Esophageal dilation with either bougie or balloon technique as a treatment for eosinophilic esophagitis: a systematic review and meta-analysis

  • Michael Dougherty
    Center for Esophageal Disease and Swallowing and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
    Search for articles by this author
  • Thomas M. Runge
    Center for Esophageal Disease and Swallowing and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
    Search for articles by this author
  • Swathi Eluri
    Center for Esophageal Disease and Swallowing and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
    Search for articles by this author
  • Evan S. Dellon
    Reprint requests: Evan S. Dellon, MD, MPH, University of North Carolina School of Medicine, Division of Gastroenterology and Hepatology, CB #7080, Room 4140 Bioinformatics Bldg, 130 Mason Farm Rd, Chapel Hill, NC 27599-7080.
    Center for Esophageal Disease and Swallowing and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
    Search for articles by this author
Published:April 28, 2017DOI:

      Background and Aims

      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%).


      Perforation from esophageal dilation in EoE is rare, and there is no evidence of a significant difference in perforation risk related to dilator type. Esophageal dilation should be considered a safe procedure in EoE.


      CI (confidence interval), EoE (eosinophilic esophagitis)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Arias Á.
        • Pérez-Martínez I.
        • Tenías J.M.
        • et al.
        Systematic review with meta-analysis: the incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies.
        Aliment Pharmacol Therap. 2016; 43: 3-15
        • Jensen E.T.
        • Kappelman M.D.
        • Martin C.F.
        • et al.
        Health care utilization, costs, and the burden of disease related to eosinophilic esophagitis in the United States.
        Am J Gastroenterol. 2015; 110: 626-632
        • Dellon E.S.
        • Liacouras C.A.
        Advances in clinical management of eosinophilic esophagitis.
        Gastroenterology. 2014; 147: 1238-1254
        • Straumann A.
        • Bussmann C.
        • Zuber M.
        • et al.
        Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients.
        Clin Gastroenterol Hepatol. 2008; 6: 598-600
        • Dellon E.S.
        • Kim H.P.
        • Sperry S.L.W.
        • et al.
        A phenotypic analysis shows eosinophilic esophagitis is a progressive fibrostenotic disease.
        Gastrointest Endosc. 2014; 79: 577-585
        • Hirano I.
        • Aceves S.S.
        Clinical implications and pathogenesis of esophageal remodeling in eosinophilic esophagitis.
        Gastroenterol Clin North Am. 2014; 43: 297-316
        • Eluri S.
        • Runge T.M.
        • Cotton C.C.
        • et al.
        The extremely narrow-caliber esophagus is a treatment-resistant subphenotype of eosinophilic esophagitis.
        Gastrointest Endosc. 2016; 83: 1142-1148
        • Aceves S.S.
        • Newbury R.O.
        • Chen D.
        • et al.
        Resolution of remodeling in eosinophilic esophagitis correlates with epithelial response to topical corticosteroids.
        Allergy. 2010; 65: 109-116
        • Lucendo A.J.
        • Arias Á.
        • De Rezende L.C.
        • et al.
        Subepithelial collagen deposition, profibrogenic cytokine gene expression, and changes after prolonged fluticasone propionate treatment in adult eosinophilic esophagitis: a prospective study.
        J Allerg Clin Immunol. 2011; 128: 1037-1046
        • Straumann A.
        • Conus S.
        • Degen L.
        • et al.
        Long-term budesonide maintenance treatment is partially effective for patients with eosinophilic esophagitis.
        Clin Gastroenterol Hepatol. 2011; 9: 400-409
        • Richter J.E.
        Esophageal dilation in eosinophilic esophagitis.
        Best Pract Res. 2015; 29: 815-828
        • Runge T.M.
        • Eluri S.
        • Cotton C.C.
        • et al.
        Outcomes of esophageal dilation in eosinophilic esophagitis: safety, efficacy, and persistence of the fibrostenotic phenotype.
        Am J Gastroenterol. 2016; 111: 206-213
        • Schoepfer A.M.
        • 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
        • Schoepfer A.M.
        • 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
        • Lipka S.
        • Keshishian J.
        • Boyce H.W.
        • et al.
        The natural history of steroid-naïve 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
        • Dellon E.S.
        • Gonsalves N.
        • Hirano I.
        • et al.
        ACG Clinical Guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE).
        Am J Gastroenterol. 2013; 108: 679-692
        • Liacouras C.A.
        • Furuta G.T.
        • Hirano I.
        • et al.
        Eosinophilic esophagitis: updated consensus recommendations for children and adults.
        J Allerg Clin Immunol. 2011; 128: 3-20
        • Richter J.E.
        Eosinophilic esophagitis dilation in the community—try it, you will like it—but start low and go slow.
        Am J Gastroenterol. 2016; 111 ([Editorial]): 214-216
        • Cohen M.S.
        • Kaufman A.B.
        • Palazzo J.P.
        • et al.
        An audit of endoscopic complications in adult eosinophilic esophagitis.
        Clin Gastroenterol Hepatol. 2007; 5: 1149-1153
        • Furuta G.T.
        • Liacouras C.A.
        • Collins M.H.
        • et al.
        Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.
        Gastroenterology. 2007; 133: 1342-1363
        • Hirano I.
        Dilation in eosinophilic esophagitis: to do or not to do?.
        Gastrointest Endosc. 2010; 71: 713-714
        • Kaplan M.
        • Mutlu E.A.
        • Jakate S.
        • et al.
        Endoscopy in eosinophilic esophagitis: “feline” esophagus and perforation risk.
        Clin Gastroenterol Hepatol. 2003; 1: 433-437
        • Bohm M.E.
        • Richter J.E.
        Oesophageal dilation in adults with eosinophilic oesophagitis.
        Aliment Pharmacol Therap. 2011; 33 ([Review]): 748-757
        • Jacobs J.W.
        • Spechler S.J.
        A systematic review of the risk of perforation during esophageal dilation for patients with eosinophilic esophagitis.
        Dig Dis Sci. 2010; 55: 1512-1515
        • Moawad F.J.
        • Cheatham J.G.
        • DeZee K.J.
        Meta-analysis: the safety and efficacy of dilation in eosinophilic oesophagitis.
        Aliment Pharmacol Therap. 2013; 38: 713-720
        • Dellon E.S.
        • Gibbs W.B.
        • Rubinas T.C.
        • et al.
        Esophageal dilation in eosinophilic esophagitis: safety and predictors of clinical response and complications.
        Gastrointest Endosc. 2010; 71: 706-712
        • Jung K.W.
        • Gundersen N.
        • Kopacova J.
        • et al.
        Occurrence of and risk factors for complications after endoscopic dilation in eosinophilic esophagitis.
        Gastrointest Endosc. 2011; 73: 15-21
        • Menard-Katcher C.
        • Furuta G.T.
        • Kramer R.E.
        Dilation of pediatric eosinophilic esophagitis-adverse events and short term outcomes.
        J Pediatr Gastroenterol Nutr. 2017; 64: 701-706
        • Al-Hussaini A.
        Savary dilation is safe and effective treatment for esophageal narrowing related to pediatric eosinophilic esophagitis.
        J Pediatr Gastroenterol Nutr. 2016; 63: 474-480
        • Kavitt R.T.
        • Ates F.
        • Slaughter J.C.
        • et al.
        Randomized controlled trial comparing esophageal dilation to no dilation among adults with esophageal eosinophilia and dysphagia.
        Dis Esoph. 2015; 29: 983-991
        • Saligram S.
        • McGrath K.
        The safety of a strict wire-guided dilation protocol for eosinophilic esophagitis.
        Eur J Gastroenterol Hepatol. 2014; 26: 699-703
        • Ukleja A.
        • Shiroky J.
        • Agarwal A.
        • et al.
        Esophageal dilations in eosinophilic esophagitis: a single center experience.
        World J Gastroenterol. 2014; 20: 9549-9555
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J Clin Epidemiol. 2009; 62: e1-e34
        • Dekkers O.M.
        • Egger M.
        • Altman D.G.
        • et al.
        Distinguishing case series from cohort studies.
        Ann Intern Med. 2012; 156: 37-40
        • Nyaga V.N.
        • Arbyn M.
        • Aerts M.
        Metaprop: a Stata command to perform meta-analysis of binomial data.
        Arch Public Health. 2014; 72: 39
        • Robles-Medranda C.
        • Villard F.
        • le Gall C.
        • et al.
        Severe dysphagia in children with eosinophilic esophagitis and esophageal stricture: an indication for balloon dilation?.
        J Pediatr Gastroenterol Nutr. 2010; 50: 516-520
        • Simpson A.
        • Wilson M.S.J.
        • Ellefson A.
        • et al.
        PTU-164 The clinical utility of the endoscopic functional luminal imaging probe in eosinophilic oesophagitis: a case series.
        Gut. 2012; 61: A252-A253
        • Dhalla S.
        • Jodorkovsky D.
        • Bochner B.S.
        • et al.
        Through-the-scope hydrostatic balloon dilation of strictures and rings is associated with low incidence of perforation in adults with eosinophilicesophagitis and dysphagia: the four-year experience of a single tertiary-care medical center.
        Gastroenterology. 2012; 142: S439
        • Lee G.S.-C.
        • Craig P.I.
        • Freiman J.S.
        • et al.
        intermittent dysphagia for solids associated with a multiringed esophagus: clinical features and response to dilatation.
        Dysphagia. 2007; 22: 55-62
        • Seeger K.
        • Achem S.R.
        Hepatic portal venous gas: an unusual complication following upper endoscopy and dilation.
        ACG Case Rep J. 2014; 1: 128-130
        • Eisenbach C.C.
        • Merle U.
        • Schirmacher P.
        • et al.
        Perforation of the esophagus after dilation treatment for dysphagia in a patient with eosinophilic esophagitis.
        Endoscopy. 2006; 38: E43-E44
        • Morrow J.B.
        • Vargo J.J.
        • Goldblum J.R.
        • et al.
        The ringed esophagus: histological features of GERD.
        Am J Gastroenterol. 2001; 96: 984-989
        • Straumann A.
        • Rossi L.
        • Simon H.-U.
        • et al.
        Fragility of the esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis?.
        Gastrointest Endosc. 2003; 57: 407-412
        • Repici A.
        • Small A.J.
        • Mendelson A.
        • et al.
        Natural history and management of refractory benign esophageal strictures.
        Gastrointest Endosc. 2016; 84: 222-228
        • Siersema P.D.
        • de Wijkerslooth L.R.H.
        Dilation of refractory benign esophageal strictures.
        Gastrointest Endosc. 2009; 70: 1000-1012
        • Grooteman K.V.
        • Wong Kee Song L.M.
        • Vleggaar F.P.
        • et al.
        Non-adherence to the rule of 3 does not increase the risk of adverse events in esophageal dilation.
        Gastrointest Endosc. 2016; 85: 332-337
        • Hagel A.F.A.F.
        • Naegel A.
        • Dauth W.
        • et al.
        Perforation during esophageal dilatation: a 10-year experience.
        J Gastrointest Liver Dis. 2013; 22: 385-389
        • Pasha S.F.
        • DiBaise J.K.
        • Kim H.J.
        • et al.
        Patient characteristics, clinical, endoscopic, and histologic findings in adult eosinophilic esophagitis: a case series and systematic review of the medical literature.
        Dis Esoph. 2007; 20: 311-319
        • Papadopoulou A.
        • Koletzko S.
        • Heuschkel R.
        • et al.
        Management guidelines of eosinophilic esophagitis in childhood.
        J Pediatr Gastroenterol Nutr. 2014; 58: 107-118
        • Bohm M.
        • Richter J.E.
        • Kelsen S.
        • et al.
        Esophageal dilation: simple and effective treatment for adults with eosinophilic esophagitis and esophageal rings and narrowing.
        Dis Esoph. 2010; 23: 377-385
        • Croese J.
        • Fairley S.K.
        • Masson J.W.
        • et al.
        Clinical and endoscopic features of eosinophilic esophagitis in adults.
        Gastrointest Endosc. 2003; 58: 516-522
        • Potter J.W.
        • Saeian K.
        • Staff D.
        • et al.
        Eosinophilic esophagitis in adults: An emerging problem with unique esophageal features.
        Gastrointest Endosc. 2004; 59: 355-361
        • Straumann A.
        • Spichtin H.-P.
        • Grize L.
        • et al.
        Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years.
        Gastroenterology. 2003; 125: 1660-1669
        • Attwood S.E.
        • Smyrk T.C.
        • Demeester T.R.
        • et al.
        Esophageal eosinophilia with dysphagia.
        Dig Dis Sci. 1993; 38: 109-116
        • Langdon D.
        Corrugated ringed esophagus.
        Am J Gastroenterol. 1993; 88: 1461
        • McKinley M.
        • Eisner T.
        • Fisher M.
        • et al.
        Multiple rings of the esophagus associated with gastroesophageal reflux.
        Am J Gastroenterol. 1996; 91 ([case report]): 574-576
        • Ahn Y.
        • Coomarasamy C.
        • Ogra R.
        Efficacy of intralesional triamcinolone injections for benign refractory oesophageal strictures at Counties Manukau Health, New Zealand.
        N Z Med J. 2015; 128: 44-50
        • Lenglinger J.
        • Rieder E.
        • Mesteri I.
        • et al.
        Dilation of an esophageal stricture using a balloon with integrated impedance planimetry imaging.
        Dis Esoph. 2014; 27: 3A-168A
        • Ally M.R.
        • Dias J.
        • Veerappan G.R.
        • et al.
        Safety of dilation in adults with eosinophilic esophagitis.
        Dis Esoph. 2013; 26: 241-245
        • Enns R.
        • Kazemi P.
        • Chung W.
        • et al.
        Eosinophilic esophagitis: clinical features, endoscopic findings and response to treatment.
        Can J Gastroenterol. 2010; 24: 547-551
        • Shepherd B.D.
        • Slaughter J.C.
        • Vaezi M.F.
        Eosinophilic esophagitis: dilate or medicate?.
        Gastroenterology. 2009; 136: A281-A282
        • Jawa H.
        • Chande N.
        Dilation treatment in eosinophilic esophagitis.
        Can J Gastroenterol. 2009; 23
        • Rajagopalan J.
        • Triadafilopoulos G.
        Ring(s)-related esophageal meat bolus impaction: biopsy first, dilate later.
        Dis Esoph. 2009; 22: E14-E16
        • Zuber-Jerger II,
        • Ratiu N.
        • Kullman F.
        Long-lasting effect of endoscopic dilatation of an esophageal stenosis due to eosinophilic esophagitis.
        J Gastrointest Liver Dis. 2006; 15: 167-170
        • Cantù P.
        • Velio P.
        • Prada A.
        • et al.
        Ringed oesophagus and idiopathic eosinophilic oesophagitis in adults: an association in two cases.
        Dig Liver Dis. 2005; 37: 129-134
        • Kumar K.S.
        • Smith J.W.
        Eosinophilic esophagitis: the Ochsner Clinic experience.
        Am J Gastroenterol. 2005; 100: S41
        • Vasilopoulos S.
        • Murphy P.
        • Auerbach A.
        • et al.
        The small-caliber esophagus: an unappreciated cause of dysphagia for solids in patients with eosinophilic esophagitis.
        Gastrointest Endosc. 2002; 55: 99-106
        • Mahajan L.
        • Wyllie R.
        • Petras R.
        • et al.
        Idiopathic eosinophilic esophagitis with stricture formation in a patient with long-standing eosinophilic gastroenteritis.
        Gastrointest Endosc. 1997; 46: 557-560
        • Feczko P.J.P.
        Radiographic abnormalities in eosinophilic esophagitis.
        Gastrointest Radiol. 1985; 10: 321-324