Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
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Role of endoscopy in eosinophilic esophagitis

  • Eun-Jin Yang (Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kee Wook Jung (Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine)
  • Received : 2024.01.26
  • Accepted : 2024.04.04
  • Published : 2025.01.30
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Abstract

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease involving inflammation of the esophagus. Endoscopy is essential in the diagnosis and treatment of EoE and shows typical findings, including esophageal edema, rings, exudates, furrows, and stenosis. However, studies involving pediatric and adult patients with EoE suggest that even a normally appearing esophagus can be diagnosed as EoE by endoscopic biopsy. Therefore, in patients with suspected EoE, biopsy samples should be obtained from the esophagus regardless of endoscopic appearance. Moreover, follow-up endoscopies with biopsy after therapy initiation are usually recommended to assess response. Although previous reports of endoscopic ultrasonography findings in patients with EoE have shown diffuse thickening of the esophageal wall, including lamina propria, submucosa, and muscularis propria, its role in EoE remains uncertain and requires further investigation. Endoscopic dilation or bougienage is a safe and effective procedure that can be used in combination with medical and/or dietary elimination therapy in patients with esophageal stricture for the management of dysphagia and to prevent its recurrence.

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References

  1. Muir A, Falk GW. Eosinophilic esophagitis: a review. JAMA 2021;326:1310–1318. https://doi.org/10.1001/jama.2021.14920
  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. https://doi.org/10.1053/j.gastro.2018.07.009
  3. Dellon ES. Eosinophilic esophagitis: what's in a name? Dig Dis Sci 2024;69:330–334. https://doi.org/10.1007/s10620-023-08205-8
  4. Dellon ES. Red between the lines: evolution of eosinophilic esophagitis as a distinct clinicopathologic syndrome. Dig Dis Sci 2020;65:3434–3447. https://doi.org/10.1007/s10620-020-06642-3
  5. Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 2007;133:1342–1363. https://doi.org/10.1053/j.gastro.2007.08.017
  6. 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. https://doi.org/10.1016/j.jaci.2011.02.040
  7. Molina-Infante J, Bredenoord AJ, Cheng E, et al. Proton pump inhibitor-responsive oesophageal eosinophilia: an entity challenging current diagnostic criteria for eosinophilic oesophagitis. Gut 2016;65:524–531. https://doi.org/10.1136/gutjnl-2015-310991
  8. Dellon ES, Hirano I. Epidemiology and natural history of eosinophilic esophagitis. Gastroenterology 2018;154:319–332. https://doi.org/10.1053/j.gastro.2017.06.067
  9. Kim GH, Park YS, Jung KW, et al. An increasing trend of eosinophilic esophagitis in Korea and the clinical implication of the biomarkers to determine disease activity and treatment response in eosinophilic esophagitis. J Neurogastroenterol Motil 2019;25:525–533. https://doi.org/10.5056/jnm19066
  10. Kim GH, Jung KW, Jung HY, et al. Diagnostic trends and clinical characteristics of eosinophilic esophagitis: a Korean, single-center database study. J Neurogastroenterol Motil 2018;24:248–254. https://doi.org/10.5056/jnm17047
  11. Kim SJ, Park MI, Kim GH, et al. Practice patterns for eosinophilic esophagitis patients in Busan and Gyeongnam: a Korean multicenter database study. J Neurogastroenterol Motil 2021;27:71–77. https://doi.org/10.5056/jnm20069
  12. Kim GH, Park H, Jung KW, et al. Incidence, morbidity, and mortality of achalasia: a nationwide, population-based cohort study in South Korea. Gut Liver 2023;17:894–904. https://doi.org/10.5009/gnl220334
  13. Aceves SS, Alexander JA, Baron TH, et al. Endoscopic approach to eosinophilic esophagitis: American Society for Gastrointestinal Endoscopy Consensus Conference. Gastrointest Endosc 2022;96:576–592. https://doi.org/10.1016/j.gie.2022.05.013
  14. Richter JE. Endoscopic treatment of eosinophilic esophagitis. Gastrointest Endosc Clin N Am 2018;28:97–110. https://doi.org/10.1016/j.giec.2017.07.009
  15. Falk GW. Top tips for high-quality endoscopy in eosinophilic esophagitis. Gastrointest Endosc 2023;98:237–240. https://doi.org/10.1016/j.gie.2023.02.006
  16. Dhar A, Haboubi HN, Attwood SE, et al. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022;71:1459–1487. https://doi.org/10.1136/gutjnl-2022-327326
  17. Gonsalves N, Policarpio-Nicolas M, Zhang Q, et al. Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis. Gastrointest Endosc 2006;64:313–319. https://doi.org/10.1016/j.gie.2006.04.037
  18. Saffari H, Peterson KA, Fang JC, et al. Patchy eosinophil distributions in an esophagectomy specimen from a patient with eosinophilic esophagitis: implications for endoscopic biopsy. J Allergy Clin Immunol 2012;130:798–800. https://doi.org/10.1016/j.jaci.2012.03.009
  19. Salek J, Clayton F, Vinson L, et al. Endoscopic appearance and location dictate diagnostic yield of biopsies in eosinophilic oesophagitis. Aliment Pharmacol Ther 2015;41:1288–1295. https://doi.org/10.1111/apt.13201
  20. Arias-González L, Rey-Iborra E, Ruiz-Ponce M, et al. Esophageal perforation in eosinophilic esophagitis: a systematic review on clinical presentation, management and outcomes. Dig Liver Dis 2020;52:245–252. https://doi.org/10.1016/j.dld.2019.10.019
  21. Hirano I, Furuta GT. Approaches and challenges to management of pediatric and adult patients with eosinophilic esophagitis. Gastroenterology 2020;158:840–851. https://doi.org/10.1053/j.gastro.2019.09.052
  22. 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. https://doi.org/10.1136/gutjnl-2011-301817
  23. Dellon ES, Cotton CC, Gebhart JH, et al. Accuracy of the eosinophilic esophagitis endoscopic reference score in diagnosis and determining response to treatment. Clin Gastroenterol Hepatol 2016;14:31–39. https://doi.org/10.1016/j.cgh.2015.08.040
  24. Wechsler JB, Bolton SM, Amsden K, et al. Eosinophilic esophagitis reference score accurately identifies disease activity and treatment effects in children. Clin Gastroenterol Hepatol 2018;16:1056–1063. https://doi.org/10.1016/j.cgh.2017.12.019
  25. 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. https://doi.org/10.1016/j.cgh.2012.04.019
  26. Mackenzie SH, Go M, Chadwick B, et al. Eosinophilic oesophagitis in patients presenting with dysphagia: a prospective analysis. Aliment Pharmacol Ther 2008;28:1140–1146. https://doi.org/10.1111/j.1365-2036.2008.03795.x
  27. Murray IA, Joyce S, Palmer J, et al. Incidence and features of eosinophilic esophagitis in dysphagia: a prospective observational study. Scand J Gastroenterol 2016;51:257–262. https://doi.org/10.3109/00365521.2015.1093166
  28. Ravi K, Talley NJ, Smyrk TC, et al. Low grade esophageal eosinophilia in adults: an unrecognized part of the spectrum of eosinophilic esophagitis? Dig Dis Sci 2011;56:1981–1986. https://doi.org/10.1007/s10620-011-1594-1
  29. 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. https://doi.org/10.1111/apt.12977
  30. Carlson DA, Shehata C, Gonsalves N, et al. Esophageal dysmotility is associated with disease severity in eosinophilic esophagitis. Clin Gastroenterol Hepatol 2022;20:1719–1728. https://doi.org/10.1016/j.cgh.2021.11.002
  31. Dellon ES, Khoury P, Muir AB, et al. A clinical severity index for eosinophilic esophagitis: development, consensus, and future directions. Gastroenterology 2022;163:59–76. https://doi.org/10.1053/j.gastro.2022.03.025
  32. O'Shea KM, Aceves SS, Dellon ES, et al. Pathophysiology of eosinophilic esophagitis. Gastroenterology 2018;154:333–345. https://doi.org/10.1053/j.gastro.2017.06.065
  33. Chen J, Oshima T, Tomita T, et al. Regulatory T cells are increased and correlate with mast cells in eosinophilic esophagitis. J Neurogastroenterol Motil 2024;30:29–37. https://doi.org/10.5056/jnm23040
  34. Hirano I, Aceves SS. Clinical implications and pathogenesis of esophageal remodeling in eosinophilic esophagitis. Gastroenterol Clin North Am 2014;43:297-316. https://doi.org/10.1016/j.gtc.2014.02.015
  35. Yadlapati R, Kahrilas PJ, Fox MR, et al. Esophageal motility disor-derson high-resolution manometry: Chicago classification version 4.00 Neurogastroenterol Motil 2021;33:e14058. https://doi.org/10.1111/nmo.14053
  36. Noh JH, Jung KW, Yoon IJ, et al. Comparison of diagnosis of esoph-ageal motility disorders by Chicago classification versions 3.0 and 4.0. J Neurogastroenterol Motil 2023;29:326-334. https://doi.org/10.5056/jnm22121
  37. Cha B, Choi K, Jung KW, et al. High-resolution impedance manom-etry for comparing bolus transit between patients with non-obstruc-tive dysphagia and asymptomatic controls. Neurogastroenterol Motil 2023;35:e14452. https://doi.org/10.1111/nmo.14452
  38. Choi JY, Jung KW, Pandolfino JE, et al. Dysphagia associated with esophageal wall thickening in patients with nonspecific high-res-olution manometry findings: understanding motility beyond the Chicago classification version 4.0. Neurogastroenterol Motil 2024;36:e14736. https://doi.org/10.1111/nmo.14736
  39. Reddy SB, Ketchem CJ, Dougherty MK, et al. Association between eosinophilic esophagitis and esophageal dysmotility: a systematic review and meta-analysis. Neurogastroenterol Motil 2023;35:e14475. https://doi.org/10.1111/nmo.14475
  40. Jung KW. The clinical usefulness of functional luminal imaging probe in esophageal dysmotility disorder. J Neurogastroenterol Motil 2022;28:509-511. https://doi.org/10.5056/jnm22135
  41. Moosavi S, Shehata C, Kou W, et al. Measuring esophageal compli-ance using functional lumen imaging probe to assess remodeling in eosinophilic esophagitis. Neurogastroenterol Motil 2023;35:e14525. https://doi.org/10.1111/nmo.14525
  42. Carlson DA, Hirano I, Gonsalves N, et al. Composite score of phys- iomechanical esophageal function using functional lumen imaging probe panometry in eosinophilic esophagitis. Gastrointest Endosc 2024;99:499-510. https://doi.org/10.1016/j.gie.2023.10.048
  43. Araujo IK, Shehata C, Hirano I, et al. The severity of reduced esoph-ageal distensibility parallels eosinophilic esophagitis disease dura-tion. Clin Gastroenterol Hepatol 2024;22:513-522. https://doi.org/10.1016/j.cgh.2023.04.027
  44. Wong S, Tippett M, Zobel I, et al. Distal esophageal wall thickness correlates with dysphagia in adult patients with eosinophilic esopha-gitis. Esophagus 2022;19:554-559. https://doi.org/10.1007/s10388-022-00924-7
  45. Suzuki Y, Ochiai Y, Hosoi A, et al. Mucosal and submucosal thick-ening of esophageal wall is a promising factor in the development of symptoms in eosinophilic esophagitis. Gut Liver 2024;18:50-59. https://doi.org/10.5009/gnl220490
  46. Muroi k, Kakushima N, Furukawa K, et al. Subjective symptoms in patients with eosinophilic esophagitis are related to esophageal wall thickness and esophageal body pressure. Dig Dis Sci 2021;66:2291-2300. https://doi.org/10.1007/s10620-020-06527-5
  47. Fox VL, Nurko S, Teitelbaum JE, et al. High-resolution EUS in chil-dren with eosinophilic 'allergic' esophagitis. Gastrointest Endosc 2003;57:30-36. https://doi.org/10.1067/mge.2003.33
  48. Rabinowitz SS, Grossman E, Feng L, et al. Predicting pediatric esophageal wall thickness: an EUS study. Endosc Ultrasound 2020;9:259-266. https://doi.org/10.4103/eus.eus_15_20
  49. Visaggi P, Baiano Svizzero F, Savarino E. Food elimination diets in eosinophilic esophagitis: practical tips in current management and future directions. Best Pract Res Clin Gastroenterol 2023;62-63:101825. https://doi.org/10.1016/j.bpg.2023.101825
  50. Franciosi JP, Mougey EB, Dellon ES, et al. Proton pump inhibitor therapy for eosinophilic esophagitis: history, mechanisms, efficacy, and future directions. J Asthma Allergy 2022;15:281-302. https://doi.org/10.2147/JAA.S274524
  51. Alexander JA, Jung KW, Arora AS, et al. Swallowed fluticasone im- proves histologic but not symptomatic response of adults with eosin-ophilic esophagitis. Clin Gastroenterol Hepatol 2012;10:742-749. https://doi.org/10.1016/j.cgh.2012.03.018
  52. Cotton CC, Eluri S, Wolf WA, et al. Six-food elimination diet and topical steroids are effective for eosinophilic esophagitis: a meta-re-gression. Dig Dis Sci 2017;62:2408-2420. https://doi.org/10.1007/s10620-017-4642-7
  53. Snyder DL, Dellon ES. Biologics in the treatment of eosinophilic esophagitis: ready for use? Clin Gastroenterol Hepatol 2023;21:3230-3233. https://doi.org/10.1016/j.cgh.2023.07.025
  54. Kagalwalla AF, Wechsler JB, Amsden K, et al. Efficacy of a 4-food elimination diet for children with eosinophilic esophagitis. Clin Gas-troentero1 Hepatol 2017;15:1698-1707. https://doi.org/10.1016/j.cgh.2017.05.048
  55. Nielsen JA, Lager DI, Lewin M, et al. The optimal number of biop-sy fragments to establish a morphologic diagnosis of eosinophilic esophagitis. Am U Gastroenterol 2014;109:515-520. https://doi.org/10.1038/ajg.2013.463
  56. Jung KW, Gundersen N, Kopacova B, et al. Occurrence of and risk factors for complications after endoscopic dilation in eosinophilic esophagitis. Gastrointest Endosc 2011;73:15-21. https://doi.org/10.1016/j.gie.2010.09.036
  57. Kaplan M, Mutlu EA, Jakate S, et al. Endoscopy in eosinophilic esophagitis: 'feline' esophagus and perforation risk. Clin Gastroen-terol Hepatol 2003;1:433-437. https://doi.org/10.1016/S1542-3565(03)00222-2
  58. Hirano I. Dilation in eosinophilic esophagitis: to do or not to do? Gastrointest Endosc 2010;71:713-714. https://doi.org/10.1016/j.gie.2009.12.026
  59. Moawad FJ, Molina-Infante J, Lucendo AJ, et al. Systematic review with meta-analysis: endoscopic dilation is highly effective and safe in children and adults with eosinophilic oesophagitis. Aliment Phar-macol Ther 2017;46:96-105. https://doi.org/10.1111/apt.14123
  60. 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. https://doi.org/10.1038/ajg.2009.657
  61. Kim JP, Weingart G, Hiramoto B, et al. Clinical outcomes of adults with eosinophilic esophagitis with severe stricture. Gastrointest En-dosc 2020;92:44-53. https://doi.org/10.1016/j.gie.2020.01.015
  62. Runge TM, Eluri S, Woosley JT, et al. Control of inflammation de-creases the need for subsequent esophageal dilation in patients with eosinophilic esophagitis. Dis Esophagus 2017;30:1-7. https://doi.org/10.1093/dote/dox042
  63. Runge TM, Eluri S, Cotton CC, et al. Outcomes of esophageal dila- tion in eosinophilic esophagitis: safety, efficacy, and persistence of the fibrostenotic phenotype. Am J Gastroenterol 2016;111:206-213. https://doi.org/10.1038/ajg.2015.399
  64. Lipka S, Keshishian B, Boyce HW, et al. The natural history of ste-roid-naive 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. https://doi.org/10.1016/j.gie.2014.02.012
  65. 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. https://doi.org/10.1053/j.gastro.2013.08.015
  66. Warners MJ, Oude Nijhuis RA, de Wijkerslooth LR, et al. The nat- ural course of eosinophilic esophagitis and long-term consequenc-es of undiagnosed disease in a large cohort. Am T Gastroenterol 2018;113:836-844. https://doi.org/10.1038/s41395-018-0052-5
  67. Schupack DA, Ravi K, Geno DM, et al. Effect of maintenance ther- apy for eosinophilic esophagitis on need for recurrent dilation. Dig Dis Sci 2021;66:503-510. https://doi.org/10.1007/s10620-020-06192-8
  68. 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 En-dosc 2017;86:581-591. https://doi.org/10.1016/j.gie.2017.04.028
  69. Madanick RD, Shaheen NJ, Dellon ES. A novel balloon pull-through technique for esophageal dilation in eosinophilic esophagitis (with video). Gastrointest Endosc 2011;73:138-142. https://doi.org/10.1016/j.gie.2010.09.034
  70. Baron TH, Wong Kee Song LM, Zielinski MD, et al. A comprehen-sive approach to the management of acute endoscopic perforations (with videos). Gastrointest Endosc 2012;76:838-859. https://doi.org/10.1016/j.gie.2012.04.476