KSG Video Tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Hi everybody, my name's Ellie Adler. I'm a third year gastroenterology fellow at Kaiser Permanente, Northern California. And I'm here with Dr. Angela Lam, one of my attendings, who is an expert on eosinophilic esophagitis. And she's gonna help us today talk about the EREF score and how we can use our upper endoscopy to better stage eosinophilic esophagitis. So I first just wanted to introduce the concept of the EREF score, which is a validated grading tool to report and quantify endoscopic disease features using a uniform language. So there's a couple components. The E stands for edema, which is an inflammatory component of EOE. R stands for rings, which is a fibrostenotic component. The second E is exudate, which is an inflammatory component. The F stands for furrows, which is an inflammatory component. And the S, which we'll get into a little bit more in depth, is a fibrostenotic component, it stands for strictures. So a couple of tips I've gotten from Dr. Lam over the years is, if we're gonna use EREFs, there's a few things we can do endoscopically to help us. One is to inflate the esophagus completely. The second is to examine and determine your EREF score on your initial intubation of the esophagus, especially if you're gonna take biopsy so you get a really good view. And then you wanna photo document the entire esophagus from proximal to distal. So now we're gonna get a little bit more into the S, the stricture, because that can be a particularly confusing aspect of the EREF score. And so you'll see some photos and Dr. Lam is just gonna take us through that. Yeah, thank you, Ellie. So identifying strictures in the eosinophilic esophagitis can actually be more challenging than we think it is. And we're actually not great on finding all of them on endoscopies. And I think a large part of that is because we primarily look for strictures on our forward viewing exams. And a lot of people only characterize a stricture if they're having trouble passing the scope through the G junction or through part of the esophagus. But at that point, you already have a quite severe stricture. So this is where it's important to know the diameter of your scopes and what the normal diameter of an esophagus should be. And the normal diameter of an adult esophagus should be anywhere from two to three centimeters. And the regular upper endoscope is about 10 millimeters or about a centimeter in the widest diameter. And so a stricture, especially anything below 13 millimeters really puts patients at heightened risk for food impactions. And we think about the diameter of the scope and the diameter of the esophagus, the scope can easily pass through anything that's larger than 10 millimeters. And so you could really be missing strictures from 10 to 20 millimeters just in forward view. So that's where the careful retroflex view comes in. And to do that, you wanna get, well, first, actually, you wanna start before you do the procedure. You wanna make sure you have a scope that is able to do a full retroflexion. And then when you go in and do your retroflex view, you wanna get really close to that G junction and make sure you have it fully insufflated. And you're looking at that opening. And ideally you want the patient to release a little bit of air through a burp and get a transient relaxation of that low esophageal sphincter. And in a normal esophagus, you should see that esophagus diameter open up to at least twice the diameter of your upper endoscope. And oftentimes in the EOE, you'll see that you have actually a ring that you can pick up on that retroflex view that you didn't initially see going in because it didn't hinder the passage of your scope. But the patient would actually benefit from having a dilation. And they may be still having ongoing dysphagia symptoms even though you've maybe gotten their inflammation under control. So retroflex view, lots of air. And then sometimes you just have to sit on the air for a few minutes to allow the esophagus to open up and get a transient relaxation of the lower esophageal sphincter. And then the other benefit of doing that exam is you can also assess for a hatal hernia to check if there could be any her contributing to the disease process. So looking at this endoscopy here, so this is an example where we're looking at the retroflex view. And in it, you're able to see, the first picture is one where the G-junction is tight and then we're allowing it to relax. And then we see the esophagus diameter open up. And it looks like it's actually, it's opened up to more than double the diameter of the upper scope. This is a normal G-junction. The second set of photos here, so you can see going down, you may not pick up that there's a stricture, but now doing the same retroflex exam on this patient, you're able to see actually there is a stricture there. There's a ring around the upper endoscope that is certainly narrower than twice the diameter. So you can use your knowledge of the scope diameter to guess what size that stricture is. So that looks to be, I would guess, maybe around 13 millimeters of a stricture, just slightly wider than the scope itself. Okay, two more examples. Yes, and this is another great example where going forward, you may not notice that there's a stricture. It's certainly patent to the upper endoscope, but the minute you do that retroflex exam and put in a lot of air to evaluate, you see that there is actually a stricture there, just slightly wider than the scope itself, maybe 12 to 13 millimeters. Perfect, and then finally, let's look at this one. Yeah, and then this is another example of another stricture in EOE that you may not have picked up for review. And this one also comes in the setting of a Haydell for an N2. So someone you want to make sure that you're not missing any concomitant reflux. Perfect, thank you so much, Dr. Lamb. This has been your ASGE video tip.

eosinophilic esophagitis

EREF score

upper endoscopies

edema

strictures