common one being GERD. In a recent book chapter that we published, we discussed the mimickers of GERD being eosinophilic esophagitis and lymphocytic esophagitis. Some of the diseases associated with esophageal esophilia are celiac disease, Crohn's disease, eclasia, that should be considered in the clinical scenario. Some other adjunctive modalities to EGD for diagnosis of eosinophilic esophagitis are barium swallow, which is more sensitive for esophageal strictures. EGD has been reported to have a sensitivity of only 25% when a cutoff of 15 millimeters is used for the esophageal diameter. Barium swallow can also help plan for dilations. pH testing can be used in patients with primarily reflux-like symptoms. Esophageal manometry is usually not diagnostic or specific for eosinophilic esophagitis. So now coming to the treatment of eosinophilic esophagitis, management of eosinophilic esophagitis is multimodal, and this will be reviewed in more detail in a separate talk by Dr. Katska in this course. I will be focusing on the role of endoscopic dilation of eosinophilic esophagitis strictures, which has a role in the initial and the maintenance therapy of eosinophilic esophagitis. Strictures can be seen in 30% to 80% of adults with eosinophilic esophagitis. Dilation of strictures on narrow-caliber esophagus in patients with dysphagia is an important therapeutic modality, especially for stricturing fibrostenotic disease. It can have a prolonged effect for months to years and on an average lasts about a year. The main principle for dilation in eosinophilic esophagitis strictures is to start low and go slow, and the goal is to get the luminal diameter to about 16 to 18 millimeters. 75% of the patients can report chest pain after the procedure, and the key is the use of medical and diet therapy in combination with dilations. Dilation is recommended in patients with acute symptoms such as food impaction, daily dysphagia, those with established tight strictures, narrow-caliber esophagus, and patients not responding to diet or medical management. Endoscopic dilation can be performed using bougies or balloons. The bougies help dilate entire esophagus and long strictures. Endoscope reinsertion and inspection can be performed once there is tactile resistance to the passage of a bougie or at 2 millimeter increments. The absence of heme on dilator is not a reliable indicator of mucosal disruption. Balloons can be used for focal strictures. Pullback on inflated balloon to the cervical esophagus can be performed to assess for proximal strictures, and reexamination can be performed after each dilation to evaluate for mucosal disruption. Some key considerations when performing endoscopic dilation. The most important thing to remember is to start low and go slow. Patients have had the luminal, narrowing, and fibrotic strictures for a long time, and the key is to not over dilate and create a complication. Forewarn the patient of post-procedural pain and its response to pain medications. Examine the entire esophagus prior to dilation to assess the location and size of the stricture. In case of a tight stricture, use the transnasal scope to minimize the need of fluoroscopy and blind dilations. Start with small dilators and gradually dilate to a goal of 16 to 18 millimeters. This may require several sessions about three to four weeks apart. Limit the dilations to moderate resistance or mucosal tears. After induction dilations, repeat dilations are based on recurrence of dysphagia symptoms. Many patients only need maintenance dilations every two to three years. Dilation therapy should be performed in conjunction with the medical treatment such as PPI, steroid use, and diet therapy to decrease the rate of stricture recurrence by treating the underlying inflammation. This is a patient with a multifocal stricture in the esophagus from EOE at the proximal as well as distal esophagus. Subsequent focal savory dilations were undertaken. And with subsequent success, focal dilation with the balloon catheters was performed and the patient responded really well in addition to medical therapy. Endoscopic dilation and use in ophilic esophagitis strictures is efficacious. In a meta-analysis of 27 studies with over 2,000 patients with dysphagia and undergoing about 1,820 esophageal dilations, clinical improvement was seen in 95% of the patients. Bougies and balloons were used equally and there were no deaths reported from the dilations and perforation was seen in 0.38% of the patients. Safety of endoscopic dilation of using ophilic esophagitis strictures has also been reported. In a meta-analysis of 37 studies with over 2,000 dilations in 977 patients, clinical significant bleeding was seen in 0.03% of patients. Clinically significant chest pain was seen in 3.6%. Perforation rate was 0.03% per procedure with majority reported before 2009. And thus, perforation from esophageal dilation in EOE is rare and there was no significant difference in perforation risk related to the dilator type. The endoscopic functional luminal imaging probe is used to measure compliance and distensibility in the esophagus and has been reported on use in ophilic esophagitis patients in some series. The probe and balloon pull-through techniques may help in judging optimal caliber for dilation and measure outcomes of therapy. However, cost effectiveness and clinical impact studies are warranted. Some practical tips for consideration when performing dilation of using ophilic esophagitis strictures. Discuss the procedure in detail with the patient and obtain an informed consent. Inform the patient that post-dilation chest pain is common and risk of perforation is no greater than that with dilation of other esophageal diseases. Discuss the need for repeat endoscopy and dilation sessions based on the severity of the underlying stricture. Use CO2 when performing the procedure. Do not panic when you see mucosal tears and assess it adequately to ensure there is no perforation. If perforation is identified, then close it adequately during the procedure. Provide clear instructions of post-procedure diet and follow-up. Do not neglect if patient continues to have severe chest pain, fever, or tachycardia post-procedure and evaluate it and manage it appropriately. Thus, in summary, eosinophilic esophagitis is a chronic inflammatory condition with diagnosis performed taking into consideration both clinical and pathologic information. A detailed history is important with high level of clinical suspicion since endoscopy findings can range from a normal-looking esophagus to frank strictures. EGD with multilevel biopsies with greater than 15 eosinophils per high-power field is needed for diagnosis. It is a chronic inflammatory condition that can lead to fibrostenotic complications requiring dilations. Dilation is safe and effective for EOE strictures. The key is to start low and go slow. And multimodality therapy and follow-up is important in managing these patients. Thank you very much for your attention.

eosinophilic esophagitis

endoscopy diagnosis

dilation

diagnostic criteria

esophageal dysfunction