Dr. Tiwani and I have this task of not only talking about esophageal strictures, but also keeping up some energy post-lunch, so we'll do our best for that. And so to start, you know, we have about 30 minutes that we're going to talk about really the key symptoms of esophageal stricture and what are some of those diagnostic techniques. Importantly, we're going to talk about how do APPs play a critical role in the diagnosis, the management, and the follow-up of these patients. What are some of those treatment approaches, including the risks and the potential complications, and then finally, some strategies for managing complex cases. So we'll start with a case presentation, and this is a patient that we had seen, true case presentation, a 36-year-old male who came to the ED with food impaction after eating dinner. While in the ED, that food bowl is passed spontaneously and he was sent home, but he was given a referral to GI prior to discharge. At that initial GI visit, he had said, well, you know, I've actually had three similar episodes. They all kind of went away on their own. Only one of them lasted long enough that I went to the emergency room, but similar things have happened three times and all of them had happened to meat, two to chicken and one to beef. He didn't have any other complaints, so no pyrosis, no regurgitation, no unintentional weight loss, otherwise was feeling pretty good. And he said, you know, in between the episodes, he really hasn't changed his diet or done anything differently. Past medical history is notable for mild seasonal allergies and childhood asthma, no prior esophageal or foregut surgeries, and his only medication is cetirizine. So we'll switch to a polling question here. What is the most appropriate next step in this patient? Should we start either PPI therapy and then do an endoscopy, PCABS followed by an endoscopy, EGD now, or swallow topical corticosteroids? Yeah, so 78% said refer for EGD now. What are your thoughts, Dr. Twani? Thanks, Sarah. And thanks, Dr. Napski, for the kind introduction earlier. I hope you can hear me well. I agree, actually. I think with this patient's presentation with food impactions and dysphagia, it's important that we get an assessment sooner than later as to what exactly is going on. We have a broad differential. Of course, we're thinking about eosinophilic esophagitis, but we need to make a confirmed diagnosis. So we send the patient for an upper endoscopy. And these are a couple of images from his presentation from his initial endoscopy. I'll point out a couple of features here. Actually, you can see serial rings throughout the esophagus, best seen on the second picture here. And we'll come back to some of the more subtle features in a couple of slides that we can highlight. So it's important to recognize features or symptoms in the history that should make you think about esophageal strictures. This patient specifically complained of recurrent food impactions, but several different features patients may complain about include a sensation of food getting stuck or is moving slowly through the throat. I have pain while I eat. I regurgitate food every time I eat or I cough and gag. These are important historical features that they may volunteer or you may be able to elicit when you're trying to understand their pathology. And these should be indicators that you should be thinking along the lines of an esophageal stricture. It's also important to note that anywhere between 30 and 50 percent of patients that present with food impactions probably have underlying eosinophilic esophagitis. And one of the important considerations for us as endoscopists is at the time of presentation with that food impaction, are we able to or are we safely able to understand the underlying pathophysiology? Should we be taking biopsies in that setting at that initial presentation with the food impaction? That's an important consideration. So back to our patient. Our patient specifically, well actually before we go back, we're going to review some features to look for on the endoscopy and then we'll go back and look at those patients specifically. But we start with, we have to understand what the underlying EREF score is. I don't know if this has been covered already this morning. Sorry, I was in and out. But the EREF score is an important endoscopic score that we use as a tool to understand how severe the underlying disease is. And there's various features that we look at as are outlined here. Edema, we look for the presence of rings endoscopically, exudate, sparrows, and stricture. And so that EREF score allows us to quantify some of the inflammatory features present on at the time of endoscopy. And this is also something that we can follow on follow-up endoscopy is to see if there are, if there are some of these features are reversing or improving with therapy. You can see that there's different grading levels for each of these, each of these findings, edema, rings, and severity of the rings is important in terms of the grading there. The presence or absence of exudate and how much exudate is present, how deep the linear furrows are, if they are present, are they superficial or are they, do they have depth that's appreciated endoscopically and is there a discrete stricture or not? So going back to our patient, if you remember from the previous slides, we have the images again here, you can take a careful look and we really don't appreciate that vascular pattern that you would appreciate in a normal endoscopy. We don't actually see any vascular patterns. So this patient has absent vascular patterns. So it has a grade II edema. They have visible rings that actually obstruct the passage of the upper endoscope. And so those rings are considered to be severe rings. That's three for the rings. Mild exudate, you can see some focal areas of whitish material here. Sometimes it'll look like candida, sometimes it'll look like residue, but those are actually microabscesses that can be appreciated endoscopically. So he has mild exudates, less than 10%, affecting less than 10% of the esophagus. So mild on that characterization. Mild furrowing, I guess it looks better, I think, on the larger images, but on the left-hand side, there are some linear features. They don't really carry a lot of depth to them. So this is a mild, considered mild furrowing and a significant stricture. And this is stricturing, this is preventing the passage of the upper endoscope. So he gets a score of stricture of one there. So total ERF score is eight. And again, that's something that we can follow on future endoscopies to see how he's responding to therapy. I think we had a whole course on histology previously, so I won't go into a lot of detail here. Back to you, Sarah. And so once we have those biopsies, and what I remember from this morning is that I see a lot of blue. And so that tells me there's a lot of eosinophils there. And the eosinophil count was quite high. It was actually over 68 in the proximal esophagus per high power field. So the patient comes in and we have that discussion to say, good news, we found out why you have these episodes. But it's a little bit of a challenging conversation in the sense that now we're talking about a chronic disease in somebody who is symptomatic only three times over 18 months and feels well in between those food impactions. But we have those images, we know that there's a stricture. And so certainly we want to have that conversation about treatment. And as we've heard kind of an overview of throughout the morning, there's several options for treatment. So elimination diet, certainly high dose PPI, topical steroids, and then we have some of our biologic therapy. Dr. Twoney, in a patient like this who has the significant structuring and has had food impactions, what's your thought and how do you kind of approach that treatment plan? So I think it's important to approach this collaboratively in the sense that we want to treat him both medically with dietary therapy, medical options, and also considering endoscopic procedures that may be able to help him with his underlying symptoms. So there is an important role both to diet therapy, medications, and then when do we consider endoscopy. We'll get into some of those features there. But if there are persistent symptoms, despite, you know, elimination diet and medical therapy, those would be an important consideration to referring the patient both for follow-up endoscopy to assess the status of the disease as well as consideration of therapeutic interventions. Yeah, absolutely. And from my standpoint, certainly whenever I'm starting to think about could this patient need dilation, I'm involving the physician because medical therapy and following them in clinic is something that I can do, but I really need to get their buy-in, their input, and also understand, you know, when should we be repeating endoscopy and what's the role for that and the timing of that. And so for this patient, we started both high-dose PPI and swallowed fluticasone. That was done because of the extent of stricturing and the high EREF score of eight. At follow-up, two months later, the patient came in and he said, you know, I feel better. And sitting there, I said, well, it didn't give me really any other symptoms when we first started to go through this other than those food infections. But it turns out that in retrospect, he had modified his diet some without necessarily noticing. He had felt a little bit of chest tightness, maybe a little bit of pyrosis when eating and had kind of adapted to that, where that had become that level of normal. And so after starting therapy, he had noticed a really significant difference, actually, and was feeling well and came in very animated and excited to talk about those changes. And so a polling question, at this point, we have a patient who's on therapy, feeling better, what should we do next? Either discontinue the PPI, but continue the corticosteroids, discontinue all therapy, escalate therapy, or repeat the endoscopy. Thank you. Yeah. So 80% said repeat endoscopy, which is exactly what we had talked about. You know, before we go to that, I just want to add, this was kind of a learning point for me. We asked patients those standard questions and Dr. Tawani reviewed that slide that said, you know, these are common chief complaints or things that the patients may bring up. And so we asked them, you know, what are some of the things that the patients may bring up? And they said, you know, they may bring up, you know, they may bring up, you know, these are common chief complaints or things that the patients may bring up. But what I think I've learned over time is that sometimes it's how we ask the questions. And so, you know, are you on a regular diet? A lot of them are going to say yes, but are there any particular foods that you avoid? Do you find that you tend to eat more soft foods? Do you eat meat as often as you used to? Sometimes it's really taking a little bit of probing because people are naturally adjusting to the fact that they have some changes. And sometimes this is going on for a longer period of time than we realize, especially when you have stricturing to this extent. This probably didn't happen overnight, right? And so they've probably been making these modifications over time. So this is something that I will frequently refer back to when we're thinking about how we approach the endoscopic management of eosinophilic esophagitis. This is from the ASGE position statement published in 2022 in GIE and here specifically recommending repeat endoscopy with biopsy sampling to assess the disease activity after instituting diet elimination therapy and medical therapy. So even though the patient is feeling better without symptoms, feels significantly better and didn't realize how many changes they had already been making and adjustments, now that we've treated the disease, we also want to see how much eosinophilic infiltrate and how many changes there are on those biopsies. This will also allow us to reassess that EREF score we referenced earlier. Yeah. And so this comes back really to looking at what's actually happening. And so patients who have this eosinophilic inflammation, ultimately untreated, it can lead to fibrosis and that fibrosis is leading to strictures. And so in the beginning, when it's inflammatory, there's not a lot of stricturing. We really can focus on pharmacologic and dietary therapy. But as it starts to progress, that's when we're starting to think about dilation as well. That inflammation causing that fibrosis, the longer that we wait to diagnose it, the higher the rate of strictures in these patients. And when we talk about goals of therapy, it really has to be this comprehensive goal of therapy. And so we're looking to not only, you know, eliminate symptoms, but we also, like Dr. Twani just said, we want to reduce the mucosal inflammation. We really want to revert any strictures. We want to go back to as much as we can, a relatively normal lumen and then prevention of complications over time. And that's where that long-term therapy comes from. You know, like I said, this is a conversation about a chronic disease. And so even when patients are feeling well, they still have a chronic underlying disease. And so that adherence to therapy remains important. So our patient comes back for his repeat endoscopy and biopsies are obtained along with dilation of the esophageal stricture. The biopsies reveal less than five ESNFOs per high-power field in both the mid and lower esophagus. The dilation is performed to 14 millimeters and the patient reports no further dysphagia. So we want to think about how are we going to manage this patient moving forward? What other collaboration do we have in terms of endoscopic follow-up, endoscopic therapy? What are our targets that we should be looking towards, both medical and endoscopic treatments? So going back to that ASGE position statement, there are several statements here actually to specifically address the role of dilation. And I'll highlight a couple of these as we go through here in the next minute. But the first one I think is an important fact, feature that will come up frequently in these patients is when should we be considering endoscopic dilation? And specifically the statement states that endoscopic dilation should be considered for all patients with euthanophilic esophagitis and endosophageal stricture with symptoms of dysphagia. So if they're not having ongoing symptoms of dysphagia, it may not, you know, symptoms may not be the only thing that guide your decision-making. The presence or absence of an esophageal stricture as known from the previous endoscopy or from other imaging would be an important consideration. And so the target endpoints that we use endoscopically, one is symptoms, of course, but then also what is the diameter of the esophagus? And that's where topics 12 and 13 come into play. We're looking to achieve symptomatic control, but we also want to try to reduce the risk of future food infections, future symptoms. And so typically we target a diameter endoscopically of 15 or 16 millimeters. And that requires us to understand the initial luminal diameter at the first endoscopy and how that diameter is improving with serial endoscopies. 15 or 16 millimeters is the typical choice that we use because we know that above that is when most patients will have relief of their underlying symptoms. And so even if patients describe resolution of their symptoms, resolution of dysphagia at smaller diameters, we understand that those patients are still at a higher risk of potentially coming back with frequent symptoms sooner. It's important to note that we don't always go to that target on the initial endoscopy. Sometimes we do have to take things gradually. It depends on the starting diameter and starting dilation that we use. And so these patients may have multiple endoscopies every few weeks to the point where we are able to achieve that goal. When we do these endoscopies, when we're examining the esophagus after dilation, we're basically looking for mucosal disruption or improvement in that luminal diameter. And the subsequent topics here under the dilation really focus on the importance of combining endoscopic therapy with diet and medication therapy. So endoscopic therapy is gonna provide some relief of those chronic fibrotic or stenotic areas of the esophagus, but without also implementing dietary changes and medical therapy, we're only treating half of the disease. We really need to control the underlying inflammation to allow the endoscopic dilations to work better. Patients will respond better if they're doing well with their diets and their medications. You'll need less frequent dilations. You'll be able to achieve your goals more easily. The last one, or the last two here, 18 and 19. So 18 discusses empiric dilation. This is also an important consideration. Those patients where actually their endoscopic features have resolved, they appear to have histologic remission on biopsies, on follow-up endoscopy, but they do complain of persistent dysphagia, it may be reasonable to consider empiric dilation in those situations. There may be subtle rings or structures that you can't appreciate endoscopically that may respond to empiric dilation. And then finally, we're always concerned about the risks of perforation anytime we do dilation. So topic number 19, statement 19 here does note that most often when perforation does occur in the setting of dilations in patients with eosinophilic esophagitis, usually these are microperforations most commonly, and they can be managed with conservative therapy. They will rarely need any endoscopic therapy or surgical interventions. So how do we do dilation? That's where the next slide comes in. We have a couple of options. These are the two commonly used options are balloon dilation and bougie dilation. And when we're looking at the diagrams at the top of the slide, on the left-hand side, you'll see what a bougie dilation looks like. And bougie does not mean bourgeois, bougie actually comes from the French word for candlestick. And if you have ever seen one of these, you can imagine back in the days where they were advising their patients to swallow these long candlesticks to perform self dilations for esophageal strictures. So we'll do an endoscopy, we place a wire into the stomach, a guide wire into the stomach, remove the scope and then advance a long stiff dilator over the wire to achieve the dilation. I then will most routinely re-examine the esophagus to assess what responses has occurred as a consequence of that dilation. But that's done really under guide wire guidance without an endoscopy at the same time. Balloon dilations are most commonly performed with through the scope balloons. So this is on the right-hand side, we'll do the endoscopy, identify the level of the stricture, pass the balloon through the endoscope, position it at the level of the stricture and inflate the balloon. And under endoscopic visualization, you'll be able to see the balloon dilate and treat the stricture. And then immediately after we release the balloon, we usually hold the balloon up for an hour, sorry, for a minute, for 60 seconds at a time. And we can do progressive dilations at one millimeter at a time to improve that luminal diameter. And then immediately afterwards, we can visualize exactly what the therapeutic effect was. Either of these is an acceptable option. So our endoscopist, it really comes down to comfort, preference from the endoscopist perspective. And some decisions as to how many levels they are trying to treat endoscopically, what the complexity of the stricture might look like. So either of these are acceptable forms for dilation. Both have been shown to be very effective at improving symptoms greater than 95% and very low risks, essentially the same risks as we would encounter with dilation for peptic strictures and rings with a less than 1% perforation rate down about 0.3, 0.4%. It is important to note that patients with EOE as the underlying disease do seem to have more pain after the procedure and the mucosal tears can look more impressive endoscopically, but the actual risks and perforation rate is very similar to that with peptic stricture. So I wanted to take this opportunity just to talk a little bit about informed consent and ASGE did come out in 2022 with this guideline on it. And so what they're saying really is that any provider should learn what the applicable standard of informed consent for the states that they practice. We know for APPs that can look different depending on PA or NP and within the state itself. Informed consent in general can be obtained informed consent in general can be obtained by any trained member of the GI team and it should be performed and documented prior to a procedure. When available, it's always recommended to use some kind of tools. And so we have some virtual diagrams that we use when we're in the office. If I'm doing a Zoom visit, it's always nice that we can now share the screen. I used to draw pictures, but we have more tools available that I don't have to subject people to my art skills any longer. If you're going to use anything that's off-label or non-FDA approved, that should be discussed within the consent process. And in an emergency situation, certainly getting consent when you can either from the patient or from a family member. And I think that it's important to know when we talk about informed consent, it's really talking about what is the procedure? How is it performed? Who is performing it? What's the risks? What's the benefits? What are the alternatives? And I think also what's the follow-up? You know, do we anticipate there's going to be biopsies? How are we going to deliver those biopsies? I think all of those can be put into one conversation so that the patients really understand. And in patients with EOE, the conversation may be we're going to do an endoscopy and we may or may not dilate depending on what it looks like. But making sure that they know that that's a possibility prior to going into the procedure. So some of the specifics in terms of risks of esophageal dilation include and should be discussed specifically including bleeding, perforation, risks of infection, risks of mediastinitis, risks of sedation and anesthesia reactions, including cardiopulmonary complications. Some of us may or may not actually state a definitive mortality or morbidity rate associated, but it is important that the patients understand that there are risks involved with each of these endoscopic procedures and especially therapeutic endoscopic procedures. This is a picture basically of what the balloon dilation would appear under endoscopically. So you actually see the purple part of the through the scope balloon dilator. The balloon is not entirely inflated at this point, but I think in a couple of slides, we'll have a couple of pictures that we can look through even better. So best practices for dilation and eosinophilic esophagitis. So in patients that have persistent dysphagia, patients that have recurrent food impactions despite on active anti-inflammatory therapy. So that means dietary and medical therapy. Our goal is a gradual slow dilation every few weeks with that same goal in mind of 15 to 16 millimeters. Again, that's the target goal where patients above which will typically have resolution of their symptoms. It's important to note for patients prior to the procedure that post-procedure chest pain is common. We quoted close to 10% of patients with underlying EOE may experience some chest pain after dilation. But again, this only addresses the stenotic or fibrotic component of the stricturing and does not address the underlying disease. That's where the importance of medical and dietary therapy is important in managing these patients. And just wanna drive home that specifically. Again, kind of covering very similar things. This goes back to 2018 or 2017, a couple of these papers and recommendations with guidelines for performing esophageal dilation in patients with eosinophilic esophagitis. Post-procedure pain is common. It's okay to use NSAIDs or other pain medications for control after the procedure. Start slow, start low, use gradual dilations. Every couple of weeks, here we quoted three to four weeks, target dilation about 15 to 16 millimeters. You are limited, I touched on this briefly in one of the previous slides, but you wanna be careful with your gradual dilations. Sometimes we'll restrict ourselves. There's a rule of three that many of us will follow once you start to appreciate resistance, whether that's with the Bougie dilator or when you're appreciating some luminal effect with the balloons, you limit yourself to three millimeters beyond that point because we know from older literature that pushing the dilations higher than that in one setting will significantly, more significantly increase your risk of complications, including perforation. And so we have a couple of systematic reviews that were published back in 2017 showing that endoscopic dilation in patients with eosinophilic esophagitis is highly effective and safe. This meta-analysis reviewed 1,800 plus esophageal dilations in over 800 patients. Patients needed a medium number of dilations of approximately three to achieve that target goal of dilation with symptomatic improvement. And they noted clinical improvement in over 95% with very low complication rates. Again, that perforation rate of 0.3 to 0.4%, chest pain being the most notable at close to 10%. At the same time, another meta-analysis in the same year published in GIE, similar or even more patients and more dilations, again, showing very, very low perforation rates and other complications apart from pain. Pain being in this meta-analysis only reported in about 3% of patients, but that's the most notable complication or risk that's been described. So these are, I think, nice endoscopic pictures to kind of show what our before and afters might look like. So in panel A, we have endoscopic structure prior to dilation. You can see the wire advance through the scope. Panel B shows the therapeutic effects. So you'll see a rent or a mucosal tear there, looks rather superficial. And these tears can develop not just longitudinally, they may develop at an angle as well, as you can kind of see in panel B that the dilation and therapeutic effect of that tear is more angulated, but it does have a longitudinal component to it. C is the panel that is what we look at endoscopically. So when I have a balloon, sorry, when we're doing a balloon dilation, when we're looking endoscopically, these balloons are designed in such a way where if you can get the endoscope right up against the balloon, you can see the therapeutic effect happening with the balloon in place. And so you look for the white ridge right where the stricture is. So you can see that the white ridge develops when the balloon is at a circumference that's basically forcing the stricture outward. So you're having a radial force generated. And then the area in panel C in that eight o'clock, nine o'clock region is where you're starting to see the tear develop. Panel D shows what we're gonna look at, what we're gonna see endoscopically after the dilation is performed. So you can see that there's a deeper mucosal tear, wider mucosal tear. This is gonna have significant benefit for the patient in terms of the therapeutic effect. This is hopefully a nice therapeutic intervention for this patient. And so if we go back to our case, the patient has another endoscopy two months later. If you remember, he was dilated the first time with Bougie dilator. There's still a persistent esophageal stricture. So he was dilated to 16 millimeters again with Bougie. Biopsies continue to show remission with less than five eosinophils per high power field. He is asymptomatic. And so Dr. Twain, at this point, even though there's a persistent stricture, would you bring him back again and dilate or take a look after? So at this point, I think we know that he's been able to achieve histologic remission on his biopsies. He's asymptomatic. We've reached our target of 16 millimeters. So I think it really, it's, I think we've reached our targets in terms of our goals for treatment. Ongoing monitoring, I think really will depend on if and when the patients do develop recurrent symptoms and what their compliance is with their medications. Patients may go for years and then come back in again with another food impaction. And that may send us down this road again, re-evaluating. I don't, personally, I don't routinely bring these patients back. Once we've achieved both the endoscopic goals and the histologic goals and the symptom goals, I guess all three, then I would manage this expectantly moving forward. Yeah, and that's a great segue into the ASGE position statement that says that continued monitoring with symptoms should be performed and consideration could be given to periodic endoscopy and biopsy sampling. I agree with you. I don't typically bring them back unless we are changing their therapy for some reason. If they've like self-discontinued PPI, I may consider it in that case, or if they've altered or reduced their dose for some reason, or if we're changing for some reason, sometimes insurance coverage will dictate that. Sometimes it's for, you know, medication, either contraindications or, you know, other considerations for things that they're maybe taking if there's an interaction or potential interaction. But typically I'm really following them with symptoms mostly. I will add actually that I think it is important to bring these patients back for periodic clinical visits to reassess their symptoms too, because again, they may fall into this period where they're starting to adjust their diet again or change their diet again, even though they're not complaining specifically about dysphagia, they're not presenting to the ER with food impactions. So, you know, whether that's every six months or once a year, if they're doing really well with their symptom control, I think it is still important to bring these patients back for periodic clinical assessment to make that decision. Yeah, I think that comes back. We always say that medicine's an art and a science, and I think that's the art part of it is, you know, how do we ask those questions? How do we elicit that history from people who may not voluntarily recognize or give it on their own? But once you get to know a patient, it's a little bit easier to try to ask those questions and pinpoint where some subtle changes might've happened. So, and take home points. The first is recognition. You know, clinical history is definitely helpful. I bet, like we said in the very beginning, that differential diagnosis is broad. And so, EGD with biopsies are essential for that diagnosis of EOE. If patients have persistent strict shrink, despite treatment of their underlying disease state, esophageal dilation is appropriate and usually necessary at that point. Informed consent is important. As an APP, you may be the one doing the informed consent or you may just be starting that conversation. But I think it's important for all of us to have that conversation with patients in the office, whether or not you're actually signing the form or not. Start that conversation with them so they understand when they get to the procedure room, they're not surprised to hear, you know, those potential risks, including perforation. And then finally, EOE is a chronic condition. Long-term follow-up is crucial for optimal outcomes, bringing them back into clinic periodically, and then bringing them back for endoscopy when there has been a change in their clinical symptoms.

esophageal strictures

eosinophilic esophagitis

endoscopic dilation

food impactions

swallowed corticosteroids

dietary adjustments

long-term follow-up