Open for questions, I'll take the lead on this and start by saying, I haven't looked under a microscope probably in about 17 years since I finished training. I don't expect that all of us as APPs are going to spend a lot of time looking at the microscope, but I hope that the pathology, the histopathology gave you some perspective that when we're talking about eosinophils, when we're talking about inflammation, that this is a real actual condition that's happening, and that when you see the eosinophils, when you see that those descriptions are happening, that you feel more comfortable with explaining to patients that we're dealing with an impressive chronic long-term condition. Dr. Salaria, I was going to ask about number of biopsies. Would you ever tell your clinicians that there is insufficient biopsies to be obtained and that they should go back and do more? We typically are supposed to take six biopsies at the minimum, but do you run into instances where you get insufficient amount of samples? I can say that I really have not to date run into that. Usually, if there's a consult that we get, which is a case coming from the outside for confirmation, I can say that the limiting factor in the outside pathologist, usually making that diagnosis, tends to be there's just not enough samples. In that instance, of course, we'll describe the findings and correlate with whatever limited clinical history you have. If there's less than six, oftentimes there's two to three, we'll probably ask for more. But in my everyday practice, I have been fortunate not to come across that. That's great. Dr. Menard-Katcher, excellent discussion about the multidisciplinary approach. We are fortunate to have panelists here who are at the centers of excellence for eosinophilic esophagitis. But for those of us that are in more of a community setting or perhaps a rural setting, can you give us some guidance on whether telehealth is an option in terms of engaging with your center, for example, or other centers where patients, for example, can see a dietician as opposed to seeing a whole team, something that would allow patients in more rural communities who don't have access to getting to your centers to get the care they deserve? Yeah. One of the positives that came out of COVID, I think telehealth medicine was already in place, and many, especially more rural centers, were already using it actively well before the pandemic. But what the pandemic did was really made all of us quite facile with using this technology. What I say from an EOE standpoint, one of the positives with telehealth is like, my physical exam is not that helpful when it comes to eosinophilic esophagitis. I can't palpate the esophagus through the chest. It's all in the history. Telehealth is a fantastic option. Allergists sometimes are more hesitant to do telehealth because again, the importance of listening to the lungs and looking in the nose, in the eyes, looking at the skin. Allergy can sometimes be a little bit more tricky to find allergists that will do telehealth. But even then, getting a history is very helpful. Going back to the roots of medicine and the importance of the history alone. We do offer telehealth. The state of Colorado is very large, and so for our Western slope, we will do telehealth for our patients to help with coordination of care, etc. I think the issue becomes, at least in the United States, is that who has medical licensure depending on where you're practicing. Sometimes that can be the barrier for providing telehealth to out-of-state patients. But I think that for people who live in more rural communities or may be spread out from, maybe even academic centers, but there's like one in their whole state or things of that nature, to find people who can provide even in-state, even if those providers might be hours away from where you're practicing. Dietitians, even feeding therapists really have adopted to telehealth in terms of being able to observe chewing and swallowing and talking with patients and stuff. I think telehealth is a fantastic way of creating that relay of referrals. Then in terms of referrals to centers like ours, that has actually been one of our barriers. We're working on that. Depending, again, I think it's worth contacting the center of where you are, because more and more centers are getting licensure for their providers in other states. For example, for our program, we have tried to be very purposeful about it and looked at who has the most patients from other states, and then getting the state licensure for those specific providers in the other states. It is possible, it's growing, it's an area that needs further growth. If we could enter into multi-state packs and change the way we do all this licensure, it would make it even better, but I know that's a long way off. But yes, telehealth can be absolutely used in EOE. Because again, the physical exam, particularly for the gastroenterology provider, is not that helpful. Thank you for that. I do want to just emphasize something that was asked early on about allergy testing. I think it's one of those things that really makes sense when you have a young patient coming in with their parents and the parents saying, well, why don't we do allergy testing for EOE? You mentioned it's pretty much a coin toss. That was something I was emphasizing. How do you as a GI provider talk to patients and their families about why allergy testing isn't super useful in this particular condition? I think that we all have probably examples of patients that have come to our clinic who have had testing done before they've gotten to us. The argument that I often will say is that doing the testing without support of the clinical history of having a hive or a specific reaction to a food that might signify an IgE-mediated allergy, is that more often than not, it causes harm, not help, and it leads to over-restricted diets in which the undoing of that can take months to years when patients come to us on highly restricted diets that were developed based on unnecessary testing. Most families, when they hear that, can recognize that that's not the way to go. Certainly, though, we often hear, I'm sure, that people want to know the trigger. They don't want to mask it with them, they want to know the end. I think where I've learned is from a lot of my allergy colleagues in terms of how they discuss that with the foods, is that when we really look at the literature in terms of the food elimination diets, that if you are not responding to the eight food elimination diet, the likelihood that any elimination diet other than the elemental formula will work for you is quite low. Usually, we can get some buy-in regarding that. But it can be hard because, again, there's hesitance about using daily medications in children lifelong and things of that nature. But I think our allergy colleagues do a very good job of explaining the data and helping families move away from that testing. I think the harder challenge is when they already have it in hand. Something you mentioned about restrictive feedings is we are familiar with anorexia, but there is a condition called orthorexia where people try so hard to keep themselves on this diet that we prescribe them, that ends up leading into serious medical and psychosocial problems. Simply saying, get off these four foods, although it seems easy to say, may in certain patients cause them to go down a road where they become much more cognizant of what they're eating, to their nutritional detriment, and ultimately to their health. Making sure that we tell patients what to eat, what to restrict, I should say, and only that if it's going to work is super essential. Because we don't want especially younger patients heading down the road of maladaptive behaviors because of that. Yeah. I think that that's where the time in the clinic in terms of what do you have allotted to you and where the dietician can be really helpful at picking up on those things that we just may miss in our GI practices. Thank you for all that. We do have a question. I'll read it. In regard to the pathophysiology lecture specifically, when talking about exposures, we discussed early life exposures, but are you aware if there's been any research on toxic exposures in the veteran population, and if there's some genetic predisposition that is triggered by toxic exposures in the military service? Anecdotally, I see this far more often in my veteran population than I expect to see when reading about the incidents in the literature. Anybody want to take a try on that? I personally am not aware of anything. I don't know if clinically you guys see anything that's particular in that population. Yeah. We have the privilege of taking care of veterans, not to the extent of someone who's been seeing patients at the VA. You could argue that anytime the immune system can be primed, whether it be from an environmental toxin or a food, that that might somehow trigger something. But I think longitudinal studies might be challenging to find in that population for a variety of reasons. I think the vets want to know, is it Agent Orange? The Vietnam vets that we used to take care of, is it Agent Orange? Could this be the reason? Are there someone from the Gulf War or others towards of duty that are getting exposed that might predispose them? I don't think we know enough about that. Laura, we are going to talk about food elimination in a much broader scale a little bit later, so we'll answer that question once we get to that lecture. I just have a question for Dr. Salaria. This entity of lymphocytic esophagitis that we sometimes see in biopsies of the esophagus, do you feel that's a separate entity from EOE? As clinically, I am often not sure how to treat that, or if it needs treatment. That's a great question. When it comes to the diagnosis of lymphocytic esophagitis, I think I won't be alone here with. Those of us in the GI pathology community, it's probably the most nebulous and probably the most least commonly rendered diagnosis. That's because there have been multiple studies that have shown that unlike the normal number of eosinophils in the esophagus, there's a whole number that ranges, again, this was first described, I think in 2006, and from then on, it's been this nebulous entity, where it was first described as having 12-25 lymphocytes in the esophagus along with some neutrophils was atypical, and this was considered lymphocytic esophagitis. We've then, since then, have numerous studies with up to five to 1,000 controls and patients compared, and we've found out that it has a high predilection with older females who smoke. But then aside from that, lymphocytes in the esophagus can be seen in almost any condition that can cause inflammation. Sometimes it can be a prodrome or eosinophilic esophagitis. But of course, you wouldn't make that diagnosis unless you saw the requisite number of eosinophils. It's more of a finding rather than an actual diagnosis itself. Now, certainly, there are those rare cases where you would just see lymphocyte predominant inflammation, and it's just hard to ignore that. I think that's the rare instance in which where someone would make that diagnosis. But for the most part, for example, myself, if I'm seeing lymphocytes about 10-20 in the actual epithelium itself, I attribute that to a reactive change. Not an actual lymphocytic esophagitis type entity because as you mentioned, there's no real pathology that can be identified that is very, very particular to that like you would see in a neutrophilic esophagitis which is more common in infectious etiologies or EOE. Some studies have shown that's more of a prodrome to maybe EOE actually manifesting itself. But honestly, you can see lymphocytes in the esophagus in normal patients and in just mild reactive changes too. I think it's a bit of a gray area and it's that diagnosis itself is really recommended when it's so many lymphocytes that you can't ignore and it's all lymphocytes. No neutrophils, no eosinophils, nothing else. Thank you. That's very helpful. In those cases, Dr. Szilagyi, would you check for celiac considering it's a lymphocytic mediated process as well? Lymphocytic or lymphocyte predominant inflammation can be associated with IBD, with upper GI manifestations of IBD, with celiac, sometimes with more systemic problems that the patient is undergoing some immune modulatory issue. Again, I reiterate, it's more of a feature than an actual diagnosis. Excellent. Thank you both for your participation in answering those questions.

eosinophilic esophagitis

telehealth

allergy testing

dietary management

immune response