In Adults With EoE, Dilation May Mask Underlying Inflammation

A recent study of adult patients with eosinophilic esophagitis (EoE) sought to determine if dilation modifies the association between symptoms and peak esophageal eosinophils per high-power field (eos/hpf).

The study was conducted because information on the relationship between EoE symptoms and biologic findings are limited, so researchers looked at the long-term effects of esophageal dilation, including patient-reported outcome (PRO) measures.

Esophageal dilation is known to improve dysphagia but not inflammation, and so dilation might hide any associations between clinical symptoms and biologic findings discovered during an endoscopy.

The adult EoE patients were enrolled in the Consortium of Gastrointestinal Eosinophilic Disease Researchers (CEGIR) as well as the prospective, multicenter, observational Outcome Measures for Eosinophilic Gastrointestinal Diseases Across Ages (OMEGA) study.

Patients completed the symptom-based EoE activity index (EEsAI), a PRO instrument. Biopsies were collected during endoscopic procedures.

Patients were classified based on their dilation status: no dilation, dilation performed 1 year or less before endoscopy, or dilation performed more than 1 year before endoscopy.

Statistical analysis included Spearman correlations of the relationship between symptoms and eos/hpf and linear regression with EEsAI as the outcome, eos/hpf as predictor, and interaction for dilation and eos/hpf.

Of the 100 patients who completed the EEsAI, the median disease duration was 9.7 years with a diagnostic delay of 4 years. The median age was 37 years and most (n = 61) were male.

For 15 patients, the dilation had occurred 1 year or less before the index endoscopy; for 40 patients, the dilation had occurred more than 1 year before the endoscopy, respectively. Forty-five patients were not dilated.

Findings showed that patient-reported symptoms should not be used to monitor therapy response to dilation for at least 12 months after the procedure, because while biologic findings indicated that inflammation was present for this group, for those patients who had undergone dilation, patients did not report any symptoms for more than a year, inadvertently hiding the seriousness of their condition.

Specifically, results showed:

• A moderate association between eos/hpf and symptoms (ρ = 0.49; P < .001) in patients with no dilation
• For a 10-eos/hpf increase in nondialated patients, the predicted EEsAI increased by 2.69 (P = .002)
• No association between eos/hps and symptoms in patients dilated 1 year or less and more than 1 year before endoscopy

For a 10-eos/hpf increase, the predicted EEsAI changed by –1.64 (P = .183) in patients dilated 1 year or less before endoscopy and 0.78 (P = .494) in patients dilated more than 1 year before endoscopy.

Noting the effects of dilation on patient-reported symtoms, the authors said that randomized controlled trials should take into account the impact of dilation on baseline symptom assessment, and that the using dilation means that response to therapies should not be judged by symptoms.

“The dissociation between validated PRO measures–assessed symptoms and [peak eosinophil count] in the [randomized controlled trials] of adults with EoE is a matter of concern,” the authors concluded.

Dilation status should be considered in studies evaluating EoE treatment and for clinical follow-up evaluation, they said.

Reference

Safroneeva E, Pan Z, King E, et al. Long-lasting dissociation of esophageal eosinophilia and symptoms after dilation in adults with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2022;20(4):766-775.e4. doi:10.1016/j.cgh.2021.05.049.