Okay, so my question is, you mentioned that EOE patients, 50 percent end up in the ER for food impaction. Do they first see the ER doctor and then refer you in, or how does that work to make sure that these patients don't get missed? So an excellent question. How do patients who come in with food impactions to the emergency room, how do they have good follow-up of care so that we can get them on treatment? I think this is a huge area of need. We've been doing some research on this specifically in that we do a very poor job of getting these patients in to see the gastroenterologist afterwards. As I forget who had mentioned this morning, Dr. Carpenter maybe, that the first time you may ever see these patients is in the middle of the night in the emergency room where they come in with a food impaction because they've never really realized or recognized that this was a problem for them. They come in with a food impaction and then what do you do, right? You have to have a better streamlined approach to get those patients into clinic. We've done this at Northwestern, a best practices protocol, and I think a lot of centers are doing this across the country in terms of trying to make sure that every patient that comes into the emergency room with a food impaction gets biopsies. That's part of the new ASG protocol because we know that 50% of these patients have EOE. So that's number one. They need to be biopsied at the time of that endoscopy to make that diagnosis. They need that follow-up kind of right at the emergency room. So they get a follow-up with us given to them before they leave the emergency room and then our fellows reach out to us afterwards. So that's a big area that still needs some education and awareness to make sure that they get in to see the gastroenterologist, they follow up, they get on treatment and hopefully prevent these food impactions from happening. Just a follow-up to that, any curiosity of how often you think a biopsy is occurring based on what you all have looked at because that's an interesting one. Not very often. There are a lot of abstracts that were just recently presented at DDW that say the rates of biopsy can be as low as 20% to as high as 40%, but that's still really missing the mark. Partly, that happens because sometimes people wait a long time to come into the emergency room. So it takes them a long time to get this food out and by that time, the endoscopist may not have wanted to do the biopsies for whatever reason, but it is low. So that is an area that is being addressed from an awareness campaign both at the ASGE and other places to try and increase that. I think it really speaks to the fact that EOE is really a disease that's become much more prevalent and known in the last few decades and there's some physicians that may have been practicing for a long time that may not have the same level of awareness of this. So there's a role for provider and physician education in terms of updating folks on the knowledge base. Great. We have lots of questions. I love this. This is fun. Or someone else. Okay. Were you? Go for it. I don't know if they're waiting for me. Go for it. So to that point, what are some, since you mentioned there's been so many changes in evolution in the past 20 years, what are some of the old mindsets or philosophies that you see many providers still have the old mindset that need to be educated on some newer developments in EOE? Sure. So that's an excellent question. The old mindset, when I was a fellow, I mean, I started fellowship in 2002. At that time, it was not standard to biopsy the esophagus at all in patients with dysphagia. That's a very new thing that's come about. So patients with dysphagia now get biopsied very standardly and I think that awareness campaign has been very effective. But that's something that wasn't really recognized at the time. Biopsying during the time of food impaction was not recognized at that time. We're slowly catching up with that. So we have a ways to go, but we have come a long way. Other questions? Okay. In the back. I keep repeatedly hearing about food impactions, emergency room visits at like two or three in the morning. Are the patients eating late? Are they having a flare? Or is it because the doctors aren't at work? Is there any kind of correlation to this early morning phenomenon? So I'll tell you my story. So how I got into EOE disease awareness and interest is I, as a fellow, always got called into the emergency room for a food impaction. Notoriously, anytime I was on call, I would get a food impaction, so much so that I was nicknamed the food impaction fellow. And these people would always come in in the middle of the night because partly they were out having some cocktails, like out eating, having a good time, forgetting to chew, and then they wait a while, right? They think, oh, maybe, I mean, they've dealt with this before, so maybe it'll go away. But finally, after five hours, it's not going away. They come in. So it's usually always in the middle of the night, not because we don't get the call or we wait a long time, but it is a function of when it typically occurs. But there's a lot of movement and a lot of recommendations in terms of how quickly you need to address, as a clinician, you need to address the food impaction. So it needs to be handled within a certain amount of hours to prevent complications like aspiration or tearing of the esophagus. I will tell you, another question that comes up is why do we have so many of these in Chicago and why do we have such a rich EOE population? I did an unofficial study when I was a fellow. So Northwestern's ER is right in the middle of the top 10 steakhouses in the city. So every time we had a lot of out-of-town visitors, they would go out, go out, have dinner, and then come to our ER. So that's another thing to your point about follow-ups. Sometimes when people are going to the emergency room with this, they may not be in their city, and so it's hard to kind of get that follow-up. I have an interesting anecdote before we get to the next question about that issue, why they come in, you know, two in the morning. In fact, a couple weeks ago, I saw one of our emergency room doctors, and she had swallowed some chicken around noontime and realized it was stuck. She's educated. She's an ER doc. She sees these patients all the time. She realized they're stuck, and she's heard so many complaints from our fellows about being called in the middle of the night, she decided to wait until 6 in the morning to come in and give the fellows a break. And then when she got to the emergency room, her colleague said, well, you know, look, maybe we cannot, you know, bother the GI fellows. Let's try some things. So she literally took a sip of water and jumped up in the air and came flat down on her feet, and boom, the food bolus went through, and she didn't have to call the GI fellows. She relayed that story to me to tell me that, hey, I gave your GI fellows a break just to let you know. So there are some interesting reasons why people come in at 2 in the morning and not 2 in the morning. Okay, next question. I have two, and I'll be real quick, but the first one has to do with the prevalence being more heavily weighted towards males. Is that perhaps true, or is it because it's so new that maybe when females present, it's being misdiagnosed as anxiety or something else, kind of like how fibromyalgia, the course of the treatment of fibromyalgia, came into play? Just a thought. I don't know if that's something you guys have considered or... Yeah, so there have been a lot of genetic studies looking at that specifically, and I will say across the board, it all pans out that this is a male-predominant disease. There are certain genes that are more commonly transmitted along that male pattern inheritance. So that is true. Is there a certain element of women who are misdiagnosed and have a delay of diagnosis possibly? But in my experience, our women who come in, they are more attuned to their symptoms, and they come in quicker. And oftentimes, we think that they present with slightly more severe form of the disease. We don't know what... That's still an area of investigation. But I think the male-predominant thing is true. There's something about that genetics. Interesting. And then the second question is this, you had mentioned that there's... With diagnostic delay, there's an increase of fibrosis. And is that true even if symptoms are not present or the symptoms have been... They've been adapted and kind of masked so that the patient isn't really reporting a lot of symptomology, but are they still having fibrostatitis? So does diagnostic delay with... If I'm understanding your question correctly, with longer time of the disease, with longer duration of symptoms, do you get increased fibrosis? You do. And we see that even in children. So even children will have fibrosis on their biopsies, definitely with longer duration of symptoms in adults. There's a higher risk of fibrosis and a higher risk of strictures. We see that in untreated disease. That risk of progression and the rate of progression is different per different patient. So sometimes it could take years and years, like 10 years to get those strictures. Some people we call rapid progressors, where they may get strictured very, very quickly. That's not the norm. But why you may be missing symptoms in some of those patients are they... Many of these patients have complained about this for years and years. They've been told that they ate too quickly. They were told that they weren't drinking enough water, that they're crazy. Lots of scary things that they were told. And they've adapted. So now they don't think it's a big deal because they've avoided their foods. They're chewing really well. They're drinking a lot of water. So that's the tricky part with relying on symptoms only. Thank you. Question over here. Laura. Yeah. A question back to the infants that were exposed to antibiotics that had a higher prevalence of EOE. Does that include in pre-birth? So if the mom had to take antibiotics or if she had, let's say, a positive FB strep where she has to hang antibiotics when the baby's born, are those numbers accounted in there? Is that also include? They did include that as well. And that was also folded into the C-section delivery and the NICU admissions. So they think that pre-birth exposure to antibiotics did affect that. They think that that's multifactorial, probably affecting the microbiome in some degree. Kids who are being born by C-section are not being exposed to the vaginal flora. So that's also kind of affecting their microbiome. So there are a lot of different things to look at and unfold in that data. But those risks were real. Question in the back. Is the barium x-ray used in the community GI setting? And if so, is it done at the same time as the EGD? The barium x-ray? Did I hear you correctly? Yes. Oh. So yeah. I mean, the barium x-ray is not routinely used in dysphagia, I would say, across the board, meaning I think most patients don't need a barium x-ray and an endoscopy. Sometimes where that barium x-ray or esophagram is helpful when I see patients in clinic is if I think someone's had really long-standing disease, if I think they're localizing, they're sometimes very high up in the neck, and I think they have a cervical structure, so a structure very high up that sometimes can get missed, or I think they have a narrow caliber esophagus from being so fibrotic, then I will do an esophagram before my endoscopy. But that's not a typical thing that I think is done in the community. The other role I see for the barium esophagram is when we're treating patients with EOE, and we think we've adequately treated them. Their eosinophils are normal, their esophagus looks open, but they're still having dysphagia. That's when we'll do an esophagram and try and look to see if a tablet gets caught anywhere. That's when we'll do motility to see if there's any motility problems in their esophagus. Those are the two roles that I think the esophagram helps with. One of the things we do discourage is the emergency room doctors ordering a barium swallow in somebody that comes in with a food impaction, because then you can imagine if we do have to go in endoscopically to have all that barium sitting there, it is not a lot of fun. So we try to educate our emergency room docs not to try to do that. Question in the front here. I know a lot of GIs include allergists in the treatment. How effective is diet modification and finding out what the allergen triggers are with EOE? Sure. So dietary therapy is actually very effective. It's one of the most effective treatments for EOE. Imperial diet, which is a formula-based diet, is about 90% effective, but it can be very challenging, right, putting someone on just a formula diet and then doing reintroduction. A six-food elimination diet or an empiric elimination diet is about 70% effective at treating the disease and then identifying the food trigger. So Dr. Falk is going to show you some of these slides in his next talk, but the switch is really moved away from allergy-testing-directed diets to more empiric elimination diets. Because the current available allergy tests, they check for IgE-mediated inflammation, so anaphylactic-type reactions. EOE triggers are not anaphylactic-type reactions, which is why a lot of times people go see the allergist, they'll get skin pricked and patched, and it just doesn't light up. Or everything will light up and they don't know what to do. The data for the allergy-tested-directed diet was strongest in pediatrics in children, where they used both the skin pricked test and the ATP patch test, the little wheels on the back, to try and figure out their food triggers, but it's not typically done. That being said, it's definitely a multidisciplinary field, because these patients are atopic, they have asthma, they have environmental allergens, so co-management with the allergist is important, but not so much for that skin testing for foods. A question over here. If you were talking to, let's say, three GIs, and one was saying, yes, I'm seeing EOE pretty often, like I'm seeing at least one or two patients in here a month, but then you talk to one of the other doctors in the practice, and they say they're rarely seeing it, what would you follow up with? Would you ask them, for example, that one who says they're not seeing it, are you biopsying? Are you taking multiple biopsies? Do you think that would be a fair question to ask that doctor? I think a good follow-up question would be, well, is there a specific specialty you see within your practice? Are you seeing more IBS patients, are you seeing more IBD patients, just trying to understand a little bit more about their practice pattern as you pose your questions. The other thing you can ask is, we've heard from me, whoever, that sometimes, you can blame me, throw me under the bus, that sometimes patients may not tell you that they're having difficulty swallowing. Does your practice typically ask about eating patterns and how they eat? Because some of these patients were actually misdiagnosed in teenage years with having eating disorders because they were just avoiding so many foods. So that's something that, as gastroenterologists, we need to do a better job of asking patients how they're eating and why they're avoiding things. We had a questionnaire, I will tell you, that had all our new patients check off their symptoms and dysphagia was one of them, and I was surprised at how few patients with EOE actually checked that off. And I asked them, why aren't you checking this off? Like, you have a three millimeter esophagus, and they're like, oh, I don't have difficulty swallowing because I chew. I'm like, okay, fine. So I think just asking the right questions will help tease that out. Yes, biopsies, that happens a lot. We'll have people send to us, I'll look at their reports and I'll see that two pieces were taken. That's another thing to inquire about. The other thing is the pathologist. Are they using a pathologist who is attuned, and you'll hear that lecture maybe later today or tomorrow, about pathology being up to date on the guidelines too, and could it have been missed with pathology? There are lots of different ways for this delay of diagnosis. Next picture. Yeah. Yeah. My question is on the topic of food elimination diets. In your practice, if you have patients that are well controlled with a food elimination diet, but they started then on a biologic, when would it be appropriate to reintroduce the foods into their diet? Yeah. So that's a great question. I think people who are well controlled on food elimination diets, and I want to backtrack to a question that came up earlier. The goal of food elimination diet is to eliminate it, see if people respond, but then fold the foods back to find their trigger. So assuming someone's found their trigger, they're eliminating that trigger, and they're on some other therapy that could potentially allow them to add that food back. I would say it depends on two things. At least if you're doing a set type of biologic therapy, three to four months after starting on that biologic therapy, I would think it's fair game to try and add back the foods. The caveat being in children, if they had really avoided foods for many, many, many years, there are case reports that show that they've gotten sensitized to that food. So there's some literature that suggests that they should go back to the allergist, get skin tested just to make sure that they haven't developed desensitization. We haven't seen that in adults, but I personally, if I have someone that has gotten sent to me that's avoided milk for 10 years because they were told that they had an AOE trigger, before I put them back on milk, I'll send them to the allergist to get tested to make sure that they haven't gotten sensitized. Again, we don't see this in adults, but we're just being very careful. It's come up a couple of times. So when you have an allergist send you over a patient and you diagnose them with AOE, do you typically take over management of the case or do you coordinate with allergist or send it back to allergist? How do you guys kind of coordinate that? That's a very good question. I think it's very dependent on the practice location and where you are in the community versus an academic center and even different academic centers. So our academic center, the main people that manage the patients are the gastroenterologists. So we have a co-working relationship with the allergist, but they mainly manage the allergic profile of the patients and we manage the GI piece of it and do the more day-to-day interventions from the endoscopy to manipulating all their therapy. That may not be true of every place. Some other places may have the allergist mainly running that and then asking the gastroenterologist to do endoscopies. It really just depends, I think, and it depends on the community that you're working in. Some community practices will tell me, okay, I diagnose it and I send it to the allergist and vice versa. So it's very unique. I don't think it's a one approach across the country. So you mentioned that AOE is a young disease with two cases presenting in the 80s, the two cases in the U.S. I just wonder, why do you hypothesize this is the case? Because I wonder, is it more being food-mediated, is it a change in how our, especially dairy, correct, because that's the number one food causing the allergy, or if it's a combination of education or if it's a combination of a lot of things, but I'm just curious about that. Yeah, so this is my own personal opinion. We did a study at Northwestern really looking to see when patients were diagnosed versus when their symptoms really began and kind of doing a retrospective look, and we combined this with the Swiss database, so we had a really large adult database, and we found that it was really in the 80s where these patients started to have these symptoms. And then we started to think, well, why is that? What happened in the 80s? So I think it's multiple things. One, definitely I think the hygiene hypothesis is playing a role. We have changed into a very sterile society, and I think as a result, all sorts of atopic diseases have been increasing, and that has led our bodies to not necessarily be tolerant of a lot of things. It's kind of reacting to a lot of things, including food. Two, our food chain has changed substantially. Wheat has engineered differently. Milks are processed differently. There's a lot of things that are different in our foods in terms of contamination, and I think that's definitely playing a role. Microbiome, this is really a hot topic, but microbiome have shifted across populations. That's probably playing a role. I don't think it's one clear answer, but definitely all of these things are playing a piece. Question on the aisle. Sorry. A follow-up on the microbiome. So I used to have previously, I used to sell a bowel prep. So a lot of my physicians would do, with some patients where they felt their microbiome was off, they would do like a microbiome transplant or whatever, you know, like a fecal transplant. But with new products coming out for microbiome specifically, do you anticipate that it'll affect the EOE in a positive way where with the change of microbiome, maybe their eosinophilic count drops or if their disease becomes more stable? Yeah. So there's a lot of things that affect the microbiome, like antibiotic use, diet changes affect the microbiome. I do think that there is a link to microbiome and certain things like Crohn's disease, autoimmune disease, EOE, lots of different situations. Whether or not we're at the point where we can say like a probiotic is going to help with EOE, we're not sure, but it's certainly something that is being investigated. Question in the front. I think I'd mentioned like patients kind of have adapted and done things to, you know, say they're doing okay. After diagnosis, is there an amount of time that you bring patients back and how often are you seeing them? Because you know, they could, if they're doing okay, they might be like, oh, I'm fine. I don't need to go back. And then you're delaying, you know, that process. Yeah. I'm very aggressive in terms of how I follow my patients. And so it depends on what type of treatment I put them on. If I put them on an acid-reducing medication, I'll have them back for an endoscopy in eight weeks. If I have them on dietary therapy, I have them back for an endoscopy at six weeks. If I have them on topical corticosteroids, I'll have them back at 12 weeks. And now we'll see about the pill man. I don't know yet. Very early. But I will have them back. The bottom line is I will have them back to have that endoscopy to know that it's working and it's effective. The tricky part that you hit upon is a lot of these patients are young. They start getting on therapy, and then they're like, oh, I feel great. You put me downstairs. Woo-hoo. I can eat whatever I want. And then they just don't come back. And then they'll come back in with a food impaction. So we try. I usually want to have our patients back every year to a year and a half. We're not all great about doing that. And partly, patients feel good, and they don't want to come see the doctor. So yeah. And I think part of that's educating our physicians, too, and our providers to make sure that these patients, we make them understand this is a chronic inflammatory disease with damage. And so we really need to have better long-term follow-up. And there's a lot of data that these patients with EOE fall off the grid a lot of times. And when they do fall off the grid, bad things happen. Right here. OK. So you mentioned the ER. I was just curious, when a patient goes in, before you get called in, the ER doctor, how do they diagnose that this is a food impaction and that they're going to need to call the gastroenterologist without doing an endoscopy? Yeah. Our ER has gotten really good at this. So patients present with a very classic presentation, meaning that they can't swallow anything. Essentially, there is a complete obstruction of their esophagus. When that happens, your body's compensatory response is to salivate, hyper-salivate, get a ton of saliva. You try to swallow that, it doesn't go anywhere, it comes back up. So they're constantly regurgitating and spitting into a cup. That is like the classic presentation of a food impaction. So when they come in, they come into the emergency room, that's considered an emergency in our emergency room. So our emergency room has changed to prioritize these patients to a level one kind of situation. So level one means they get to the operating room within an hour of the time that they hit our emergency room to get that food removed. Some of the emergency rooms will try some other things. As I think Dr. Tierney mentioned, not the jumping up and down or the big sip of water, but nitroglycerin and glucagon are some other agents that relax that smooth muscle that some of the ERs will try. But there is an approach that every ER in the country knows that they should be pulling that trigger to notify the gastroenterologist earlier than later. Sometimes they'll wait for that nitroglycerin, they'll wait for that glucagon in hopes that they can let our GI fellows sleep, but they will eventually call the GI. Question in the back. So I've run into a few doctors who see EOE and even food impactions as not that big of a deal. And I'm interested to see why you feel or what makes you believe that a food impaction in EOE is a big deal and impaction is considered an emergency. So there's really good data from the ASGE that put out some guidelines about duration of foreign body ingestion and when you should pull the trigger to do an endoscopy. A complete obstruction is what a food impaction is essentially. Sometimes people can have a partial obstruction where they can drink a little bit of water and it's okay. And that's probably not as much of an emergency. They can wait about six hours. But with a complete obstruction, that is an emergency because there are risks. The risks include aspiration. Because your esophagus is filling up with all that food and saliva, you can aspirate that into your lungs and that can be life threatening. While I don't want to scare anybody, there are cases where people wait too long with a food impaction and you can have a tear of your esophagus, a through and through tear of the esophagus. When you're doing an endoscopy, when there's a food impaction, it's a higher risk procedure because you can't see as well. That food's been there a long time. There's a lot of inflammation in that esophagus. You can cause a lot of damage to the esophagus. So there are a lot of bad outcomes that can happen. In our food impaction data, we've found a higher risk of days of hospitalization, chest pain, aspiration in patients who had prolonged food impaction. That was all changed when we changed our new strategy to get them into the OR within an hour. But those are things that we need to be better about in terms of advocating for our patients. And I think I'll reemphasize again, it's all about us educating our physicians and colleagues too about the nature of this. In the patient experience session tomorrow that you guys will get to hear directly from a patient, you'll see just how serious it is for that patient. Question? So after you've diagnosed a patient and put them on a PPI and or a TCS, and you said you probably don't have them come follow up for a year, year and a half, would you then do an EGD and be like, okay, you know, based on this dysphagia, they're like, oh yeah, I'm fine. I can swallow, right? But that's their new normal. Would you do an EGD and take them off of their steroids or PPI before you have the EGD? Or you just kind of, what's the kind of normal protocol? Sure. So let me clarify what I said earlier. Okay. So when I put someone on therapy, if I start them on therapy with a PPI first, I will bring them back for an endoscopy in eight weeks. So I will see them after every treatment I put them on. So after eight weeks, I bring them back for an endoscopy to make sure that their inflammation is quiet. So let's just say it's not quiet and they go on to topical corticosteroids, then I would bring them back in eight to 12 weeks for an endoscopy to see if their intervention has changed. Or if I put them on dietary therapy, I would bring them back at six weeks. So I see them back at a very close timeframe to make sure that their inflammation is quiet, their disease is improving, their strictures are better. Once I get them on a stable maintenance regimen, which Dr. Falk will talk about, once they're on maintenance and they're doing great, I will see them back in clinic at one year so that I can check on their symptoms. I can probe them about how they're eating, make sure they're not having dysphagia episodes, and that will help prompt me to decide if they need an endoscopy at that time. But I never take them off of treatment. They're always on some type of treatment during that time. I think that's what's not done very frequently in the community, and that's where we need to be better educators in that sometimes people will get started on a treatment, they feel better, and they're just left alone. And that's not exactly the right approach. Okay, one last question right here, and then we'll save the others for the next session. Okay, can you hear me? Yeah. Okay. And this might be a scenario of when you're wanting a car, you see that car all over the place. So now that I'm more aware of EOE, I feel like it's alarming how many friends' husbands have had food impactions, gone to the ER. So what percentage do you feel like if somebody's going in, they have dysphagia, they have food triggers and an impaction, that they likely have EOE? I think the pretest probability of that patient is probably like 75 to 80% likely that they're going to have EOE. And I think your experience is not unlike most of us in this room, that it is highly unrecognized. And I will give you a funny scenario to end, because I know I want to leave Dr. Falk a lot of time. But half of, not half of my patients, exaggeration, but many of my new patients that are coming in to see me are patients who are friends of my existing EOE patients, who never knew that they had problems. They're sitting in the boardroom with their colleagues. Their colleagues are either taking a medication or they're avoiding certain things in the diet. They start talking about it, and they're like, hey, I've had this problem my whole life. People thought I was crazy. I was just eating too fast. And as people start talking about this, as awareness increases, more and more patients have recognized that this was abnormal and come to see us. So I think from a disease awareness standpoint, we're not there. Everyone is doing a great job. But I think we're not at that iceberg yet. It's probably deeper down. Yeah. OK. Thank you.

eosinophilic esophagitis

follow-up care

food impactions

lack of awareness

gastroenterologists

biopsies

diagnosis and treatment