Dilation-predominant approach versus routine care in patients with difficult-to-treat eosinophilic esophagitis: a retrospective comparison

Abstract

Background Little is known about esophageal dilation as a long-term treatment approach for eosinophilic esophagitis (EoE). We examined the impact of a “dilate and wait” strategy on symptom management and safety of patients with EoE.

Methods This retrospective cohort study included two patient groups: those who underwent a dilation-predominant approach (≥ 3 dilations as sole therapy or for histologically refractory disease [> 15 eos/hpf]); and those who had routine care (< 3 dilations or histologic response). Group characteristics were compared and outcomes for the dilation-only group assessed.

Results 53/205 patients (26 %) received the dilation-predominant strategy (total 408 dilations), predominantly for histologic treatment nonresponse (75 %). These patients were younger (33 vs. 41 years; P = 0.003), had a narrower baseline esophageal diameter (9.8 vs. 11.5 mm; P = 0.005), underwent more dilations (7.7 vs. 3.4; P < 0.001), but achieved a smaller final diameter (15.7 vs. 16.7 mm; P = 0.01) vs. routine care. With this strategy, 30 patients (57 %) had ongoing symptom improvement, with esophageal caliber change independently associated with symptom response (adjusted odds ratio 1.79, 95 % confidence interval 1.16–2.78); 26 (49 %) used the strategy as a bridge to clinical trials. Over a median follow-up of 1001 days (interquartile range 581–1710), no deaths or dilation-related perforations occurred, but there were nine emergency room visits, including one for post-dilation bleeding and four for food impaction.

Conclusions A dilation-predominant long-term treatment strategy allowed for symptom control or bridge to clinical trials for patients with difficult-to-treat EoE. Close follow-up and monitoring for complications are required.

Publication History

Received: 01 November 2020

Accepted after revision: 28 April 2021

Accepted Manuscript online:
28 April 2021

Article published online:
10 June 2021

• References

• 1 Dellon ES, Liacouras CA. Advances in clinical management of eosinophilic esophagitis. Gastroenterology 2014; 147: 1238-1254
• 2 Dellon ES, Liacouras CA, Molina-Infante J. et al. Updated international consensus diagnostic criteria for eosinophilic esophagitis: proceedings of the AGREE conference. Gastroenterology 2018; 155: 1022-1033
• 3 Dellon ES, Hirano I. Epidemiology and natural history of eosinophilic esophagitis. Gastroenterology 2018; 154: 319-332
• 4 Straumann A, Bussmann C, Zuber M. et al. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol 2008; 6: 598-600
• 5 Dellon ES, Kim HP, Sperry SLW. et al. A phenotypic analysis shows that eosinophilic esophagitis is a progressive fibrostenotic disease. Gastrointest Endosc 2014; 79: 577-585
• 6 Hirano I, Aceves AA. Clinical implications and pathogenesis of esophageal remodeling in eosinophilic esophagitis. Gastroenterol Clin N Am 2014; 43: 297-316
• 7 Schoepfer AM, Safroneeva E, Bussmann C. et al. Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner. Gastroenterology 2013; 145: 1230-1236
• 8 Warners MJ, Oude Nijhuis RAB, de Wijkerslooth LRH. et al. The natural course of eosinophilic esophagitis and long-term consequences of undiagnosed disease in a large cohort. Am J Gastroenterol 2018; 113: 836-844
• 9 Rank MA, Sharaf RN, Furuta GT. et al. Technical review on the management of eosinophilic esophagitis: a report from the AGA institute and the joint task force on allergy-immunology practice parameters. Ann Allergy Asthma Immunol 2020; 124: 424-440
• 10 Hirano I, Chan ES, Rank MA. et al. AGA institute and the joint task force on allergy-immunology practice parameters clinical guidelines for the management of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2020; 124: 416-423
• 11 Aceves SS, Newbury RO, Chen D. et al. Resolution of remodeling in eosinophilic esophagitis correlates with epithelial response to topical corticosteroids. Allergy 2010; 65: 109-116
• 12 Chehade M, Sampson HA, Morotti RA. et al. Esophageal subepithelial fibrosis in children with eosinophilic esophagitis. J Pediatr Gastroenterol Nutr 2007; 45: 319-328
• 13 Eluri S, Runge TM, Cotton CC. et al. The extremely narrow-caliber esophagus is a treatment-resistant subphenotype of eosinophilic esophagitis. Gastrointest Endosc 2016; 83: 1142-1148
• 14 Dellon ES, Gonsalves N, Hirano I. et al. ACG Clinical Guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am J Gastroenterol 2013; 108: 679-692
• 15 Runge TM, Eluri S, Cotton CC. et al. Outcomes of esophageal dilation in eosinophilic esophagitis: safety, efficacy, and persistence of the fibrostenotic phenotype. Am J Gastroenterol 2016; 111: 206-213
• 16 Dougherty M, Runge TM, Eluri S. et al. Esophageal dilation with either bougie or balloon technique as a treatment for eosinophilic esophagitis: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86: 581-591
• 17 Saligram S, McGrath K. The safety of a strict wire-guided dilation protocol for eosinophilic esophagitis. Eur J Gastroenterol Hepatol 2014; 26: 699-703
• 18 Schoepfer AM, Gonsalves N, Bussmann C. et al. Esophageal dilation in eosinophilic esophagitis: effectiveness, safety, and impact on the underlying inflammation. Am J Gastroenterol 2010; 105: 1062-1070
• 19 Richter JE. Eosinophilic esophagitis dilation in the community – try it – you will like it – but start low and go slow. Am J Gastroenterol 2016; 111: 214-216
• 20 Runge TM, Eluri S, Woosley JT. et al. Control of inflammation decreases the need for subsequent esophageal dilation in patients with eosinophilic esophagitis. Dis Esophagus 2017; 30: 1-7
• 21 Chen JW, Pandolfino JE, Lin Z. et al. Severity of endoscopically identified esophageal rings correlates with reduced esophageal distensibility in eosinophilic esophagitis. Endoscopy 2016; 48: 794-801
• 22 Lipka S, Keshishian J, Boyce HW. et al. The natural history of steroid-naïve eosinophilic esophagitis in adults treated with endoscopic dilation and proton pump inhibitor therapy over a mean duration of nearly 14 years. Gastrointest Endosc 2014; 80: 592-598
• 23 Reed CC, Koutlas NT, Robey BS. et al. Prolonged time to diagnosis of eosinophilic esophagitis despite increasing knowledge of the disease. Clin Gastroenterol Hepatol 2018; 16: 1667-1669
• 24 Eluri S, Corder SR, Kim E. et al. Clinical features and time trends associated with an endoscopically normal esophagus in active eosinophilic esophagitis. Endoscopy 2020;
• 25 Hirano I. How I approach the management of eosinophilic esophagitis in adults. Am J Gastroenterol 2017; 112: 197-199
• 26 Reed CC, Wolf WA, Cotton CC. et al. Optimal histologic cutpoints for treatment response in patients with eosinophilic esophagitis: analysis of data from a prospective cohort study. Clin Gastroenterol Hepatol 2018; 16: 226-233
• 27 Reed CC, Fan C, Koutlas NT. et al. Food elimination diets are effective for long-term treatment of adults with eosinophilic oesophagitis. Aliment Pharmacol Ther 2017; 46: 836-844
• 28 Reed CC, Tappata M, Eluri S. et al. Combination therapy with elimination diet and corticosteroids is effective for adults with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2019; 17: 2800-2802
• 29 Philpott H, Dellon ES. The role of maintenance therapy in eosinophilic esophagitis: who, why, and how?. J Gastroenterol 2018; 53: 165-171
• 30 Greuter T, Hirano I, Dellon ES. Emerging therapies for eosinophilic esophagitis. J Allergy Clin Immunol 2020; 145: 38-45
• 31 Dellon ES. Management of refractory eosinophilic oesophagitis. Nat Rev Gastroenterol Hepatol 2017; 14: 479-490
• 32 Cotton CC, Eluri S, Wolf WA. et al. Six-food elimination diet and topical steroids are effective for eosinophilic esophagitis: a meta-regression. Dig Dis Sci 2017; 62: 2408-2420
• 33 Straumann A, Spichtin HP, Grize L. et al. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology 2003; 125: 1660-1669
• 34 Lipka S, Kumar A, Richter JE. Impact of diagnostic delay and other risk factors on eosinophilic esophagitis phenotype and esophageal diameter. J Clin Gastroenterol 2016; 50: 134-140
• 35 Kim JP, Weingart G, Hiramoto B. et al. Clinical outcomes of adults with eosinophilic esophagitis with severe stricture. Gastrointest Endosc 2020; 92: 44-53