Esophageal dilation in eosinophilic esophagitis: safety and predictors of clinical response and complications

doi:10.1016/j.gie.2009.10.047

Gastrointestinal Endoscopy

Volume 71, Issue 4, April 2010, Pages 706-712

https://doi.org/10.1016/j.gie.2009.10.047 Get rights and content

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.

Section snippets

Methods

We performed a retrospective study of the University of North Carolina EoE clinicopathologic database, which contains information on patients from January 2000 through December 2007. Cases included newly diagnosed EoE patients of any age who met criteria defined by the recent consensus guidelines.¹ Specifically, patients demonstrated ≥15 eosinophils in at least one high-power field (HPF) (0.23 mm²; eosinophils per high-power field [eos/HPF]) and at least one typical symptom of esophageal

Patient characteristics

There were 130 incident cases of EoE identified over the study time frame. Full characterization of this population has been presented elsewhere,³¹ but in brief, the mean age was 26 years, 75% of patients were male, 80% were white, and the mean eosinophil count at diagnosis was 66/HPF (± 38, range 15-230 eos/HPF).

Information concerning dilation status was available on 124 patients. There were a number of clinical and demographic differences among the 36 EoE patients (29%) who underwent dilation

Discussion

Dysphagia and food impaction are clinical hallmarks of EoE, and endoscopic therapy is often required to dilate rings, strictures, or a narrow esophagus. Although this technique can improve patients' symptoms,1, 13, 19, 22, 32, 33 it is potentially fraught with complications; esophageal perforations, tears, and hospitalizations have been reported.12, 14, 15, 16, 17, 18, 25, 26, 27, 29, 34 The purpose of this study was to assess the safety of esophageal dilation in EoE at a tertiary care center

References (35)

G.T. Furuta et al.
Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment
Gastroenterology
(2007)
A. Straumann et al.
Eosinophilic esophagitis: escalating epidemiology?
J Allergy Clin Immunol
(2005)
T.K. Desai et al.
Association of eosinophilic inflammation with esophageal food impaction in adults
Gastrointest Endosc
(2005)
S.S. Aceves et al.
Relationships between eosinophilic inflammation, tissue remodeling, and fibrosis in eosinophilic esophagitis
Immunol Allergy Clin North Am
(2009)
A. Straumann et al.
Fragility of the esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis?
Gastrointest Endosc
(2003)
J.B. Morrow et al.
The ringed esophagus: histological features of GERD
Am J Gastroenterol
(2001)
S. Vasilopoulos et al.
The small-caliber esophagus: an unappreciated cause of dysphagia for solids in patients with eosinophilic esophagitis
Gastrointest Endosc
(2002)
J. Croese et al.
Clinical and endoscopic features of eosinophilic esophagitis in adults
Gastrointest Endosc
(2003)
M. Kaplan et al.
Endoscopy in eosinophilic esophagitis: “feline” esophagus and perforation risk
Clin Gastroenterol Hepatol
(2003)
J.W. Potter et al.
Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features
Gastrointest Endosc
(2004)

M.S. Cohen et al.

An audit of endoscopic complications in adult eosinophilic esophagitis

Clin Gastroenterol Hepatol

(2007)

A. Straumann et al.

Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients

Clin Gastroenterol Hepatol

(2008)

P.J. Riou et al.

Esophageal rupture in a patient with idiopathic eosinophilic esophagitis

Ann Thorac Surg

(1996)

G.M. Eisen et al.

Complications of upper GI endoscopy

Gastrointest Endosc

(2002)

P. Cantu et al.

Ringed oesophagus and idiopathic eosinophilic oesophagitis in adults: an association in two cases

Dig Liver Dis

(2005)

R.J. Noel et al.

Eosinophilic esophagitis

N Engl J Med

(2004)

J. Ronkainen et al.

Prevalence of oesophageal eosinophils and eosinophilic oesophagitis in adults: the population-based Kalixanda study

Gut

(2006)

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Esophageal dilation is a now recognized to be an important therapeutic modality in eosinophilic esophagitis (EoE). We aimed to evaluate the safety of esophageal dilation in EoE, especially regarding perforation risk, and to examine perforation risk by dilator type.
We conducted a systematic review of the published literature from January 1, 1950 to June 30, 2016 using PubMed, EMBASE, and Web of Science. Studies were included if they described patients with EoE who underwent elective esophageal dilation and also reported the presence or absence of at least 1 adverse event (eg, perforation, bleeding, pain, or hospitalization). We used random-effects meta-analysis to estimate the frequency of each adverse event.
Of 923 identified articles, 37 met inclusion criteria and represented 2034 dilations in 977 patients. On meta-analysis, postprocedure hospitalization occurred in .689% of dilations (95% confidence interval [CI], 0%-1.42%), clinically significant GI hemorrhage in .028% (95% CI, 0%-.217%), and clinically significant chest pain in 3.64% (95% CI, 1.73%-5.55%). Nine perforations were documented, at a rate of .033% (95% CI, 0%-.226%) per procedure after meta-analysis. None of the perforations resulted in surgical intervention or mortality. Most (5/9) were reported before 2009 (rate, .41% [95% CI, 0%-2.75%]); from 2009 forward the rate was .030% (95% CI, 0%-.225%). Dilation method was described in 30 studies (1957 dilations), in which 4 perforations were detected. The estimated perforation rate for bougies was .022% (95% CI, 0%-.347%) and for balloons was .059% (95% CI, 0%-.374%).
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Multiple meta-analyses and systematic reviews support the safety and efficacy of endoscopic dilation in adult and pediatric patients with EoE.155-157 Some patients, especially those with smaller initial esophageal diameters, will require multiple procedures over several months to achieve improvement in esophageal caliber; others will need repeat dilation because of stricture recurrence.158 Importantly, endoscopic dilatation does not alter the underlying inflammatory process in EoE, and treatment with concomitant pharmacologic therapy or elimination diet reduces the risk of needing subsequent dilations.26,59
The eosinophilic gastrointestinal diseases (EGIDs) represent disorders of the gastrointestinal (GI) tract that result from the local infiltration and aberrant activity of eosinophils and other immune cells. Eosinophilic esophagitis (EoE) is the most well-characterized EGID and is defined by the presence of intraepithelial eosinophils in the esophagus (≥15 eosinophils per high-powered field) and clinical symptoms associated with esophageal dysfunction. The other EGIDs are rare and lack strong data regarding pathogenesis and management. The incidence and prevalence of EoE are increasing, and EoE is now a major cause of upper GI morbidity. Management is multidisciplinary, with collaboration between gastroenterologists, allergists, pathologists, and dieticians, and is aimed at amelioration of symptoms and prevention of long-term complications such as esophageal stricture. Treatment options for EoE include proton pump inhibitors, swallowed topical corticosteroids, and elimination diets. Esophageal dilation is used when esophageal strictures or fibrostenotic changes are present. Additional therapies targeting eosinophils and other mediators of Th2 inflammation are under development and are promising. Treatment options for other EGIDs typically involve corticosteroids or dietary elimination.

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: DISCLOSURE:All authors disclosed no financial relationships relevant to this publication. This work was funded, in part, by support from grant KL2RR025746 from the National Center for Research Resources as well as by a Junior Faculty Development Award from the American College of Gastroenterology.

: See CME section; p. 824

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Original articleClinical endoscopyEsophageal dilation in eosinophilic esophagitis: safety and predictors of clinical response and complications

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusions

Section snippets

Methods

Patient characteristics

Discussion

Gastroenterology

J Allergy Clin Immunol

Gastrointest Endosc

Immunol Allergy Clin North Am

Gastrointest Endosc

Am J Gastroenterol

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Clin Gastroenterol Hepatol

Clin Gastroenterol Hepatol

Ann Thorac Surg

Gastrointest Endosc

Dig Liver Dis

Eosinophilic esophagitis

N Engl J Med

Prevalence of oesophageal eosinophils and eosinophilic oesophagitis in adults: the population-based Kalixanda study

Gut

Original article
Clinical endoscopy
Esophageal dilation in eosinophilic esophagitis: safety and predictors of clinical response and complications