Older patients with eosinophilic esophagitis have high treatment response to topical steroids

SUMMARY While strictures are common in eosinophilic esophagitis (EoE), there are few data on stricture distribution and characteristics. Our primary aim was to characterize strictures by location in the esophagus in EoE and associated clinical, endoscopic, and histologic features. This was a retrospective study from the UNC EoE Clinicopathologic Database of subjects with esophageal strictures or narrowing from 2002 to 2017. Strictures were categorized as distal esophagus/gastroesophageal junction, mid-esophagus, proximal esophagus, or diffusely narrowed. Stricture location was assessed and compared with clinical, endoscopic, and histologic features, and also with treatment response to diet or topical steroids. Efficacy of combination therapy with dilation and intralesional steroid injection was assessed in a sub-group of patients with strictures. Of 776 EoE cases, 219 (28%) had strictures, 45% of which were distal, 30% were proximal, 5% were mid-esophageal, and 20% had diffuse narrowing. Those with mid-esophageal strictures were younger (P = 0.02) and had shorter symptom duration (P < 0.01). Those with diffuse esophageal narrowing were more likely to be women (57%) and have abdominal pain (25%). There was no association between other clinical, endoscopic, and histologic findings and treatment response based on stricture location. Fourteen patients (8%) received intralesional triamcinolone injection and subsequently achieved a higher mean dilation diameter after injection (13.7 vs. 15.5 mm; P < 0.01). In conclusion, almost half of strictures in EoE patients were in the distal esophagus. Therefore, EoE should be a diagnostic consideration in patients with focal distal strictures and not presumed to be secondary to gastroesophageal reflux disease.

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A14 WIDE VARIATION IN CLINICAL MANAGEMENT OF PAEDIATRIC EOSINOPHILIC ESOPHAGITIS: A CANADIAN EXPERIENCE.

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwab002.013 ◽

2021 ◽

Vol 4 (Supplement_1) ◽

pp. 16-18

Author(s):

K A Bortolin ◽

D Ashok ◽

V Avinashi ◽

J Barkey ◽

D Burnett ◽

...

Keyword(s):

Maintenance Therapy ◽

Eosinophilic Esophagitis ◽

Online Survey ◽

Treatment Algorithm ◽

Elimination Diet ◽

Practice Variation ◽

Initial Diagnosis ◽

Response To Therapy ◽

Topical Steroids ◽

Repeat Endoscopy

Abstract Background Eosinophilic esophagitis (EoE) is a chronic disorder treated by food elimination diet (FED), topical steroids and/or proton-pump inhibitors (PPI). Serial endoscopies and biopsies assess response to therapy. EoE management has evolved as guidelines are updated. Aims To identify practice variation among Canadian paediatric gastroenterologists (PG) who care for children with EoE. Methods An online survey using REDCap about decision-making in children with EoE was distributed to PG in Canada in November 2020. Results 62 PG completed the survey (response rate 69%, 62/94). The majority work in academic centres (92%). 3 centers indicated an accrual of >50 new patients per year; 9/16 centres have >100 patients in follow-up. An EoE Clinic is present in 5 centres. Diagnosis: Familiarity with the 2018 AGREE and 2020 AGA EoE guidelines was found to be 57% and 67% respectively. Criteria required to diagnose EoE according to current guidelines were correctly indicated by 42% of PG. (Figure 1). Endoscopy: The majority of PG (95%) adhere to guidelines in terms of required number and location of biopsies for the initial diagnosis. Ideal timing of repeat endoscopy after change in therapy in patients who are not in histological remission was 8–12 weeks by 67% of PG, timing in stable patients on maintenance therapy varied (33% only if patient is symptomatic). 25% used the EREFS Score in reporting endoscopic findings. Therapy: Improvement of symptoms was the highest ranked goal (64%), followed by remission of histologic findings (30%). A treatment algorithm was in place in 4 centers. The majority routinely assess adherence to therapy (73%) and consult a dietitian for FED (77%). Most (87%) do not consult an allergist for initial management. Preferred choices of 1st-line therapy varied among PG (Figure 2). When FED was selected, 32% of PG started with 1 food, 32% started with 2 foods, most frequently excluding dairy, followed by wheat. 14 (26%) start with ≥6 FED. Prescription of budesonide slurry was consistent among PG with doses of 1 and 2 mg/day in children <10 and >10 years, respectively. Conclusions The is the first Canadian study to assess the variation in management of children with EoE by PG. Overall, PG demonstrated good adherence to the guidelines in terms of initial diagnosis, but differences in maintenance therapy choice and timing of endoscopies. The results highlight a need for standardized management algorithms to deliver uniform care to this growing group. Grounding these guidelines in evidence will warrant a significant investment in further paediatric EoE research. Funding Agencies None

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Mo1188 DETERMINATION OF AN ENDOSCOPIC RESPONSE THRESHOLD FOR THE EOSINOPHILIC ESOPHAGITIS ENDOSCOPIC REFERENCE SCORE: ANALYSIS OF A RANDOMIZED COMPARATIVE CLINICAL TRIAL OF TOPICAL STEROIDS.

Gastroenterology ◽

10.1016/s0016-5085(20)32728-1 ◽

2020 ◽

Vol 158 (6) ◽

pp. S-819-S-820

Author(s):

Cary C. Cotton ◽

John T. Woosley ◽

Susan E. Moist ◽

Sarah J. McGee ◽

Nicholas J. Shaheen ◽

...

Keyword(s):

Clinical Trial ◽

Eosinophilic Esophagitis ◽

Response Threshold ◽

Topical Steroids ◽

Comparative Clinical Trial ◽

Score Analysis

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Su1122 The Effect of Topical Steroids on Tight Junction Proteins and Spongiosis in Esophageal Epithelia in Patients With Eosinophilic Esophagitis

Gastroenterology ◽

10.1016/s0016-5085(12)61620-5 ◽

2012 ◽

Vol 142 (5) ◽

pp. S-430

Author(s):

Ravikanth Tadi ◽

Eesha Katarya ◽

Navtej Buttar ◽

Thomas C. Smyrk ◽

Ganapathy A. Prasad ◽

...

Keyword(s):

Tight Junction ◽

Eosinophilic Esophagitis ◽

Topical Steroids ◽

Tight Junction Proteins ◽

Junction Proteins

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A meta-analysis of efficacy of topical steroids in eosinophilic esophagitis: From the perspective of histologic, clinical, and endoscopic outcome

Gastroenterología y Hepatología ◽

10.1016/j.gastrohep.2020.07.010 ◽

2020 ◽

Author(s):

Li-xiao Hao ◽

Yi Lu ◽

Tao Li ◽

Biao Gong

Keyword(s):

Eosinophilic Esophagitis ◽

Meta Analysis ◽

Topical Steroids

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Practice patterns and adherence to clinical guidelines for diagnosis and management of eosinophilic esophagitis among gastroenterologists

Diseases of the Esophagus ◽

10.1093/dote/doaa025 ◽

2020 ◽

Vol 33 (7) ◽

Author(s):

Swathi Eluri ◽

Edward G A Iglesia ◽

Michael Massaro ◽

Anne F Peery ◽

Nicholas J Shaheen ◽

...

Keyword(s):

Eosinophilic Esophagitis ◽

Practice Patterns ◽

Further Education ◽

Dietary Therapy ◽

Topical Steroids ◽

Line Treatment ◽

Consensus Guidelines ◽

First Line ◽

Diagnosis And Management ◽

First Line Treatment

Summary Real-world practice patterns of eosinophilic esophagitis (EoE) among gastroenterologists are not well-described. The aim is to describe practice patterns of EoE diagnosis and management and assess concordance with consensus guidelines. We conducted a cross-sectional online survey of gastroenterologists in the USA using Qualtrics, which was dispersed through the North Carolina Society of Gastroenterology (NCSG) and the American College of Gastroenterology member listservs. A similar survey was sent to NCSG members in 2010 and responses were compared in a subanalysis. Of 240 respondents, 37% (n = 80) worked in an academic setting versus 63% (n = 138) community practice setting. Providers saw a median of 18 (interquartile range 2–100) EoE patients annually and 24% (n = 52) were ‘very familiar’ with EoE guidelines. A proton-pump inhibitor (PPI) trial was required by 37% of providers prior to EoE diagnosis. In total, 60% used a ≥15 eosinophils per high-power field cut point for diagnosis and 62% biopsied from the proximal and distal esophagus on initial exam. Only 12% (n = 28) followed EoE diagnosis guidelines. For first-line treatment, 7% used dietary therapy, 32% topical steroids, and 61% used PPIs; 67% used fluticasone as first-line steroid; 41% used maintenance steroid treatment in responders. In the NCSG cohort, a higher proportion in 2017 followed guideline diagnosis recommendations compared with 2010 (14% vs. 3%; P = 0.03) and a higher proportion used dietary therapy as first-line treatment (13% vs. 3%; P = 0.046). There is variability in EoE practice patterns for EoE management, with management differing markedly from consensus guidelines. Further education and guideline dissemination are needed to standardize practice.

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