Great presentation. Thank you, Dr. Tawani and Sarah. Sarah, if I can ask you a couple questions. How do you deal with patients that are so grateful to you that they've been dilated that they don't want to get any other therapy because their symptoms are gone? And why are you putting me through all this other fuss when all I need is a good stretch every so often? Can you, from a PA standpoint, can you approach how the conversation might go with them? Yeah, so that comes back to that crucial conversation of chronic disease. And so when I'm first giving them the diagnosis, I'm outlining that path. I tell them we're going to be good friends. I tell them I'm going to become like a cousin to you. And this is a long term relationship. And so from the very beginning, I'm setting that stage. There still are times where they say, you know, I'm feeling really good, or maybe they cancel an appointment. I haven't seen them in a while. I think that what's important is that we're explaining to them what's happening. I use a lot of medical terms with my patients, and I explain what they are. And the reason I do that is because of open notes, they can read what we see, they can read the endoscopy report, they don't need to understand everything that they read. But when they see those terms, I want them to at least have heard it once before. And so I tell them all of these things. And I say, you know, these are things that I'm watching, but I can only watch it if I see you. And so I need to be able to see you so we can continue these conversations. And I can continue to have you do well. I also tell them if we stop all therapy, the chance of this happening again is pretty high. And if you get tight stricturing, if you have all that fibrosis that we talked about in the beginning, it may be harder to dilate. It may take more sessions, it may increase your risk over time. The best thing we can do is control it and prevent that from happening again. Great answer. And what percentage of your GI doctors are providing EREF scores when you're seeing your patients? That's a great question. It's getting better. It's about 90%. I can tell you in the community, even in our group, we haven't been good about that. And I wonder what the rest of the audience might say about that. But one of the things I think as APPs you can do is when you go back to your clinics and medical communities to highlight the importance of getting those EREF scores in so that you can have a gauge endoscopically of what's happening. And that's one of the things we've been trying to emphasize even in our group with some of the docs that might not be familiar with the EREF scores and how important that is. That's a great point. I actually had talked to my group about this maybe about a year and a half ago. And what we do is we put in our notes and we bolded request distal, mid and proximal biopsies. And then we put request EREF score so that when the physician's opening it, they're seeing that and it's bolded in the notes so they know exactly what we're looking for. That's a good way to do that. Dr. Tewani, your preference of bougie or balloon dilation in your experience? Yeah, that's a great question. And again, I would say endoscopically, if I'm dealing with a discrete structure, I tend to favor balloon dilations. I like the fact that I can visually see during the dilation what's happening, what's going on. I have a better sense as to when that mucosal disruption is starting to occur, at what level that's starting to occur when I'm watching that balloon. And so then I can get a better sense as to how much further am I going to push the balloon in terms of achieving the goal. That also is influenced, though, if I have a patient that has multiple levels of stricturing or rings developing throughout the esophagus, that can be a little bit more time-consuming if you're doing that with balloons. And so the bougie dilators offer the nice alternative of providing basically dilation across the entire esophagus, so panesophageal dilation, and you can treat multiple levels of stricturing in one setting. Obviously, we have to be comfortable with that, so understanding the point at which you're feeling resistance with the bougie dilator. So it comes with practice, and I'd have to say I'm comfortable with both, but my personal preference would be balloons if they're focal structures, bougies if there's multiple levels of stricturing. So with your comment earlier in your presentation about doing esophagrams and noting a significant discrepancy between what we see endoluminally and what's seen radiographically, do your colleagues at Mayo have a preference between bougie or balloon dilations? Yeah, that's a good question. It depends on if it's really an EOE-specific endoscopist. I think they tend to do the bougie or the salivary dilations more so than the non-esophageal endoscopist. Gotcha. Is there a way we can do show of hands with our guests, Michelle, to see, maybe raise your hand if your doctors are doing savory or bougie dilations? Is that a possibility to do it that way? Sure. They have a raise their hand feature, and you can look at it in the participants tab. Great. Gotcha. I'm just curious if you think it's worthwhile if- It won't count, though, but yeah. No, no, just kind of this anecdote to see what's done in their various communities, I guess. So raise your hand if you do savory dilations, the bougie dilations, not the balloons. So some of this may be obviously influenced by who's actively on and obviously a smaller number of attendees. I guess we could say, why don't we raise our hands to the opposite of which ones of your gastroenterologists, how many do the balloon dilations in most cases? We might be seeing more of that. One of the reasons for that I noticed in some of our younger partners is that I don't know if savory dilation or bougie dilation is actually offered as much in training as balloon because of some of the convenience factors. So it's one of those things I think that the next generation of gastroenterologists understanding the role of bougie dilation, particularly for EOE, since it's a pan-esophageal process, I think it's important for us to think about that. We've got some questions from, thank you for your hand raising, folks. Question is, in what case would you possibly see a mildly narrowed esophagus, 13 millimeters, with normal biopsies? This is in a patient who's during their initial EGD has had a history of pill impaction that's self-resolved and maybe some GERD symptoms. So not EOE per se, but certainly enough luminal narrowing to cause some pills to get stuck. Dr. Tawani, thoughts on that? Sure. So the normal biopsies, obviously taking eosinophilic esophagitis, making that less likely, thinking about a history of caustic injections, whether that's other pills that have led to maybe some pill dysphagia in the past or pill ulcers that maybe that's resolved and has caused more of a focal narrowing. If you're talking about more pan-esophageal processes, thinking along the lines of things that I don't know necessarily how well they're visualized pathologically, but like in plantus esophagus is something we see periodically. There can be a lot of overlap in terms of the endoscopic features that we'll see compared with what we see with the eosinophilic esophagitis. I have seen a handful of patients over time with more of lymphocytic esophagitis as opposed to eosinophilic esophagitis, but endoscopically, the appearance can be very similar. Those might be things that I would keep in my differential. Yeah. To add to that, sometimes patients will have some subclinical reflux where you don't have any particular manifestations, but yet the fibrotic process is still going on. So that would be a patient that I would dilate as much as I could like any other luminal abnormality. Then fortunately for them, they don't have EOE that they have to reckon with, and that may be the only time they need that. Next question is, what is the practice guideline for tissue sampling for EOE diagnosis? Sarah mentioned proximal, mid, and distal. Is it six biopsies from two areas? Yeah. So it's biopsies from distal and proximal or mid. There've been a lot of studies done. I think that it says two to four biopsies from each. The literature suggests that at six biopsies increases that sensitivity to, I believe, about 99%. I don't know if any of our endoscopists have something to add to that. That's spot on. I think there was some concern about the distal esophagus sharing overlap with reflux, but you definitely want to get some proximal esophageal biopsies. You know, Pierce would say two from each segment perhaps, but at least six biopsies to achieve that sensitivity specificity that Sarah mentioned. Are these guidelines on ASGE website for EOE? Michelle, can we comment on that? I don't know the answer to that, but I can definitely find that out. If there are, we will put it in their GI. Yeah, I think that's the best thing. We'll put it in the LEAP for you. Obviously, it's readily available if you're an ASGE member, but all the more reason to have it in a nice referenceable area for this particular course. Okay. What other questions do anybody have for our esteemed colleagues? Anything we can... Question for Dr. Twani or Nilsi, what are your thoughts on steroid injections after dilating a stricture? Subit, you want to... Yeah, that's a great question, Cyril. Thanks. I think certainly those patients that I'm bringing back for serial endoscopies and I don't appear to be having a therapeutic effect or an improvement luminally in terms of the diameter or the appearance of the stricture. If I brought the patient back for a second, third endoscopy and I'm not able to actually safely progress in the diameter of my dilation, that's basically considering a refractory stricture. I do consider semicostal injection of steroids at the time of the endoscopy. I do that in combination with the dilation. So we'll do a dilation and localized injection of steroids. You want to limit how often you do that. So certainly if you're doing that, I wouldn't do that on each endoscopy, but if I've had a couple of endoscopies without improvement, I'll do it at that time and then see how the improvement is on the subsequent endoscopy. I don't have a specific guideline that I follow in terms of how often to do it, but just based off of what we know about steroids, I would try to limit it to basically once every three months or once every few endoscopies. But these patients also with their panesophageal disease process, many of them will be on swallowed steroids anyway. So I don't know that the endoscopic addition of steroids changes their risk at all, but certainly something that's been shown to improve our management of refractory structures. And so I do use that for these patients. I haven't needed it particularly in EOE patients so much. I tell patients that once we soften up the esophagus with the right medical therapy, that the dilation typically is pretty effective. I can't recall injecting an esophageal stenosis from EOE with steroids, but it's feasible and it's doable and it's probably in line in terms of effectiveness with peptic strictures or other causes.

chronic esophageal conditions

continuous therapy

endoscopic benefits

EOE diagnosis

refractory esophageal strictures