Severity of endoscopically identified esophageal rings correlates with reduced esophageal distensibility in eosinophilic esophagitis

Background/Aims: A grading system for the endoscopic features of eosinophilic esophagitis (EoE) has recently been validated. The EoE Endoscopic Reference Score (EREFS) incorporates both inflammatory and remodeling features of EoE. High resolution impedance planimetry using the functional luminal imaging probe (FLIP) is a technique for quantification of esophageal remodeling. The aim of this study was to evaluate the association between endoscopic severity with EREFS and esophageal distensibility as measured with the FLIP.

Methods: Upper gastrointestinal endoscopy with biopsies and FLIP were performed in 72 adults with EoE. Endoscopic features of edema, rings, exudates, furrows, and stricture were evaluated using the EREFS system. Esophageal distensibility metrics obtained by FLIP, including the distensibility slope and distensibility plateau, were compared with EREFS parameters. Bivariate associations between EREFS parameters and histologic eosinophil density were assessed.

Results: Higher ring scores were associated with a lower distensibility plateau (r_s = −0.46; P < 0.0001). An association was found between severity of exudates and eosinophil density (r_s = 0.27; P = 0.02), as well as between furrows and eosinophil density (r_s = 0.49; P < 0.0001). Severity of exudates and furrows, and degree of eosinophilia were not associated with the distensibility parameters.

Conclusions: Endoscopic assessment of ring severity can serve as a marker for esophageal remodeling and may be useful for food impaction risk stratification in EoE. Eosinophil count was not significantly associated with esophageal distensibility, consistent with previous reports of dissociation between inflammatory activity and fibrostenosis in EoE. Endoscopic inflammatory features show a weak correlation with histopathology but should not replace histologic indices of inflammation.

• References

• 1 Liacouras CA, Furuta GT, Hirano I et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128: 3-20 e6; quiz 1-2
• 2 Kidambi T, Toto E, Ho N et al. Temporal trends in the relative prevalence of dysphagia etiologies from 1999–2009. World J Gastroenterol 2012; 18: 4335-4341
• 3 Aceves SS, Newbury RO, Dohil R et al. Esophageal remodeling in pediatric eosinophilic esophagitis. J Allergy Clin Immunol 2007; 119: 206-212
• 4 Lucendo AJ, Arias A, De Rezende LC et al. Subepithelial collagen deposition, profibrogenic cytokine gene expression, and changes after prolonged fluticasone propionate treatment in adult eosinophilic esophagitis: a prospective study. J Allergy Clin Immunol 2011; 128: 1037-1046
• 5 Mishra A, Wang M, Pemmaraju VR et al. Esophageal remodeling develops as a consequence of tissue specific IL-5-induced eosinophilia. Gastroenterology 2008; 134: 204-214
• 6 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
• 7 Hirano I, Aceves SS. Clinical implications and pathogenesis of esophageal remodeling in eosinophilic esophagitis. Gastroenterol Clin North Am 2014; 43: 297-316
• 8 Kim HP, Vance RB, Shaheen NJ et al. The prevalence and diagnostic utility of endoscopic features of eosinophilic esophagitis: a meta-analysis. Clin Gastroenterol Hepatol 2012; 10: 988-996 e5
• 9 Dohil R, Newbury R, Fox L et al. Oral viscous budesonide is effective in children with eosinophilic esophagitis in a randomized, placebo-controlled trial. Gastroenterology 2010; 139: 418-429
• 10 Straumann A, Conus S, Degen L et al. Budesonide is effective in adolescent and adult patients with active eosinophilic esophagitis. Gastroenterology 2010; 139: 1526-1537 , 37 e1
• 11 Peterson KA, Thomas KL, Hilden K et al. Comparison of esomeprazole to aerosolized, swallowed fluticasone for eosinophilic esophagitis. Dig Dis Sci 2010; 55: 1313-1319
• 12 Hirano I, Moy N, Heckman MG et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut 2013; 62: 489-495
• 13 van Rhijn BD, Warners MJ, Curvers WL et al. Evaluating the Endoscopic Reference Score for eosinophilic esophagitis: moderate to substantial intra- and interobserver reliability. Endoscopy 2014; 46: 1049-1055
• 14 Schoepfer AM, Panczak R, Zwahlen M et al. How do gastroenterologists assess overall activity of eosinophilic esophagitis in adult patients?. Am J Gastroenterol 2015; 110: 402-414
• 15 Schoepfer AM, Straumann A, Panczak R et al. Development and validation of a symptom-based activity index for adults with eosinophilic esophagitis. Gastroenterology 2014; 147: 1255-1266 e21
• 16 Kwiatek MA, Pandolfino JE, Hirano I et al. Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP). Gastrointest Endosc 2010; 72: 272-278
• 17 Pandolfino JE, de Ruigh A, Nicodeme F et al. Distensibility of the esophagogastric junction assessed with the functional lumen imaging probe (FLIP) in achalasia patients. Neurogastroenterol Motil 2013; 25: 496-501
• 18 Kwiatek MA, Hirano I, Kahrilas PJ et al. Mechanical properties of the esophagus in eosinophilic esophagitis. Gastroenterology 2011; 140: 82-90
• 19 Nicodeme F, Hirano I, Chen J et al. Esophageal Distensibility as a Measure of Disease Severity in Patients with Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2013; 11: 1101-1107
• 20 McMahon BP, Frokjaer JB, Kunwald P et al. The functional lumen imaging probe (FLIP) for evaluation of the esophagogastric junction. Am J Physiol Gastrointest Liver Physiol 2007; 292: G377-G384
• 21 Hirano I. Therapeutic end points in eosinophilic esophagitis: is elimination of esophageal eosinophils enough?. Clin Gastroenterol Hepatol 2012; 10: 750-752
• 22 Desai TK, Stecevic V, Chang CH et al. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointest Endosc 2005; 61: 795-801
• 23 Gentile N, Katzka D, Ravi K et al. Oesophageal narrowing is common and frequently under-appreciated at endoscopy in patients with oesophageal eosinophilia. Aliment Pharmacol Ther 2014; 40: 1333-1340
• 24 Lim JR, Gupta SK, Croffie JM et al. White specks in the esophageal mucosa: An endoscopic manifestation of non-reflux eosinophilic esophagitis in children. Gastrointest Endosc 2004; 59: 835-838