Which food group is associated with the highest risk of esophageal eosinophilia? A, dairy. I don't even have to get through it. Thanks. Yeah, perfect. Dairy. Is there another one? What would be next after dairy? What did we learn? Soy, wheat, then eggs, etc. Good. All right. What level of eosinophilia in esophageal is required for diagnosis? 15. Oh, I love it. You guys are in sync. All right, here we go. 15. An esophageal biopsy with very high levels of eosinophils is always EOE or acid reflux. True or? False. Perfect. I love it. Look at all the learning going on. All the following are associated with a higher risk of EOE except residency in a warmer climate, male sex, history of atrophy, early exposure to antibiotics. A, yeah, cold weather climate, higher risk, northeast. All right. What percentage of patients presenting with a food impaction have EOE? Whoa, that was fast. I didn't even read that. That was great. Yes. Oh, my gosh. Look at that. I think we're going to have some high scores today. What do you think? All right. Natural history. All the following are associated with esophageal eosinophilia except celiac, IBD, GERD, pill-induced esophagitis, or peptic ulcer disease. Ooh. We got the stump us. Oh, E, right? So all the following are associated with eosinophils except. So which one is not associated with the eosinophils? Now we've got the ulcer disease. Pill-induced esophagitis, it's inflammation, you get eosinophils. GERD, we talked about it, you get eosinophils, right? Inflammation. IBD, Crohn's, et cetera, you can have inflammation, so you get eosinophils. And then celiac, there's some low-grade inflammation as well, so you can get eosinophils. So peptic ulcer disease, that's ulcers in the stomach. You're not going to get that one. All right. Eosinophilic esophagitis is associated with all the following signs and symptoms except dysphagia, chest pain, heartburn, failure to thrive, or GI bleeding. E, perfect. Yeah. Thankfully, no GI bleeds with EOE. Now, they will bleed if you have an impaction in there, and you try to pass it through, and then you get tearing of the mucosal lining. Then they can bleed. But EOE in and of itself will not cause bleeding. Good. Which of the following is the earliest compound released in the stimulation of esophageal eosinophilic inflammation following allergen exposure? Wow, you guys are good. Which of the following is not part of the three Ds of EOE treatment? Diet, dilation, drugs, dysphagia? D, yeah. D is not one of the treatments. D is a symptom that you get. Good. Which of the following is an acceptable first-line therapy for EOE? H2 blockers, PPIs, anti-TNF agents, or 5-aminosalicylates? B, perfect. All right, next one. Which of the following is an FDA-approved therapy for EOE? E, yes, correct. Wow, what would be the name of that? All right, D, none of these on the list there. Perfect. Which of the following, or sorry, what is the most common adverse event after endoscopic dilatation? Chest pain, bleeding, perforation, or food impaction? A, yeah. This is what scares you, right? You see this big rant, the mucosal rant, we've talked about it, and then the patient in recovery complains of chest pain. And most of those patients will have chest pain after dilation because you're tearing the mucosa. And so in our practice, a lot of times before we dilate a person like this, we will tell them, you will probably wake up with chest pain. It actually helps their anxiety. It helps nurses in recovery's anxiety. It helps our anxiety. But if that goes on and on, a conservative thing to do is to make sure you didn't perforate because there is that risk there. So don't just say, oh, you're going to have chest pain, whatever. Let them know, assess patient, do your exam, make sure vital signs are stable. If you need an image, et cetera, you can, but chest pain is a very common symptom. We try to let people know about that beforehand. All right, which of the following is true regarding EOE treatment? Control of inflammation reduces the need for endoscopic dilatation. Maintenance topical steroids should be avoided. H2 blockers improve esophageal eosinophilia. Allergy testing guided dietary restriction is more effective than a six-food elimination diet. Yeah, absolutely. Control of inflammation, and we've talked about that as well, reducing endoscopic dilatation because you're trying to prevent those fibrostenotic strictures from forming, and that leads to problems with recurrent dilations and strictures and problems. All right, which of the foods should be avoided in a two-food elimination diet in adults with EOE? Ah, thank you. Saving me from talking. A, dairy and wheat. Perfect. Which of the following regarding EOE is true? Once eosinophilia is controlled, relapse is rare after medications are discontinued. Fibrostenotic strictures are more common when diagnosis is delayed. Adolescents are more likely than adults to have strictures. Symptom resolution is a reliable indicator of improved esophageal inflammation. A. Yeah, absolutely, B. Fibrostenotic strictures, that was part of that two-part lecture series that we did. We showed that chart there. As inflammation goes on and on under control, you're going to get stenosis. Good. All right, that was the end. I think we should probably have our winners. We good? We're good on the back. All right, here we go. Lyle, you want to pull up the slide there for us? All right. Who thinks they're going to win today? I mean, who has a good feeling about this? Nobody has a good feeling about if they're going to win? We got one? We got a ringer over here? All right. I'll just get the prize. I'm just going to bring the prize over here because we have somebody that's confident. Here, I'm going to put these right here because we have some confident contestants. All right, here we go. You ready? Here we go. Prize number one. All right. All right. In fifth place, Lori. Where is Lori? Where is Lori? Good work, Lori. Excellent job. Do you want to make a speech? No speech? No speech. Yes. The Academy, yes. Perfect. I like it. Thank you. All right. Who's the next one? Those are high points. Look at that. All right, here's the next one. Jordan. All right. Congratulations, Jordan. Where is Jordan? Awesome. I'm gonna steal yours, sorry. We're gonna go this way. Don't worry, I got the big ones for you. Congratulations. All right, you ready? Here we go. Next one. Lenny, where is Lenny? Good work, Lenny. Yeah, we got the prize bag for you. Yeah, absolutely. All right, next one. Gate, where is Gate? Congratulations. Do you wanna say anything? All right, he's good. He is good, he's number two. That's awesome. All right, and then Ed, one of the big prizes goes for this, is that right? And then the other big prize goes for the Post-its. Perfect. All right, here we go. Number one, anybody guess? You're gonna point to your neighbor? All right, here we go. Rob, where's Rob? Come on down. Good work, Rob. Now you wanna go for the showcase? All right. All right, here we go, next set. So the learning nuggets. All right, here we are. So you're gonna get these in email. These came all from the Post-it notes that we have over there that everybody participated in. When we have winners, it means that you posted the most amount of things, the learning nuggets, that we all hopefully either learned or should remember to learn or that you thought was really helpful and important. So here we go. These are some of them. I'm not gonna read them all. We've highlighted some of them that are fun and I might ask faculty some stuff. So, you know, biologic targeted treatment is further down treatment in the algorithm. Crohn's is inflammatory there. Tug sign for EOE in the esophagus. It's harder taken during biopsies. Walt, I think, was that one that you presented? Good work, do you want a prize? Do you want a prize? No? Daryl, yeah, that's what I was gonna say. So Daryl, tell us. UC is inflammatory. Yeah, so both are inflammatory bowel disease. The difference between Crohn's and ulcerative colitis, Crohn's disease can be anywhere. Mouth to the anus. UC is inflammation of the colon. Perfect, so they're both inflammatory. What's that with IBS? So IBS, IBD. IBS, non-inflammatory, in case you missed that one there. All right, next one. IBS causes abdominal pain. Yeah, pig stomachs are disgusting. I mean, okay, yeah. Colon cancer, this is important. You know, colon cancer screening recommendations, we down the age from 50 to 45, right? So 45 years old, start your colon cancer screening. Good. Rugae is also called gastric folds, nice. We are all a donut. Thank you, Dr. Lightdell, for that enlightenment. Goes back there, good. I mean, this is awesome. Look here, EOE, prolonged disease duration without treatment leads to fibrous stenotic complications. That was great. We've done that several times on there and you found it important as well, kudos. The esophagus grows as you grow. Dr. Lightdell, you made like a significant impression. All right, women, seven drinks and men, 14 drinks. Dr. Pardee, you made an impression as well. And this was the one that we love from this morning. You know, my wife was not exactly right when she said I was an idiot for buying the Squatty Potty. Thanks, Dr. Callaway, you know, awesome. All right, ileum absorbs B12 and bile salts, nice. The length of the intestine is generally the same despite gender and height, et cetera. And the esophagus is two millimeters thick. It's small, good. All right, another tug sign. You get two. All right, so this is a question here. You mentioned there are times when a patient has IBD and EOE. I'm gonna have this one over to Dr. Nayak. You mentioned there were several times when a patient has IBD and EOE. Would you use a biologic to treat IBD? Dupixan has no FDA indication for Crohn's or ulcerative colitis. So in itself, it won't help you with inflammatory bowel disease. So first is to control the inflammation from IBD. So if you are endoscopic remission for inflammatory bowel disease, and you still have ES and inflammatory esophagus, that still could be esophageal Crohn's. So you need to make sure, first, you're in true remission as well, too. So we have a lot of patients who have stricture disease of the esophagus who have Crohn's disease already as well. So is that a true EOE that's independent? I don't think so. Some may have an independent disease process as well, too. But we have a discussion with our group and also nationally as well, too, about using other biologics which are gut-specific, like integrin inhibitors like Intivio instead, which may be helpful as well. I do tend to inject steroids for those esophageal strictures. But I'd be very careful saying they have an independent EOE process if they have Crohn's disease. Now, if they have UC, then that would make more sense. They shouldn't have esophageal disorders for UC. But I'd be reticent to say they have Crohn's disease and an independent EOE process as well, though it can happen. Now, if you've already managed all of them endoscopically with a management for their Crohn's disease and died of them, maybe Dipixan has a role. But it won't help you with underlying inflammation of the colon. So I'd be careful using that drug on that indication. Perfect. All right. Thank you. All right, let's see. The guy meant kidney shot, not liver shot. Does that change your thoughts on MMA? I don't know. Dr. Kim, tell us your thoughts on MMA. Did it change it? No, I still don't watch it. But I had Peter in my group today, and we clarified a liver shot as a shot of whiskey. Nice. Very, very good. All right. How many eosinophils do you see? And there's a drawing there. I don't know. If you get this one, I'll give you the prize and the mic. Good. It looks like EOE to me. It looks like EOE to me. Collective education is valuable. Agreed. Be a patient advocate and partner with your office. Agree even more. Super, super, super. Great question asked. What is the provider's end result for EOE the patient? Walter, is it to prevent choking at a wedding? with EOE? What are you looking for? What do you want? not just preventing choking, but preventing future fibrosinosis. Awesome, thank you. All right, Dr. Booth in the Spanish for great presentation. Learn the visual difference between EOE and GERD. Excellent there. Goals of dilation, mucosal tear. Perfect. All right, how long do you have to be off of a biologic before you start to develop antibodies? Ooh, Dr. Park. You don't have to be off biologics to develop antibodies. You can develop antibodies while on biologics, but, and also off of them, but there's not an exact time. Everybody hear that? The highest risk is during the first six months. All right, so you don't have to be off of biologics. You can develop antibodies on biologics, and that's why in IBD we tend to do dual therapy when we're using certain biologics like anti-TNFs. We also know the highest risk of forming antibodies is in the first six months, but you can still form antibodies later on in your disease course as well. Great, thank you. Here we go. All skin reactions don't always correlate to EO reactions. Cool. EOE is on his mind every time he goes out to eat. Sometimes he forgets and the situation occurs. That is true. I learned that during a dilatation a tear is looked for and required. Right. That's how you know you actually did something successful. Perfect. Should endoscopy be repeated or should repeat endoscopy be used to assess EOE after a change in treatment? If yes, how often? I think that is the holy grail question. Nobody knows the answer. Yeah. You should always repeat endoscopy if you change therapy. I think the main question is if they're already in remission, do you need to keep scoping them? I think there's no consensus, but every time you change therapy, whether you're changing agent or changing dosage, you should repeat endoscopy to make sure that they're still in remission after. How often? Usually if you do it and they're in remission, you don't have to repeat it, especially if their symptoms remain in control. All right. And then we have some really good ones. Learn that patients aren't always willing to pay for certain therapies if they feel okay. Right. And we can all look introspectively at ourselves and be like, look, if I'm feeling all right, how much am I willing to pay? Right. I might be like, whatever, I'm fine. I'll just pay the next catastrophe. And some are like, I'll pay whatever it is each month to continue to feel well. Everybody's different. You know, and then learn that shared decision making helps when setting up sort of the patient picture and how this works. And a lot of that's also where you guys fit into the healthcare team as well, is to help facilitate that. And part of that shared decision making also is, can I have access to these medications and how easy is it? How many hurdles do I have to jump through, letters, et cetera, to get stuff on board and approved? And is the patient going to be happy at the end of the day? Because a big frustration is we'd say, let's do this, and the patient can't get it. And then they're angry at us, despite us having no sort of choice or role in that. And so if we can alleviate all that, and your help is essential in that healthcare thing, the patients feel better, and their attitude is better, and we have a better therapeutic relationship. So the odds are they're probably going to continue with therapy more. So facilitating that relationship and helping with shared decision making is awesome. That's super important. So thank you for bringing that up. So let's do the learning nugget winners. Here we go. Most number. Guesses? All right, no guesses. All right, Kelly. Kelly. All right. Next one that we have is Heather. Great job, Heather. Thank you so much. All right. And then we have our final one. Leslie. Thank you. Next on the deck, so just a couple of things that I want to say, first of all, this sort of concludes our session here. Are there any last-minute burning questions that people have? Questioned out. No problem. I want to say a huge, huge thank you to all of you for coming here, for taking the time out of your schedules, your days, to be here with us at the ASGE yesterday and today. I sincerely want to thank you for your participation, your enthusiasm, your communication, and your questions. They were awesome. You've been a fantastic group to work with, and it does not go unnoticed, and it is super appreciated. So thank you. I think we should all give a round of applause to Chris and Nicole for organizing this together for us, so amen. And then to Ed, Lyle in the back, Michelle, and the entire team, so kudos. And we wouldn't have a course without our awesome faculty, so thank you guys for being here.

esophageal eosinophilia

association

diagnosis

EOE

treatment

learning nuggets