Role of endoscopic esophageal dilation in managing eosinophilic esophagitis

Abstract

Background:Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disorder of the esophagus characterized by mucosal eosinophilic infiltration. Topical glucocorticoids are considered standard line of treatment, whereas endoscopic dilations are performed for patients presenting with treatment-resistant disease or manifestations of dysphagia and/or food impactions. Efficacy and safety of esophageal dilation in these patients are currently unclear.Aims:Primary outcomes were to evaluate the efficacy, adverse events, and mortality rates of endoscopic esophageal dilation in patients with EoE.Methods: Study Selection Criteria:Studies that reported the use of esophageal dilation in EoE patients were included in this meta-analysis.Data collection and extraction:Articles were searched in Medline, Pubmed, and Ovid journals. Two authors independently searched and extracted data. The study design was written in accordance to PRISMA statement. Clinical improvement was defined as patient-reported symptom relief noted by the authors of individual studies. The symptoms were assessed on various nonstandardized, however, relevant questionnaires that were deemed appropriate by the senior authors of individual studies.Statistical Method:Pooled proportions were calculated using fixed- and random-effects model. I2 statistic was used to assess heterogeneity among studies.Results:Initial search identified 491 reference articles, in which 39 articles were selected and reviewed. Data were extracted from 14 studies (N = 1607) using esophageal dilation for EoE management, which met the inclusion criterion. Mean age of patients was 41years. Pooled patients included 75% males. The pooled proportion of patients that showed clinical improvement with esophageal dilations, after the median follow-up period of 12 months, was 84.95%. No procedure-related deaths were noted. The pooled proportion of patients with post procedural esophageal perforation, chest pain, hospitalization, deep mucosal tear (involving muscularis propria), small mucosal tear, and hemorrhage were 0.61%, 0.06%, 0.74%, 4.04%, 22.32%, and 0.38% respectively. I2 (inconsistency) was 0% (95% confidence interval [CI] = 0–49.8) and Egger: bias was 0.06 (95% CI = −0.30 to 0.42).Conclusions:In patients with conformed diagnosis of EoE, endoscopic esophageal dilation seems to be an effective and safe treatment option. Majority patients with chest pain and deep mucosal tears did not require hospitalization and symptoms were self-limiting

Heterogeneity in Clinical, Endoscopic, and Histologic Outcome Measures and Placebo Response Rates in Clinical Trials of Eosinophilic Esophagitis: A Systematic Review

“…However, similar symptom-based and histologic outcomes are measured in both prospective and retrospective observational studies of dietary interventions in EoE, with heterogeneity in the defined thresholds for response and remission remaining an important challenge. [59][60][61][62][63] A previous systematic review has also evaluated outcomes after endoscopic dilation for EoE 64 ; efficacy was typically assessed by using dysphagia scoring systems, although there is an increased focus on safety outcomes, particularly with respect to esophageal perforation. Finally, we could not pool placebo rates to generate single point estimates.…”

Intrabolus Pressure Has Better Correlation Than Eosinophilia with Dysphagia Severity in Fibrostenotic Eosinophilic Esophagitis: A Pilot Study

“…These results question the significance of histologic response alone in EoE, particularly in those patients with fibrostentotic disease. In the presence of fibrostenosis, esophageal dilatation is required to provide long-lasting improvement of dysphagia despite ongoing mucosal eosinophilia [19][20][21].…”

Understanding fibrosis in eosinophilic esophagitis: Are we there yet?

“…Esophageal dilation is reserved for patients with treatment‐resistant disease, dysphagia, and/or food impactions. Although early case series reported high rates of perforations in adults with EoE, recent meta‐analysis indicates that esophageal dilation (both balloon and bougie) is safe for both pediatric and adult patients . The most frequent complications reported are mucosal tear and chest pain .…”

“…Although early case series reported high rates of perforations in adults with EoE, recent meta‐analysis indicates that esophageal dilation (both balloon and bougie) is safe for both pediatric and adult patients . The most frequent complications reported are mucosal tear and chest pain . Despite dilation and concurrent treatment with topical corticosteroids, a high percentage of patients require repeat dilations suggestive of possible ongoing remodeling …”

“…15,84 The most frequent complications reported are mucosal tear and chest pain. 10,84 Despite dilation and concurrent treatment with topical corticosteroids, a high percentage of patients require repeat dilations suggestive of possible ongoing remodeling. 10…”