Eosinophilic Esophagitis: New Guidelines
Eosinophilic Esophagitis: New Guidelines
When performing the endoscopic evaluation, what can you do endoscopically to treat patients?
[ CLOSE WINDOW ]
(Enlarge Slide)
In patients who present with food impaction, it is reasonable to dilate them. My choice is a hydrostatic balloon, which may be less likely to produce shear stress injury than an axial dilator, such as a bougie or Savary dilator. The data are too scant to say that one dilator is safer than another, but the balloon seemed to be the preference of the guidelines committee.
In dilating the esophagus, it is reasonable to proceed slowly and carefully (because the mucosa is quite fragile) with conservative endpoints. If you are dilating with a hydrostatic balloon dilator, you can assess the mucosa between dilations. If you see mucosal disruption, that is your endpoint. You should stop and come back another day, and follow the patient symptomatically.
You should warn these patients that chest pain is almost inevitable after dilation. The guidelines recognize that about 75% of patients will experience chest pain after esophageal dilation, so it is not infrequent. Put these patients on alert; you don't want to perforate them, and the risk is not increased if you are following the appropriate guideline recommendations for dilation.
It is important to educate these patients about how to chew and swallow, and to cut food into small pieces. They should avoid tough meat, doughy bread products, foods with skin, and raw vegetables. Food impaction is often attributed to pasta in these patients. Review what they should be eating. Most of these people can acclimate to their new diet and move forward.
How about maintenance therapy? The natural history of EoE is that it doesn't resolve completely. Patients learn to live with it. Following these patients sequentially, there have been no reports of them developing hypereosinophilic syndrome or eosinophilic gastroenteritis. It is reasonable to consider maintenance therapy in some patients who have a rapid relapse, or a patient with Boerhaave syndrome who developed a food impaction and a perforated esophagus. The likelihood of that patient developing a bolus obstruction is not low, and it is reasonable to use maintenance therapy.
Be aware that with topical swallowed steroids, there is a risk for esophageal and pharyngeal candidiasis. About one third of these patients will develop esophageal candidiasis if they are not careful when they swallow the fluticasone or budesonide. The patient should not swallow food or water for 30 minutes afterward, and when they do swallow, they should rinse their mouth out very well. Because these patients are on steroids, they can develop candida infections.
The bottom line is that we now have much better evidence for consensus. It is not absolute evidence. The recommendations and guidance for what to do in practice have been improved by the current ACG guidelines, but the answers are not all in yet.
Hopefully this has given you a strategy for the next patient you see with EoE.
This is Dr. David Johnson. Thanks again for listening.
Other Treatment Considerations
When performing the endoscopic evaluation, what can you do endoscopically to treat patients?
[ CLOSE WINDOW ]
(Enlarge Slide)
In patients who present with food impaction, it is reasonable to dilate them. My choice is a hydrostatic balloon, which may be less likely to produce shear stress injury than an axial dilator, such as a bougie or Savary dilator. The data are too scant to say that one dilator is safer than another, but the balloon seemed to be the preference of the guidelines committee.
In dilating the esophagus, it is reasonable to proceed slowly and carefully (because the mucosa is quite fragile) with conservative endpoints. If you are dilating with a hydrostatic balloon dilator, you can assess the mucosa between dilations. If you see mucosal disruption, that is your endpoint. You should stop and come back another day, and follow the patient symptomatically.
You should warn these patients that chest pain is almost inevitable after dilation. The guidelines recognize that about 75% of patients will experience chest pain after esophageal dilation, so it is not infrequent. Put these patients on alert; you don't want to perforate them, and the risk is not increased if you are following the appropriate guideline recommendations for dilation.
It is important to educate these patients about how to chew and swallow, and to cut food into small pieces. They should avoid tough meat, doughy bread products, foods with skin, and raw vegetables. Food impaction is often attributed to pasta in these patients. Review what they should be eating. Most of these people can acclimate to their new diet and move forward.
How about maintenance therapy? The natural history of EoE is that it doesn't resolve completely. Patients learn to live with it. Following these patients sequentially, there have been no reports of them developing hypereosinophilic syndrome or eosinophilic gastroenteritis. It is reasonable to consider maintenance therapy in some patients who have a rapid relapse, or a patient with Boerhaave syndrome who developed a food impaction and a perforated esophagus. The likelihood of that patient developing a bolus obstruction is not low, and it is reasonable to use maintenance therapy.
Be aware that with topical swallowed steroids, there is a risk for esophageal and pharyngeal candidiasis. About one third of these patients will develop esophageal candidiasis if they are not careful when they swallow the fluticasone or budesonide. The patient should not swallow food or water for 30 minutes afterward, and when they do swallow, they should rinse their mouth out very well. Because these patients are on steroids, they can develop candida infections.
The bottom line is that we now have much better evidence for consensus. It is not absolute evidence. The recommendations and guidance for what to do in practice have been improved by the current ACG guidelines, but the answers are not all in yet.
Hopefully this has given you a strategy for the next patient you see with EoE.
This is Dr. David Johnson. Thanks again for listening.
Source...