Clinical relevance of esophageal subepithelial activity in eosinophilic esophagitis - PubMed (original) (raw)
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Clinical relevance of esophageal subepithelial activity in eosinophilic esophagitis
Ikuo Hirano. J Gastroenterol. 2020 Mar.
Abstract
Esophageal subepithelial activity (ESEA) is an important determinant of disease severity and complications in eosinophilic esophagitis (EoE). Inflammation and fibrosis of the lamina propria and muscularis propria result in esophageal dysfunction and stricture formation that are clinically manifest by symptoms of dysphagia and food impaction as well as the need for esophageal dilation. Esophageal biopsies that are limited to the evaluation of the esophageal epithelium are an inadequate means to assess overall, clinical disease severity in EoE. Instruments for the assessment of subepithelial activity in EoE are both limited and/or underutilized and thus represent an important unmet clinical need. Studies using endoscopic features, endoscopic ultrasonography, and barium esophagography have demonstrated improvement in ESEA parameters with topical steroid therapy. Impedance planimetry is being evaluated as an objective and quantifiable measure of esophageal distensibility that is a consequence of ESEA. In conjunction with symptom and histologic assessment, evaluation of ESEA provides a more complete evaluation of disease activity in EoE that will enhance clinical care as well as provide insights into the strengths and limitations of therapeutic interventions.
Keywords: Dysphagia; Eosinophilic esophagitis; Eosinophilic gastrointestinal disease; Esophageal stricture.
Conflict of interest statement
Ikuo Hirano: consulting: Adare, Celgene, Regeneron, Shire, Allakos, Esocap; research funding: Celgene, Regeneron, Shire. Allakos; Royalties: up to date.
Figures
Fig. 1
Full-thickness esophageal histology in EoE demonstrates eosinophilic inflammation in the mucosa, submucosa and muscularis propria (a). Trichrome staining of the same specimen demonstrated transmural esophageal fibrosis
Fig. 2
Narrow caliber esophagus in EoE can be a smooth diffuse tapered appearance (a) or a more typical “trachealization” with distinct ring-like deformation (b). Inflammatory features are more apparent on endoscopic imaging compared to barium esophagram (a). With medical therapy of EoE, inflammatory features may resolve but remodeling changes can persist (b, i pretherapy, b, ii post topical steroids). Such patients often require esophageal dilation to alleviate persistent dysphagia related to stricture formation (b, iii)
Fig. 3
(Left) Esophageal ring severity can be graded as mild (grade 1), moderate (grade 2), or severe (grade 3) based on endoscopic imaging. (Right) Both self-limited food impaction (SLFI) and emergency room visits for food impaction (% ER visit) increase with higher degrees of severity of esophageal rings as demonstrated on endoscopy [2]
Fig. 4
Impedance planimetry recording equipment (functional lumen imaging probe, FLIP). The left image shows the FLIP device which is a portable, bedside recording instrument with pump system to allow for volumetric distension of the gastrointestinal tract. The right image depicts the FLIP catheter that incorporates impedance electrodes that measure the cross-sectional area at 16 different longitudinally separated sites along with intraluminal pressure within an infinitely compliant balloon that fills with an electrode conducting solution
Fig. 5
Impedance planimetry in eosinophilic esophagitis. Distensibility curves plot esophageal cross-sectional area along the most narrowed segment of the esophagus versus intraluminal distension pressure. Esophageal distensibility if reduced in EoE patients with food impaction compared to those without food impaction. This illustrates the relevance of esophageal subepithelial activity measured by impedance planimetry as related to clinical outcomes [3]
Fig. 6
Impedance planimetry topographic plot mapping esophageal diameters over time with increasing volumetric esophageal distension. The upper plot depicts the upper 16 cm of the esophagus landmarked to the upper esophageal sphincter. The lower plot depicts the lower 16 cm of the esophagus landmarked to the lower esophageal sphincter. This plot demonstrates a focal stricture in the proximal esophagus with inner diameter of 10 mm in a patient with eosinophilic esophagitis
Fig. 7
Impedance planimetry topographic plot illustrating diffuse narrow caliber esophagus in a patient with eosinophilic esophagus. With the exception of the upper 5 cm of the esophagus, the majority of the esophagus is less than 14 mm in diameter. The distensibility plateau in the distal esophagus is 10 mm
Fig. 8
Impedance planimetry topographic plots of the distal esophagus in patient with eosinophilic esophagitis before and after swallowed topical budesonide administration. Prior to therapy, the patient demonstrates diffuse esophageal narrowing with a distensibility plateau of 7 mm and absent peristalsis. Following treatment, the distensibility plateau improved to 13 mm with more global improvement across the esophageal lumen. In addition, esophageal peristaltic function recovered [54]
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