Background and Aims Some patients with eosinophilic esophagitis (EoE) have an extremely narrow esophagus, but the characteristics of this group have not been extensively described. We aimed to ...characterize the narrow-caliber phenotype of EoE, determine associated risk factors, and identify differences in treatment response in this subgroup of patients. Methods This retrospective cohort study from 2001 to 2014 included subjects with a new diagnosis of EoE per consensus guidelines. Demographic, endoscopic, histologic, and treatment response data were extracted from medical records. An extremely narrow-caliber esophagus was defined when a neonatal endoscope was required to traverse the esophagus due to the inability to pass an adult endoscope. Patients with and without an extremely narrow-caliber esophagus were compared. Multivariable logistical regression was performed to assess treatment outcomes. Results Of 513 patients with EoE, 46 (9%) had an extremely narrow-caliber esophagus. These patients were older (33 vs 22 years; P < .01), had longer symptom duration (11 vs 3 years; P < .01), more dysphagia (98% vs 66%; P < .01), and food impactions (53% vs 31%; P < .01). Dilation was more common with extreme narrowing (69% vs 17%; P < .01). Patients with a narrow-caliber esophagus were more refractory to steroid treatment, with lower symptom (56% vs 85%), endoscopic (52% vs 76%), and histologic (33% vs 63%) responses ( P < .01 for all), and these differences persisted after multivariate analysis. Conclusion The extremely narrow-caliber esophagus is a more treatment-resistant subphenotype of EoE and is characterized by longer symptom duration and the need for multiple dilations. Recognition of an extremely narrow-caliber esophagus at diagnosis of EoE can provide important prognostic information.
Background The epidemiology of esophageal foreign-body impaction (EFBI) is poorly described, and the impact of the increasing prevalence of eosinophilic esophagitis (EoE) on this is unknown. ...Objective To assess the characteristics of patients with EFBI, to determine whether EFBI cases increased in proportion to EoE cases, and to identify predictors of EFBI. Design Retrospective study. Setting Tertiary care center. Patients Cases of EFBI from 2002 to 2009 were identified by querying billing, clinical, and endoscopy databases for the International Classification of Diseases, 9th Revision, Clinical Modification code 935.1, “foreign body in the esophagus.” Charts were reviewed to confirm EFBI and to extract pertinent data. Cases of EoE were defined per guidelines. Results Of 548 patients with EFBI (59% male, 68% white, bimodal age distribution), 482 (88%) required a procedure, 347 (63%) had food impactions, and 51 (9%) had EoE. EFBIs increased over the study time frame, and the number of EGDs performed for EFBI nearly quadrupled. Increasing diagnosis of EoE did not fully account for this trend, but only 27% of patients who underwent EGD had esophageal biopsies. Of patients who underwent biopsy, 46% had EoE. EoE was the strongest predictor of multiple EFBIs (odds ratio 3.5; 95% CI, 1.8-7.0). Limitations Retrospective, single-center study. Conclusions The number of EGDs performed for EFBI has increased dramatically at our center, but increasing EoE prevalence only partially explains this trend. Because only a minority of EFBI patients underwent biopsies and because nearly half of those who did undergo biopsy had EoE, the incidence of EoE may be substantially underestimated. Physician education is needed to increase the proportion of subjects with EFBI who undergo biopsies.
Background Phenotypes of eosinophilic esophagitis (EoE) are not well-characterized. Objective To describe clinical features of patients with EoE with predefined phenotypes, determine predictors of ...these phenotypes, and make inferences about the natural history of EoE. Design Retrospective study. Setting Tertiary-care center. Patients Incident EoE cases from 2001 to 2011 that met consensus diagnostic guidelines. Intervention Review of records. Main Outcome Measurements Endoscopic phenotypes, including fibrostenotic, inflammatory, or mixed. Other groups of clinical characteristics examined included atopy, level of esophageal eosinophilia, and age of symptom onset. Multinomial logistic regression assessed predictors of phenotype status. Results Of 379 cases of EoE identified, there were no significant phenotypic differences by atopic status or level of eosinophilia. Those with the inflammatory phenotype were more likely to be younger than those with mixed or fibrostenotic (13 vs 29 vs 39 years, respectively; P < .001) and less likely to have dysphagia, food impaction, and esophageal dilation ( P < .001 for all). The mean symptom length before diagnosis was shorter for inflammatory (5 vs 8 vs 8 years; P = .02). After multivariate analysis, age and dysphagia independently predicted phenotype. The odds ratio (OR) for fibrostenosis for each 10-year increase in age was 2.1 (95% CI, 1.7-2.7). The OR for dysphagia was 7.0 (95% CI, 2.6-18.6). Limitations Retrospective, single-center study. Conclusion In this large EoE cohort, the likelihood of fibrostenotic disease increased markedly with age. For every 10-year increase in age, the odds of having a fibrostenotic EoE phenotype more than doubled. This association suggests that the natural history of EoE is a progression from an inflammatory to a fibrostenotic disease.
Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC), a disease with increasing burden in the Western world, especially in white men. Risk factors for BE include obesity, ...tobacco smoking, and gastroesophageal reflux disease (GERD). EAC is the most common form of esophageal cancer in the United States. Risk factors include GERD, tobacco smoking, and obesity, whereas nonsteroidal antiinflammatory drugs and statins may be protective. Factors predicting progression from nondysplastic BE to EAC include dysplastic changes on esophageal histology and length of the involved BE segment. Biomarkers have shown promise, but none are approved for clinical use.
Background Radiofrequency ablation (RFA) is a safe and effective treatment for Barrett’s esophagus (BE) that results in high rates of complete eradication of intestinal metaplasia (CEIM). However, ...recurrence is common after CEIM, and surveillance endoscopy is recommended. Neither the anatomic location nor the endoscopic appearance of these recurrences is well-described. Objective Describe the location of histologic specimens positive for recurrence after CEIM and the testing performance of endoscopic findings for the histopathologic detection of recurrence. Design Retrospective cohort. Setting Single referral center. Patients A total of 198 patients with BE with at least 2 surveillance endoscopies after CEIM. Interventions RFA, EMR, surveillance endoscopy. Main Outcome Measurements The anatomic location and histologic grade of recurrence. Results In a mean 3.0 years of follow-up, 32 (16.2%; 95% confidence interval CI, 11.0%-22.0%) patients had recurrence of disease, 5 (2.5%; 95% CI, 0.3%-4.7%) of whom progressed beyond their worst before-treatment histology. Recurrence was most common at or near the gastroesophageal junction (GEJ). Recurrence >1 cm proximal to the GEJ always was accompanied by endoscopic findings, and random biopsies in these areas detected no additional cases. The sensitivity of any esophageal sign under high-definition white light or narrow-band imaging for recurrence was 59.4% (42.4%, 76.4%), and the specificity was 80.6% (77.2%, 84.0%). Limitations Single-center study. Conclusion Recurrent intestinal metaplasia often is not visible to the endoscopist and is most common near the GEJ. Random biopsies >1 cm above the GEJ had no yield for recurrence. In addition to biopsy of prior EMR sites and of suspicious lesions, random biopsies oversampling the GEJ are recommended.
Background Insufflation of the lumen is required for visualization during GI endoscopy. Carbon dioxide (CO2 ) has been proposed as an alternative to room air for insufflation. Objectives To assess ...the safety and efficacy of CO2 insufflation for endoscopy. Design Systematic review that focuses on evidence from randomized controlled trials (RCT). Methods Two investigators independently searched MEDLINE from 1950 to February 13, 2008, to identify all articles that reported the use of CO2 in a GI endoscopy application. Bibliographies of relevant articles were also hand searched to identify other pertinent reports. Data from RCTs, as well as from nonrandomized studies, were extracted. Results Nine RCTs were identified that compared CO2 and air insufflation for GI endoscopy. Fifteen other nonrandomized studies or reports were also reviewed. In the 8 RCTs in which postprocedural pain was assessed, pain was lower in the CO2 insufflation group compared with the air group. Two RCTs found decreased flatus in the CO2 group compared with the air group, and 3 RCTs showed there was decreased bowel distention on abdominal radiography in the CO2 group compared with the air group. Also, in all 9 RCTs and 6 additional studies in which safety was assessed, there was no CO2 retention and no adverse pulmonary events related to CO2 insufflation. Limitations Because of study heterogeneity, meta-analytic techniques could not be used. Conclusions Consistent RCT evidence indicates that CO2 insufflation is associated with decreased postprocedural pain, flatus, and bowel distention. CO2 insufflation also appears to be safe in patients without severe underlying pulmonary disease.
Background Esophageal strictures resulting from eosinophilic esophagitis present management challenges, and high rates of rents and perforation have been reported. Objective To assess the safety of ...esophageal dilation in eosinophilic esophagitis and to characterize predictors of both clinical response and complications of the procedure. Design Retrospective study of the University of North Carolina eosinophilic esophagitis database. Setting Tertiary care referral center. Patients Cases of eosinophilic esophagitis were defined as per consensus guidelines. Intervention Dilation with either Savary or through-the-scope balloon techniques. Main Outcome Measurements Complications (deep mucosal rents, contained or free perforation, and chest pain requiring medical attention or hospitalization) and the global clinical symptom response. Results Of 130 eosinophilic esophagitis cases identified, 70 dilations (12 Savary, 58 balloon) were performed in 36 patients. Esophageal size improved from 12 to 16 mm ( P < .001), with an overall symptom response rate of 83%. The only predictor of clinical response was final dilation diameter. There were 5 complications (7%): 2 deep mucosal rents and 3 episodes of chest pain. There were no perforations. There was one hospitalization for chest pain. All complications occurred in patients being treated with topical steroids, who underwent balloon dilation. Complications were associated with younger age (23 vs 42; P = .02) and more dilations (4 vs 1.7; P = .009). Limitations Single center, retrospective study. Conclusions Esophageal dilation can be performed in eosinophilic esophagitis with low rates of tears, chest pain, and hospitalization. No perforations were found in our database. The effectiveness of dilation was best when a larger esophageal caliber was achieved, but patients undergoing more procedures was associated with complications.
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