In Eosinophilic Esophagitis, Reducing the Need for Dilation

By Michael Broder, PhDReviewed by Jordan E. Axelrad, MD, MPH, Assistant Professor, Department of Medicine, NYU Grossman School of Medicine, New York, NY

Eosinophilic esophagitis (EoE) has emerged in the last 2 decades as a leading cause of food impaction and dysphagia among both pediatric and adult patients, with other symptoms that vary by

age at presentation.1,2

As the prevalence of EoE has increased, along with its burden on the healthcare system, considerable progress has been made in elucidating the diagnostic criteria, clinical evaluation,

disease assessment, and pathogenic pathways of the condition.3 A consensus guideline defined EoE as “a chronic, immune/antigen-mediated, esophageal disease characterized clinically by

symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.”4 Treatment is sometimes referred to in terms of “3 Ds,” which include drugs (such as

proton pump inhibitors [PPIs] and swallowed topical steroids) to moderate the Th2 cellular response, elimination diets to mitigate the impact of dietary antigens, and esophageal dilation to

reduce inflammation and prevent the clinical consequences of esophageal remodeling.2,3

Endoscopic dilation plays an important role for patients with treatment-resistant disease or persistent manifestations of dysphagia or food impactions. A 2017 systematic review and

meta-analysis evaluated the efficacy, adverse events, and mortality rates of endoscopic dilation among those with EoE. Based on data from 14 studies (N=1607), the pooled proportion of

participants exhibiting clinical improvement with esophageal dilations at 12 months was nearly 85%. The pooled proportion of postprocedural esophageal perforation, chest pain, hemorrhage,

and hospitalization were all less than 1%, with higher rates of deep mucosal tear (4%) and small mucosal tear (22%).5

Evidence from a number of studies suggests that dilating to a larger diameter (i.e., ≥17 mm) and control of inflammation may limit esophageal remodeling and reduce the need for further

dilation. One study found that patients with EoE treated with topical swallowed steroids for 8 weeks needed less repeat dilation. Among experts who encourage the use of maintenance therapy

for those with EoE requiring steroids, there’s disagreement regarding dose and duration of such therapy. Moreover, the precise impact of induction and maintenance regimens on the need for

dilation remains uncertain.6

To shed light on this issue, Schupack and colleagues assessed the effect of maintenance therapy on the need for repeat dilation among those with EoE who had undergone an initial adequate

esophageal dilation to a diameter ≥17 mm.6

“Maintenance therapy for EoE is important in that it can prevent recurrent eosinophilic infiltration of the esophagus, leading to lower risk of developing fibrostenotic disease that’s likely

to require endoscopic dilation therapy to achieve symptomatic relief,” says Daniel A. Schupack, MD, a gastroenterologist at the Mayo Clinic in Rochester, Minn., and the lead author of the

study. “This will hopefully lead to improved quality of life for patients in that symptoms will be less likely to develop and the procedural burden and risk should also decrease.”

“Given the relative paucity of data on maintenance therapy for EoE, studies like ours will hopefully help to increase the knowledge on the effectiveness and safety of long-term maintenance

therapy, so that we know when it’s more appropriate to use,” Dr. Schupack adds.

The new study included 77 participants with EoE (59.7% male, mean age 41.6 years) recruited from a single clinic from June 2000 to August 2017. Dr. Schupack and his colleagues documented

participants’ history of medication use, elimination diet, and dilation. Over a mean follow-up of 164 weeks, 51 participants achieved histologic remission, with 42 of these patients

remaining on maintenance therapy (23 on PPIs, 14 on topical steroids, and 5 using dietary therapy).

The study found that a significantly lower proportion of those on maintenance therapy required repeat dilation (29%) compared to those not on maintenance therapy (89%) (hazard ratio [HR]

0.12, 95% confidence interval [CI] 0.04 to 0.42; P