Thank you to all the speakers. Those were all excellent and very high-yield topics. Got some questions here. Let's see if we can hit those first, and then I have a few as well. Henny Hodges is asking, just wondering if there is any reservations in using PPIs, and definitely, some of our patients are very cautious to take long-term PPI to do what they hear about side effects. Yeah. I'll take that on first. There have been a lot of studies looking at hazard ratios and associations between PPIs in a variety of conditions, dementia, kidney issues, osteoporotic risk fractures, low magnesium, low B12. None of those studies have really shown a clear causal explanation. It's made it to the reader's digest world, if you will, and people looking at blogs and looking at different websites, and so now all of a sudden you get on your Instagram feed and you see that everything, PPIs are associated with really a lot of other potential complications. I think what we have to tell our patients is, none of us want to be on any medication for any period of time longer than we need to. But what these studies have done is asked us, are we on the right medication for the right indication for the right amount of time? In some patients who come in, for example, with a chronic cough, and they get started on PPI because they think there's some type of cough variant or laryngopharyngeal reflux, and it turns out that's not the case, don't keep refilling these medications. On the other hand, if you have a patient who's got Barrett's esophagus, that's a no-brainer. I think in anything that you talk about when you're talking about shared decision-making, the decision is, do you want to have a precancerous condition, RAIN unchecked, or do you want to be on a medication that's been shown to slow the progression of this condition and prevent the development of something more serious? That would be the approach that I would take when it comes to talking to PPIs about PPIs. I'd like to add a little bit to that too. I 100 percent agree. Reason for use is super important and expectation too. In pediatric world, majority of PPIs being prescribed are not from the gastroenterologist. It's a lot of unlayering and being in a gastroenterology specialist, we have options to really confirm the need for this medication. That's in finding Barrett's and finding EOE, and that's the only thing that works for your EOE. In pediatrics, it comes up a lot that parents are worried about using this, and what does this mean long-term? It's a question we address a lot. What I tend to say is, this isn't the only option. If PPI is the only thing that works, then I do a reduced dosing strategy to see if once daily or we get away the minimum dose to really see what helps. The only monitoring that I do with PPI is iron. In younger kids, there's really nothing else that really needs to be done in terms of long-term use of PPI, and the benefit outweighs the risk of not treating EOE. I just think just focusing on the disease that you're using it for helps guide the conversation with the patient. Great points. Can location of EOs be a reliable way to determine potential reflux component? Dr. Hobson, going back to your case, when that patient had superimposed reflux with their EOE, what has been your experience clinically in that case? Yeah. I think this is the benefit of doing multi-level biopsies. In the case where you have EOs everywhere in proximal and distal esophagus, I don't think that the majority of them being distally helps guide you. But I think if you have only distal eosinophilia, and I'll speak in pediatric ways, is you have distal eosinophilia only, and proximally you have no eosinophils, and it doesn't meet endoscopic criteria, so it's like a low ERAS, that's where I say, I bet this is reflux and not EOE. But that's the beauty of having two-level biopsies, and also again, having really robust reflux testing that you can do to confirm it. In the adult world, we can certainly run into that. But most of the time, by the time we're entertaining the diagnosis of EOE, reflux has been treated in one form or another, or in three forms, or with three different PPIs. We start to sift out those patients a little bit more reliably, I think, and we get to the diagnosis probably a little bit faster. All right. Roseanne asks, how do you discuss going from medical therapy with proven remission to diet elimination? If you stop meds, do you scope when patient becomes symptomatic or when you start the diet? Beth, any thoughts on that? Yes. Typically, the way that we do it, like on the adult side, I guess I should say, is if someone starts on medical therapy, and there's a follow-up scope to show that that works, of course, and let's say it's usually patient-driven, the patient saying, you know, I feel like I want to try diet, for example. What we usually will do is make sure that they can stop their budesonide, let's say, and start the diet sort of at the same time. But we want to account for roughly six weeks to make sure that that budesonide has really sort of washed out, so to speak. So we typically do the diet for about six weeks, but we might put a little like bumper in there and do a buffer, I guess I should say, not bumper, but we'll do a follow-up scope about eight weeks after stopping the steroids, starting the diet to see if it works. That way we feel like we're getting then reliable results of what is the diet actually doing off of, let's say, medical therapy. Bethany, you mentioned a selection bias at Northwestern, obviously, with your expertise, but when you're looking at that 18-week treatment regimen, there were three or four endoscopies in there. Can you comment a little bit on patients' receptiveness to that, to take time off out of their day to drive into the big city, so to speak, and get those scopes done? Yeah, it's a little, it's changing. You know, I think our patients are savvy, they're reading, they're saying, hey, maybe I don't have to sign up for all of this. And we certainly, you know, we are finding in our practice, too, that we are being a little more selective about who we recommend six-food for. We are usually sort of capturing patients who have tried other, you know, single food or two-food diets that have not worked for them. And so we already are sort of getting them saying, okay, we may have to do something a little bit more, you know, a few more layers of food exclusion. But if I have someone who's sort of naive to diet therapy, and we're sort of laying out that discussion of, you know, we have medical therapy, we have diet, and with diet, you know, here's the layers of how we could start and what the scope schedule would look like, I would say most people are saying, yeah, I want to start simple and work my way up. Unless we have someone that is a very allergic person, and then usually people are saying, boy, I feel like I have sort of reactions to so many foods that I feel like it would be wise for me to start with something a little bit more, you know, complicated. So we're currently sort of tracking some of the data to see what are sort of new experiences with patients. But I would say anecdotally that unless someone has tried diet therapy before failed, most people are opting for a more simplified approach to start. That makes sense. Dr. Hobson, I wanted to go back to the anchoring bias comment you meant. I think as clinicians, one of the things that we can get really into is this perpetuation of a history. And so that patient that came through the ED also, that came through the hospital also got diagnosed with a little bit of anxiety. And then there was the idea of cyclic vomiting syndrome. And so it was a food bolus. And so, you know, as a clinician, I worry that if we don't really start taking accurate histories, we're going to get into these things where patients who have anxiety all of a sudden get labeled as something functional when there's actually something inflammatory and organic. And I think as APPs and as physicians alike, it was just a comment that we really need to be careful about not letting that get perpetuated in the chart and really taking a fresh look. Can you add anything more to that? Yeah, no, that's one reason why I wanted to bring that case up because it definitely always sticks in my mind because not that I was anchored into it, but I was definitely like, let's get the esophagram. And I was surprised to see a food bolus and a food impaction. And I think the most important thing is if you're going to start off in pediatrics, for one, but in any rate, if you have a suspicion that, for example, for that kid that this is an allergy, then the most important thing is that you have close follow up and you confirm your suspicion. And if that doesn't fit with that script, that illness script or that diagnostic script, then it's not it. And I've seen kids also have been diagnosed with eating disorders, both in ARFID, but also in anorexia, who had anxiety with eating. And then there was maybe this weight loss, and then that was like perpetuated as it was a female, you know? And there's all these little factors that go into maybe making that diagnosis and saying, this is it, and let's not check anywhere else. And for a couple of them, EOE was their underlying diagnosis. Or even for one, there was achalasia, you know? And I was like, this kid, he's anxious because it hurts when he swallows. So it's really tough, I think, in order to get away from the anchoring bias. Number one, it's always to take a step back and do your own history. Take it like another look at it. And then the second is to have close follow-up and be consistent with your message. Because the moment that goes in the chart, it can be hard in a busy clinic to just go off of what you read. For sure. And Bethany, to build on that, you mentioned ARFID. And I think you mentioned at one of the steering committees the risk of orthorexia. And I mentioned that earlier on. As the dietician who's assessing these patients, and sometimes patients will be very vigilant about coming in and they're taking these detailed notes. When do you start to worry that maybe I need to send somebody to a behavioral specialist to maybe get into a little bit of a deeper understanding of what's going on in their mindset? Yeah, great question. I think the one thing I also would add to this is just to add to Dr. Hobson's comment that when people are having symptoms, there is a disease-specific anxiety that develops. And they deserve to feel anxious. Having a food impaction really does a number on you. I think we all really are sensitive to that. I think for me clinically, when I am wanting to sort of escalate to another level of care regarding eating behaviors, it's with extreme weight loss, so unintentional weight loss. Not the adult patient who's saying, hey, this is a chance for me to really clean up my eating. More the patient who's saying, I don't know what to eat. Everything gives me chest pain. And so their eating has really become diminished. That would be one thing. I think the other big thing is where people are very reluctant to add back food groups. So for example, I've had patients who have done the six-food elimination diet, feel really great, and don't want to go through the food reintroduction protocol. And not that that means that they have ARFID, but that's where we start having the discussion of like, but this is not the end game. The goal is to actually go through the process to figure out what your triggers are and whittle that down. And I think when people also add a food group that maybe they've passed, but they have food fears about eating that food, and they really start expressing some clear anxieties related to the food and what it's doing to their body. And I read that gluten is pro-inflammatory, even though it doesn't trigger my esophagus. And so really starting to get that maybe food fear component into it. So we usually look at weight loss, failure to re-progress with food reintroduction, and then also a lot of food fears and food anxiety. Great. I can't help but think about the patients sometimes that we see with celiac that say, oh, I'm so gluten-free. I'm always gluten-free except Friday night when I have pizza. And so you mentioned sort of giving yourself some grace with contamination. But when you're having discussions with patients about exposures, I mean, how would you approach letting them know that a little bit is not acceptable? Is that fair to say? It is during the elimination phase. So I answer that to clients in two ways. First, I tell them that one of my research goals truly is to figure out how to help them cheat. And as we start to study more of these more minimally invasive things, we're really hoping that we can sort of establish a bit of a threshold. We just don't have that right now. We've had some patients get away with a little bit, but we can't give patients responsible guidance on how much to cheat with. On the flip side of that, we've seen during the reintroduction phase that a little bit is enough to activate people's disease. And so we sort of remind them that we don't know. And so while there may be some room for variability, we can't recommend that. And so just leading up to the scope in that six weeks during the scope or prior to the scope, we want them to be as careful as they can reasonably be without making themselves crazy and to let us know if they think they had something that was a contamination episode. I mean, sometimes people forget, and they're like, I ate my kid's mac and cheese. Other times they got contaminated and sort of realized that after the fact. If someone thinks they had a contamination episode or knows they did, usually people don't totally blow it. It's more accidental. But if they do let us know that, we will clinically push their endoscopy back a few weeks just to make sure that if we're doing this procedure, we're putting them under, that we're really getting that reliable information about whether or not this food avoidance worked. That's great. Saru, I want to pick your brain on, by the way, thank you for providing a comprehensive assessment on esophageal diseases. I think, obviously, EOE is the topic of the discussion. But having in your toolbox some understandings of the other conditions that we see is super crucial. That PPI slide that you showed, I screenshotted it and sent it to all my colleagues because I think it's important to understand that pentoprazole isn't the same as omeprazole. Can you comment on how you discuss that with patients and when there might be some movements one way or the other? Yeah, I'd like to go to that slide that I see there, that study that was done and showing really pentoprazole is on the weaker end of the spectrum. And I rarely start with that. I'm sure maybe in a primary care setting, it's OK to start with that. But when they get to me in the clinic here, they usually are beyond the pentoprazole. So it's just a nice slide to know really how effective is the different PPI. And for me, I generally start with omeprazole. That's not effective. I move to Nexium. And then I get into the dexlent or the ribiprazole field. That's kind of how I do a step up approach. One of the pearls I keep thinking of is I just finished the hospital service and one of the more common IV PPIs we give in patients who have ulcers is IV pentoprazole. And so what happens is it's the cheapest medication probably. It's on the formulary. And so that IV gets converted to PO pentoprazole. And now these patients that had a huge duodenal ulcer that I had to treat endoscopically are getting sent home with 20 BID, sorry, 40 BID of pentoprazole. And so I think some of the APPs, if you're seeing these patients back in clinic, it may be worthwhile if you had such a high risk lesion or if these patients are coming in because they're on eloquence and they're on all these other anticoagulations or dual anti-platelet therapy. It may be worthwhile to bump up that PPI to another another formulation because you're going to get better acid suppression. That was what I really resonated with me because I got off hospital service and I've had a lot of bleeders this week. All right. There's got to be some other questions from the panelists. We've got some, sorry, from our guests. Is there anybody else out there in cyberspace that wants to ask our esteemed colleagues anything else before we go to the next phase here? Speak now or... One question for Bethany. Do you see much loss of response to patients that have responded to, let's say, milk? It's a great question. You mean like sort of does the diet elimination stop working for them? Correct. Yeah. No, I'll tell you, we've had a few patients that that has happened. And so so generally, we're not finding that like if they're allergic to milk, I'm saying allergic and I mean really like, you know, if it's an EOE trigger, but if they remove it, they usually stay responsive to milk elimination. But we've seen actually sort of new food group allergy identification in that, you know, like in the case of milk, for example, you know, when we first started doing the diet, pea protein, there weren't so many milk free options. And so people did rice milk or they maybe did coconut milk. And now that there is so much emphasis on protein and so much of the protein in the non-dairy world comes from legumes. You know, we may see that, let's say, a postmenopausal woman is saying, you know, hey, I'm really trying to build weights and, you know, build up my muscle mass. And now I've started to do a protein shake. And so we're really taking the diet history sort of outlines for us what new foods really became much more prevalent in people's diets. And we've actually found some sort of new food group triggers in those patients who stopped being responsive to avoidance of, say, milk. OK, that's helpful. Thank you.

proton pump inhibitors

eosinophilic esophagitis

patient concerns

shared decision-making

dietary management