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Esophageal dilation for eosinophilic esophagitis: it’s safe! Why aren’t we doing more dilations?

      Abbreviations:

      EoE (eosinophilic esophagitis), NSAIDs (nonsteroidal anti-inflammatory drugs), PPIs (proton pump inhibitors), TTS (through-the-scope)
      Eosinophilic esophagitis (EoE) was first recognized as an inflammatory disease of the esophagus with mucosal eosinophilia, but over the past 10 years it has been slowly realized that esophageal remodeling with stricture disease is an important feature, especially in adult patients. Esophageal strictures are present in 30% to 80% of adults with EoE.
      • Richter J.E.
      Esophageal dilation in eosinophilic esophagitis.
      Several studies confirm that the presence and severity of stricture disease coincides with the longer duration of undiagnosed disease.
      • Richter J.E.
      Esophageal dilation in eosinophilic esophagitis.
      • Schoepfer A.M.
      • Safroneeva E.
      • Bussman C.
      • et al.
      Delay in diagnosis of eosinophilia esophagitis increases risk of stricture information in a time-dependent manner.
      In this latter stage, proton pump inhibitors (PPIs), topical steroids, dietary therapy, or a combination of these measures may improve any ongoing inflammation, but symptoms often persist until the fibrostenosis is disrupted by esophageal dilation.
      Although initially considered dangerous in EoE treatment,
      • Furuta G.T.
      • Liacouras C.P.
      • Collins M.H.
      • et al.
      Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendation for diagnosis and treatment.
      esophageal dilation has slowly been recognized as an extremely effective and safe treatment for those with fibrostenotic disease. The “renaissance period” for esophageal dilation began in 2010 with the publication of 3 articles from 4 groups detailing their success.
      • Richter J.E.
      Esophageal dilation in eosinophilic esophagitis.
      Over the past 7 years, the literature has evolved rapidly, with 2 systematic reviews and meta-analyses reporting on the efficacy and safety of esophageal dilation in the treatment of EoE.
      Moawad et al
      • Moawad F.
      • Molina-Infante J.
      • Lucendo A.J.
      • et al.
      Systematic review with meta-analysis: endoscopic dilation is highly effective and safe in children and adults with eosinophilic oesophagitis.
      identified 27 studies that included 2873 EoE patients. The mean age was 32.5 years, 75% were men, and all experienced dysphagia, with 59% reporting food impactions. Of this group, 845 EoE patients underwent a total of 1820 esophageal dilations; the median number of dilation sessions was 3 (range, 1-35). Clinical improvement occurred in 95% of patients. Bougies and balloons were used equally, and the reported mean diameter after dilation was 16.1 mm. Adverse events were rare: perforation (0.38%), hemorrhage (0.05%), hospitalization usually for pain (0.67%), and no deaths.
      In this issue of Gastrointestinal Endoscopy, Dougherty et al
      • Dougherty M.
      • Runge T.M.
      • Eluri S.
      • et al.
      Esophageal dilation with either bougie or balloon technique as a treatment for eosinophilic esophagitis: a systematic review and meta-analysis.
      further document the safety of esophageal dilation with their report of 2034 dilations in 977 EoE patients. On meta-analysis, postprocedure hospitalization occurred in 0.69% of dilations, hemorrhage in 0.03%, and clinically significant chest pain in 3.64%. Nine perforations were documented (0.033%), with none resulting in surgical intervention or mortality. The majority were reported before 2009 (rate of 0.41%); subsequently the rate dropped to 0.03%. Dilation methods were described in 30 studies (1957 dilations) in which 4 perforations occurred. The estimated perforation rate was similar for both techniques: 0.022% with bougies and 0.059% with through-the-scope (TTS) balloons.
      So now we know by the best quality of scientific evidence that esophageal dilation is effective and safe, but why isn’t it being used more frequently rather than as a last resort in our patients? I believe this lack of utility involves several issues: poor technical training during fellowship and continuation into general practice, bad experiences with EoE patients, and lack of society recommendations. The key for all gastroenterologists is to follow the simple tenet “start low and go slow” when performing dilation in these patients.
      • Richter J.E.
      Eosinophilic esophagitis dilation in the community – try it – you will like it – but start low and go slow.
      Table 1 summarizes my EoE dilation technique, which has evolved over the past 25 years in treating EoE patients and having discussions with many esophagologists across the country.
      • Richter J.E.
      Esophageal dilation in eosinophilic esophagitis.
      • Richter J.E.
      Eosinophilic esophagitis dilation in the community – try it – you will like it – but start low and go slow.
      Table 1Esophageal dilation in patients with eosinophilic esophagitis
      • Forewarn patients that postdilation pain is to be expected and will usually respond to reassurance and NSAIDs.
      • The endoscope is not reliable for defining strictures or esophageal narrowing in a range of 12 to 15 mm; this is the reason why all EoE patients should undergo some degree of dilation.
      • Endoscopy is required before all dilations to assess the location of obvious strictures and estimate esophageal diameter. Have available a pediatric or 5-mm transnasal endoscope for tight strictures, minimizing the need for fluoroscopy or blind dilations.
      • You can use either bougies or TTS balloons, but make sure you dilate the entire esophagus.
      • Start low with small-diameter dilators and gradually dilate to 16 to 18 mm to ensure normal eating. May require several sessions separated by 3 to 4 weeks.
      • Moderate resistance to bougie passage, blood on the dilator, or significant tears are indications to stop the dilation session.
      • After an induction dilation session to 16 to 18 mm, repeated dilations are triggered by recurrence of dysphagia.
      • Dilation therapy is not a substitute for effective anti-inflammatory treatments (PPIs, topical steroids, diet) and will reduce the rate of stricture recurrence.
      NSAID, nonsteroidal anti-inflammatory drug; TTS, through-the-scope; PPI, proton pump inhibitor.
      Forewarn the patients about pain. Mucosal tears with chest pain are common after EoE patients have undergone dilation. Surprisingly, the reported range is broad (0.6% to 100%), probably because of definition (minimal mucosal disruptions vs deep mucosal tears) or technique used (ie, TTS balloons allow easier assessment of tears).
      • Moawad F.
      • Molina-Infante J.
      • Lucendo A.J.
      • et al.
      Systematic review with meta-analysis: endoscopic dilation is highly effective and safe in children and adults with eosinophilic oesophagitis.
      These tears are not true adverse events but rather an indicator of effective esophageal dilation, where the goal is collagen disruption. In my experience, nearly all EoE patients report some chest pain. The reported rate in the literature varies, but some of this may be reporting bias, as illustrated in the study by Schoepfer et al,
      • Schoepfer A.M.
      • Gonsalves N.
      • Bussman C.
      • et al.
      Esophageal dilation in eosinophilic esophagitis: effectiveness, safety and impact on underlying information.
      where chest pain was self-reported in 74% of patients and was considered mild, but noted in only 7% of the medical reports. These patients may require narcotic analgesia, but most easily respond to reassurance and nonsteroidal anti-inflammatory drugs (NSAIDs).
      The endoscope alone is not a good tool to define esophageal strictures. Endoscopy with biopsies accurately identifies the inflammation associated with EoE but often misses esophageal narrowing in the critical range of 12 to 15 mm. Recently, investigators at the Mayo Clinic found that endoscopy had poor sensitivity (14.7%) and only modest specificity (79.2%) for identifying esophageal strictures. Even at a cutoff diameter of less than 15 mm, endoscopy had a sensitivity of only 25% for the narrowed esophagus.
      • Gentile N.
      • Katzka D.
      • Ravi K.
      • et al.
      Oesophageal narrowing is common and frequently under-appreciated at endoscopy in patients with oesophageal eosinophilia.
      This is clinically important because the esophageal lumen diameter allowing for a regular modified diet is around 15 mm; for a full diet it is 18 mm. This is the reason why I perform dilation in all of my EoE patients at the initial evaluation to assess for the presence and degree of stricture disease.
      Make sure you dilate the entire esophagus. This is important because up to 25% of patients have multiple strictures not obvious to the endoscopist’s eye. I prefer bougies, which reliably dilate the entire length of the esophagus and give better tactile assessment of the location and degree of esophageal narrowing. Strictures less than 15 mm are dilated with Savary bougies over a guidewire and then with Maloney bougies for larger diameters. I rarely need fluoroscopy but always have available both adult and transnasal 5-mm endoscopes, the latter for very tight strictures. My bougie technique adds only 1 to 2 minutes to the procedure time, and the bougies are reusable.
      Others prefer the TTS balloons and have described their techniques.
      • Madanick R.D.
      • Shaheen N.J.
      • Dellon E.B.
      A novel balloon pull-through technique for esophageal dilation in eosinophilic esophagitis.
      Briefly, after examination of the esophagus, an 8- to 9- to 10-mm multisize balloon (CRE fixed wire balloon dilator, Boston Scientific, Marlborough, Mass) is positioned across the esophagogastric junction, if there is resistance to passing an adult endoscope, or a 10- to 11- to 12-mm balloon if the endoscope passes easily. The balloon is inflated to the smallest diameter, positioned in front of the endoscope, and slowly withdrawn from distal to proximal until the entire esophagus is examined. Lumen narrowing is appreciated by the inability to easily pull the balloon through the region. If there is no resistance, then the procedure is repeated with the next size balloons in a serial fashion, in a search for subtle tears and resistance. When resistance is encountered, the balloon is deflated, and slowly inflated until it easily passes or a tear is seen. I have not tried this technique, but it seems tedious and time consuming; I am not sure how well the entire esophagus is dilated, and the balloons are expensive ($150 per balloon) and not reusable. Regardless, with experience the literature suggests that both techniques are effective and safe.
      Start low and go slow. These strictures have been present for some time, and there is no need to rush your dilations. I start with smaller-diameter bougies and progress at the first setting until a diameter of 17 mm is obtained or moderate resistance with or without blood is noted. The rule of 3 is not followed. I don’t look for tears because I know from experience and my tactile sensation that tears will be present when there is moderate resistance to passage of the bougie. Others routinely inspect the esophageal mucosa after 1- to 2-mm dilation increments or after encountering resistance to bougie passage.
      • Madanick R.D.
      • Shaheen N.J.
      • Dellon E.B.
      A novel balloon pull-through technique for esophageal dilation in eosinophilic esophagitis.
      The latter approach is easiest with TTS balloons and may be helpful for physicians using bougies who do not do frequent dilations or who are uncomfortable estimating by tactile sensation the resistance tolerated for esophageal dilation.
      All dilations have an induction phase and a maintenance phase. My goal is to start with a smaller-diameter bougie, progress slowly with dilation sessions every 3 to 4 weeks, and get all patients to a minimum diameter of 16 to 18 mm. For minimal strictures, this can be done at the initial diagnostic session, whereas tight strictures may require an average 2 to 5 sessions (10 is my record). Simultaneously, all patients are receiving anti-inflammatory treatment because this definitely reduces the restricturing rate. This “induction phase” rapidly relieves the patient’s experience of dysphagia; most can eat a regular diet, and food impactions are eliminated. After completion, patients with fibrostenotic EoE need to enter a “maintenance” program. Some practitioners will dilate at regular intervals (every 6-12 months), but I prefer to redilate only when dysphagia begins to recur with a frequency of once a week. With this approach, we have found that many patients require dilations only every 2 to 3 years with up to nearly 20 years of follow-up.
      • Lipka S.
      • Keshishian J.
      • Boyce H.W.
      • et al.
      The natural history of steroid-naïve eosinophilic esophagitis in adults treated with endoscopic dilation and PPIs over a mean duration of nearly 14 years.
      As this editorial has highlighted, esophageal dilation is no longer a barbaric “dark ages” treatment for EoE. Esophageal dilation is effective, safe, and easy to perform as long as we remember the tenet “start low and go slow.” For all physicians treating EoE patients, please join the modern age of EoE therapy in which medical and dietary therapy and esophageal dilation are equal partners in the treatment of these patients.

      Disclosure

      The author disclosed no financial relationships relevant to this publication.

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