Distensibility index superior measure for fibrostenotic severity in children with EoE
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The distensibility index provides a superior metric for fibrostenotic severity vs. esophageal diameter alone in pediatric patients with eosinophilic esophagitis, according to research published in Clinical Gastroenterology and Hepatology.
“We have observed for years that children have ongoing symptoms despite improvements in the inflammation. We have been stuck using the visual findings to guide whether to intervene and generally, the esophageal rings (early scarring) are subtle,” Joshua B. Wechsler, MD, MSCI, assistant professor of pediatrics and medicine at Northwestern University Feinberg School of Medicine, told Healio. “From existing studies at our center, we have observed rings in about 30% to 40% of kids with EoE, but never really had a sense of how significant this may be or whether they contributed significantly to symptoms.
“We hypothesized that the Endoscopic Functional Lumen Imaging Probe (EndoFLIP) was a more accurate measure of the extent of scarring, and ultimately would better guide the decision to dilate along with accuracy of dilation.”
In a prospective study, Wechsler and colleagues evaluated 59 pediatric patients (median age, 15 years; 81% boys) who underwent EndoFLIP at Ann & Robert H. Lurie Children’s Hospital of Chicago from September 2020 to January 2022 for suspected or previously diagnosed EoE. The researchers analyzed esophageal distensibility by the distensibility index (DI) and esophageal diameter at the distensibility plateau — “where diameter doesn’t increase with increasing pressure,” Wechsler noted. The primary outcome was the association of esophageal distensibility with clinical, endoscopic and histologic parameters of disease severity.
Initially, researchers compared patients with or without endoscopic features of fibrosis on endoscopy and found no difference in the proportion of patients reporting pre-procedural dysphasia (81% vs. 63%; OR = 2.64; 95% CI, 0.79-7.97), whereas there was a greater proportion of food impaction among patients with fibrostenotic findings (93% vs. 69%; OR = 5.68; 95% CI, 1.23-27.44). Further, patients with inflammatory features on endoscopy had higher peak eosinophils per high-power field (eso/hpf) compared with patients who had visually normal endoscopy results (mean, 33 vs. 6).
Overall, researchers observed lower DI among patients with fibrotic features compared with inflammatory features on endoscopy (median, 3.3 vs. 5.5) and showed no correlation with eosinophil count. DI less than 4.5 mm2/mmHg predicted grade 2 rings on endoscopy (AUC, 0.81). DI further predicted food impaction (OR = 1.44; 95% CI, 1.02-2.14).
“The DI is an accurate measure of fibrostenotic severity, more so than diameter,” Wechsler said. “DI predicts the likelihood of food impaction independent of height and age for kids aged 9 years and older. The DI is not influenced by the extent of inflammation.”
He noted that that further research is still required to understand the extent to which symptoms change with EndoFLIP-guided dilation, and whether this approach can prevent food impaction in this patient population.
“We believe our research supports EndoFLIP as critical to the management EoE for evaluating the cause of ongoing symptoms and screening for scar tissue,” Wechsler said. “We believe this has the potential to limit the risk of food impaction, which requires emergent endoscopy.”
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