Alimentary Pharmacology and Therapeutics Invited Editorials atrophy in adult patients at high risk of celiac disease. Dig Liver Dis 2012; 44: 280–5. 4. Burgin-Wolff A, Mauro B, Faruk H. Intestinal biopsy is not always required to diagnose celiac disease: a retrospective analysis of combined antibody tests. BMC Gastroenterol 2013; 13: 19. 5. Wakim-Fleming J, Pagadala MR, Lemyre MS, et al. Diagnosis of celiac disease in adults based on serology test results, without small-bowel biopsy. Clin Gastroenterol Hepatol 2013; 11: 511–6. 6. Mubarak A, Wolters VM, Gmelig-Meyling FH, Ten Kate FJ, Houwen RH. Tissue transglutaminase levels above 100 U/mL and celiac disease: a prospective study. World J Gastroenterol 2012; 18: 4399–403.
Editorial: expanding a narrow perspective on narrow calibre oesophagus in eosinophilic oesophagitis J. Molina-Infante* & I. Hirano† *Department of Gastroenterology, Hospital San Pedro de Alcantara, Caceres, Spain. † Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. E-mail: [email protected] doi:10.1111/apt.13005
Gentile et al.1 report a fascinating study demonstrating how endoscopists commonly overlook the presence of oesophageal luminal compromise in patients with symptomatic oesophageal eosinophilia. Fifty-eight patients, without impaired passage of a standard diagnostic adult endoscope, were evaluated with a barium swallow, including detailed measurements of intraluminal diameter. Exactly, 59% had a narrowed oesophageal diameter ≤20 mm and 47% had a diameter ≤13 mm. Quite surprisingly, endoscopists recognised a narrowed oesophagus (≤13 mm) and diffuse narrowing (narrowed segment >8 cm in length) only 27% and 13% of the time, respectively. Seven patients with histological remission gained symptomatic improvement after endoscopic dilation. The study design comparing a retrospective review of nonstandardised endoscopy data by endoscopists of varied experience with carefully analysed barium oesophagrams may have affected the magnitude of the low sensitivity for stricture detection by endoscopy. Nevertheless, the conclusions are both logical and convincing. The presence of narrow calibre oesophagus in eosinophilic oesophagitis (EoE) is not new.2 An important question is, therefore, why endoscopy performed so poorly in the demonstration of clinically significant Aliment Pharmacol Ther 2015; 41: 145-152 ª 2014 John Wiley & Sons Ltd
7. Tortora R, Imperatore N, Capone P, et al. The presence of antiendomysial antibodies and the level of anti-tissue transglutaminases can be used to diagnose adult coeliac disease without duodenal biopsy. Aliment Pharmacol Ther 2014; 40: 1223–9. 8. Hopper AD, Hadjivassiliou M, Hurlstone DP, et al. What is the role of serologic testing in celiac disease? A prospective, biopsyconfirmed study with economic analysis. Clin Gastroenterol Hepatol 2008; 6: 314–20. 9. Egner W, Shrimpton A, Sargur R, Patel D, Swallow K. ESPGHAN guidance on coeliac disease 2012: multiples of ULN for decision making do not harmonise assay performance across centres. J Pediatr Gastroenterol Nutr 2012; 55: 733–5.
oesophageal strictures. The answer is likely related to the disease state being examined. Prior to the emergence of EoE over the past two decades, the most common causes of dysphagia were peptic strictures and Schatzki’s rings. The focal nature of these entities makes their detection more apparent, especially when juxtaposed with the proximal, adjacent, normal oesophageal calibre. In contrast, the diffuse involvement of the oesophagus in EoE can make detection of gradual, tapered strictures more difficult. Utilisation of recently validated classification and grading systems for the oesophageal features of EoE may improve the endoscopic detection of more subtle alterations.3 In clinical practice, normalisation of dietary habits and complete resolution of dysphagia are goals of treatment of EoE, apart from histological remission.4, 5 The severity of dysphagia in EoE patients, however, is often masked by long-standing behavioural modifications that include avoidance of specific food textures, prolonged meal times and excessive mastication.6 The advent of a recently validated, patient-reported outcome assessment tool, which evaluates dysphagia severity according to eight distinct food consistencies, and which also takes into account behavioural adaptations, may better estimate disease impact and treatment benefits in EoE.7 The resolution of EoE extends beyond the mucosal healing of eosinophilic inflammation. Oesophageal reduced distensibility due to diffuse subepithelial fibrosis and remodelling [measured through the functional luminal imaging probe (EndoFLIP, Cropospon, Carlsbad, USA)], has been recently shown to be a strong predictor for food impaction risk and requirement for oesophageal dilation in EoE.8 Of note, oesophageal eosinophilia did not correlate with oesophageal distensibility, providing a potential explanation for dissociation between histopathology and symptom severity in clinical practice, as well 147
Invited Editorials as in randomised, controlled trials of topical steroids.9 A retrospective study recently showed the usefulness of a novel balloon pull-through technique to size and dilate the oesophagus in EoE.10 Similarly, resistance was encountered in 11/13 patients (85%), even though no narrowing was initially visualised on endoscopy. Oesophageal tears and improvement of dysphagia were reported in 9/ 11 patients. Further studies should elucidate whether such novel diagnostic modalities or better utilisation of existing methods like the oesophagram and endoscopy can better assess pathological and normal swallowing for EoE patients undergoing medical therapeutics. Until then, Gentile and colleagues should be congratulated for highlighting the prevalence of oesophageal remodelling in EoE and its under-appreciation on routine endoscopy.
ACKNOWLEDGEMENT Declaration of personal and funding interests: None. REFERENCES 1. Gentile N, Katzka D, Ravi K, et al. Oesophageal narrowing is common and frequently under-appreciated at endoscopy in patients with esophageal eosinophilia. Aliment Pharmacol Ther 2015; 41: 99–107.
Editorial: expanding a narrow perspective on narrow calibre oesophagus in eosinophilic oesophagitis – authors’ reply J. Alexander & D. Katzka Department of Medicine, Mayo Clinic, Rochester, MN, USA. E-mail: [email protected] doi:10.1111/apt.13016
We would like to thank Drs Molina-Infante and Hirano for their supportive and thorough editorial comments on our paper.1, 2 With regard to the important issues raised, we would like to make two points. First, all the procedures performed in the study had a staff Gastroenterologist in attendance, but many were performed by Gastroenterology fellows in training. It is therefore possible that the trainees were less astute than more experienced endoscopists at appreciating subtle resistance to passage of the endoscope. Nevertheless, for those strictures wider than an endoscope, there was still low sensitivity for detection of strictures by endoscopy. 148
2. 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. 3. Hirano I, Moy N, Heckman MG, Thomas CS, Gonsalves N, Achem SR. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut 2013; 62: 489–95. 4. Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128: 3–20. 5. Dellon ES, 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: 679–92. 6. Straumann A, Schoepfer A. Update on basic and clinical aspects of eosinophilic oesophagitis. Gut 2014; 63: 1355–63. 7. Schoepfer AM, Straumann A, Panczak R, et al. Development and validation of a symptom-based activity index for adults with eosinophilic esophagitis. Gastroenterology 2014; pii: S0016-5085 (14)01039-7. doi: 10.1053/j.gastro.2014.08.028. [Epub ahead of print] 8. Nicodeme F, Hirano I, Chen J, et al. Esophageal distensibility as a measure of disease severity in patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2013; 11: 1101–7. 9. Alexander JA, Jung KW, Arora AS, et al. Swallowed fluticasone improves histologic but not symptomatic response of adults with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2012; 10: 742–9, e1. 10. Madanick RD, Shaheen NJ, Dellon ES. A novel balloon pullthrough technique for esophageal dilation in eosinophilic esophagitis (with video). Gastrointest Endosc 2011; 73: 138–42.
Second, we have similarly found the balloon pullthrough technique to be a very useful technique as a method of pan-oesophageal dilatation to treat unappreciated, but potentially clinically significant, strictures. It also allows the endoscopist to easily identify mucosal injury, our endpoint of dilation for that session, which may occur with minimal resistance to balloon passage but give further evidence that, indeed, a stricture is present. Most importantly, it is our hope that gastroenterologists will use more accurate techniques of assessing oesophageal diameter, such as barium oesophagography or the Endoflip device when assessing oesophageal diameter in patients with eosinophilic oesophagitis. Furthermore, this implies that the radiological expertise needed to perform the former continue to be supported in clinical practice.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 Aliment Pharmacol Ther 2015; 41: 145-152 ª 2014 John Wiley & Sons Ltd
Editorial: expanding a narrow perspective on narrow calibre oesophagus in eosinophilic oesophagitis J. Molina-Infante* & I. Hirano† *Department of Gastroenterology, Hospital San Pedro de Alcantara, Caceres, Spain. † Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. E-mail: [email protected] doi:10.1111/apt.13005
Gentile et al.1 report a fascinating study demonstrating how endoscopists commonly overlook the presence of oesophageal luminal compromise in patients with symptomatic oesophageal eosinophilia. Fifty-eight patients, without impaired passage of a standard diagnostic adult endoscope, were evaluated with a barium swallow, including detailed measurements of intraluminal diameter. Exactly, 59% had a narrowed oesophageal diameter ≤20 mm and 47% had a diameter ≤13 mm. Quite surprisingly, endoscopists recognised a narrowed oesophagus (≤13 mm) and diffuse narrowing (narrowed segment >8 cm in length) only 27% and 13% of the time, respectively. Seven patients with histological remission gained symptomatic improvement after endoscopic dilation. The study design comparing a retrospective review of nonstandardised endoscopy data by endoscopists of varied experience with carefully analysed barium oesophagrams may have affected the magnitude of the low sensitivity for stricture detection by endoscopy. Nevertheless, the conclusions are both logical and convincing. The presence of narrow calibre oesophagus in eosinophilic oesophagitis (EoE) is not new.2 An important question is, therefore, why endoscopy performed so poorly in the demonstration of clinically significant Aliment Pharmacol Ther 2015; 41: 145-152 ª 2014 John Wiley & Sons Ltd
7. Tortora R, Imperatore N, Capone P, et al. The presence of antiendomysial antibodies and the level of anti-tissue transglutaminases can be used to diagnose adult coeliac disease without duodenal biopsy. Aliment Pharmacol Ther 2014; 40: 1223–9. 8. Hopper AD, Hadjivassiliou M, Hurlstone DP, et al. What is the role of serologic testing in celiac disease? A prospective, biopsyconfirmed study with economic analysis. Clin Gastroenterol Hepatol 2008; 6: 314–20. 9. Egner W, Shrimpton A, Sargur R, Patel D, Swallow K. ESPGHAN guidance on coeliac disease 2012: multiples of ULN for decision making do not harmonise assay performance across centres. J Pediatr Gastroenterol Nutr 2012; 55: 733–5.
oesophageal strictures. The answer is likely related to the disease state being examined. Prior to the emergence of EoE over the past two decades, the most common causes of dysphagia were peptic strictures and Schatzki’s rings. The focal nature of these entities makes their detection more apparent, especially when juxtaposed with the proximal, adjacent, normal oesophageal calibre. In contrast, the diffuse involvement of the oesophagus in EoE can make detection of gradual, tapered strictures more difficult. Utilisation of recently validated classification and grading systems for the oesophageal features of EoE may improve the endoscopic detection of more subtle alterations.3 In clinical practice, normalisation of dietary habits and complete resolution of dysphagia are goals of treatment of EoE, apart from histological remission.4, 5 The severity of dysphagia in EoE patients, however, is often masked by long-standing behavioural modifications that include avoidance of specific food textures, prolonged meal times and excessive mastication.6 The advent of a recently validated, patient-reported outcome assessment tool, which evaluates dysphagia severity according to eight distinct food consistencies, and which also takes into account behavioural adaptations, may better estimate disease impact and treatment benefits in EoE.7 The resolution of EoE extends beyond the mucosal healing of eosinophilic inflammation. Oesophageal reduced distensibility due to diffuse subepithelial fibrosis and remodelling [measured through the functional luminal imaging probe (EndoFLIP, Cropospon, Carlsbad, USA)], has been recently shown to be a strong predictor for food impaction risk and requirement for oesophageal dilation in EoE.8 Of note, oesophageal eosinophilia did not correlate with oesophageal distensibility, providing a potential explanation for dissociation between histopathology and symptom severity in clinical practice, as well 147
Invited Editorials as in randomised, controlled trials of topical steroids.9 A retrospective study recently showed the usefulness of a novel balloon pull-through technique to size and dilate the oesophagus in EoE.10 Similarly, resistance was encountered in 11/13 patients (85%), even though no narrowing was initially visualised on endoscopy. Oesophageal tears and improvement of dysphagia were reported in 9/ 11 patients. Further studies should elucidate whether such novel diagnostic modalities or better utilisation of existing methods like the oesophagram and endoscopy can better assess pathological and normal swallowing for EoE patients undergoing medical therapeutics. Until then, Gentile and colleagues should be congratulated for highlighting the prevalence of oesophageal remodelling in EoE and its under-appreciation on routine endoscopy.
ACKNOWLEDGEMENT Declaration of personal and funding interests: None. REFERENCES 1. Gentile N, Katzka D, Ravi K, et al. Oesophageal narrowing is common and frequently under-appreciated at endoscopy in patients with esophageal eosinophilia. Aliment Pharmacol Ther 2015; 41: 99–107.
Editorial: expanding a narrow perspective on narrow calibre oesophagus in eosinophilic oesophagitis – authors’ reply J. Alexander & D. Katzka Department of Medicine, Mayo Clinic, Rochester, MN, USA. E-mail: [email protected] doi:10.1111/apt.13016
We would like to thank Drs Molina-Infante and Hirano for their supportive and thorough editorial comments on our paper.1, 2 With regard to the important issues raised, we would like to make two points. First, all the procedures performed in the study had a staff Gastroenterologist in attendance, but many were performed by Gastroenterology fellows in training. It is therefore possible that the trainees were less astute than more experienced endoscopists at appreciating subtle resistance to passage of the endoscope. Nevertheless, for those strictures wider than an endoscope, there was still low sensitivity for detection of strictures by endoscopy. 148
2. 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. 3. Hirano I, Moy N, Heckman MG, Thomas CS, Gonsalves N, Achem SR. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut 2013; 62: 489–95. 4. Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128: 3–20. 5. Dellon ES, 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: 679–92. 6. Straumann A, Schoepfer A. Update on basic and clinical aspects of eosinophilic oesophagitis. Gut 2014; 63: 1355–63. 7. Schoepfer AM, Straumann A, Panczak R, et al. Development and validation of a symptom-based activity index for adults with eosinophilic esophagitis. Gastroenterology 2014; pii: S0016-5085 (14)01039-7. doi: 10.1053/j.gastro.2014.08.028. [Epub ahead of print] 8. Nicodeme F, Hirano I, Chen J, et al. Esophageal distensibility as a measure of disease severity in patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2013; 11: 1101–7. 9. Alexander JA, Jung KW, Arora AS, et al. Swallowed fluticasone improves histologic but not symptomatic response of adults with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2012; 10: 742–9, e1. 10. Madanick RD, Shaheen NJ, Dellon ES. A novel balloon pullthrough technique for esophageal dilation in eosinophilic esophagitis (with video). Gastrointest Endosc 2011; 73: 138–42.
Second, we have similarly found the balloon pullthrough technique to be a very useful technique as a method of pan-oesophageal dilatation to treat unappreciated, but potentially clinically significant, strictures. It also allows the endoscopist to easily identify mucosal injury, our endpoint of dilation for that session, which may occur with minimal resistance to balloon passage but give further evidence that, indeed, a stricture is present. Most importantly, it is our hope that gastroenterologists will use more accurate techniques of assessing oesophageal diameter, such as barium oesophagography or the Endoflip device when assessing oesophageal diameter in patients with eosinophilic oesophagitis. Furthermore, this implies that the radiological expertise needed to perform the former continue to be supported in clinical practice.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2 Aliment Pharmacol Ther 2015; 41: 145-152 ª 2014 John Wiley & Sons Ltd
