A PhysioMechanical Model of Esophageal Function in Eosinophilic Esophagitis

Dustin A. Carlson; Ikuo Hirano; Nirmala Gonsalves; Peter J. Kahrilas; Isis K. Araujo; Mira Yang; Marie Pier Tetreault; John E. Pandolfino

doi:10.1053/j.gastro.2023.05.031

A PhysioMechanical Model of Esophageal Function in Eosinophilic Esophagitis

Dustin A. Carlson^*, Ikuo Hirano, Nirmala Gonsalves, Peter J. Kahrilas, Isis K. Araujo, Mira Yang, Marie Pier Tetreault, John E. Pandolfino

^*Corresponding author for this work

Medicine, Gastroenterology Division

Research output: Contribution to journal › Article › peer-review

18 Scopus citations

Abstract

Background & Aims: Eosinophilic esophagitis (EoE) is characterized by eosinophilic inflammation, but also heterogeneous presentations involving fibrostenotic esophageal remodeling and esophageal dysmotility. We aimed to define and evaluate phenotypes of EoE using functional lumen imaging probe (FLIP) panometry (ie, a PhysioMechanical classification of EoE). Methods: Patients with EoE who completed FLIP during endoscopy were included in a cross-sectional study. FLIP studies were analyzed for distensibility plateau and compliance of the esophageal body, maximum esophagogastric junction diameter, and contractile response pattern. These FLIP features were then applied to define PhysioMechanical classifications. Results: A total of 215 patients with EoE (mean [standard deviation] age 38 [12] years; 31% female) were included. Seven PhysioMechanical classifications were identified that differed by various clinical characteristics, including symptom duration (P <.001) and Endoscopic EoE Reference Scores (EREFS) (P <.001). In particular, patients with “nonreactive fibrostenosis” (n = 14), had greater symptom duration (median [interquartile range] 20 [10–30] years) and more frequently had EREFS grade 2 or 3 ring scores (14 of 14 patients) than patients with a “normal” PhysioMechanical classification (symptom duration: 3 [1–8] years; 4 of 50 [8%] had EREFS grade 2 or 3 rings). In addition, among patients off treatment at cross-sectional evaluation (n = 46), there was a difference between PhysioMechanical classifications in future proton pump inhibitor (PPI) response rates (ie, achieving peak mucosal eosinophil count <15 per high-powered field after PPI treatment); P =.009. PPI response ranged from 87% (13 of 15 patients) with “isolated esophagogastric junction outflow obstruction” to 11% (1 of 9 patients) with “spastic-reactive fibrostenosis.” Conclusions: Classifying PhysioMechanical esophageal function in EoE based on FLIP panometry features may facilitate defining disease severity and directing management in EoE.

Original language	English (US)
Pages (from-to)	552-563.e4
Journal	Gastroenterology
Volume	165
Issue number	3
DOIs	https://doi.org/10.1053/j.gastro.2023.05.031
State	Published - Sep 2023

Funding

Dustin A. Carlson, MD, MSCI (Conceptualization: Equal; Data curation: Lead; Formal analysis: Lead; Methodology: Lead; Supervision: Lead; Writing – original draft: Lead). Ikuo Hirano, MD (Investigation: Equal; Writing – review & editing: Equal). Nirmala Gonsalves, MD (Investigation: Equal; Writing – review & editing: Equal). Peter J. Kahrilas, MD (Investigation: Equal; Writing – review & editing: Equal). Isis K. Araujo, MD (Formal analysis: Supporting). Mira Yang, BS (Formal analysis: Supporting). Marie-Pier Tetreault, PhD (Writing – review & editing: Supporting). John E. Pandolfino, MD, MS (Conceptualization: Equal; Funding acquisition: Lead; Investigation: Equal; Supervision: Supporting; Writing – review & editing: Equal). Funding This work was supported by P01 DK117824 from the NIH (PI: John E. Pandolfino).

Keywords

Dysphagia
Motility
Peristalsis
Stricture

ASJC Scopus subject areas

Hepatology
Gastroenterology

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10.1053/j.gastro.2023.05.031

Cite this

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title = "A PhysioMechanical Model of Esophageal Function in Eosinophilic Esophagitis",

abstract = "Background & Aims: Eosinophilic esophagitis (EoE) is characterized by eosinophilic inflammation, but also heterogeneous presentations involving fibrostenotic esophageal remodeling and esophageal dysmotility. We aimed to define and evaluate phenotypes of EoE using functional lumen imaging probe (FLIP) panometry (ie, a PhysioMechanical classification of EoE). Methods: Patients with EoE who completed FLIP during endoscopy were included in a cross-sectional study. FLIP studies were analyzed for distensibility plateau and compliance of the esophageal body, maximum esophagogastric junction diameter, and contractile response pattern. These FLIP features were then applied to define PhysioMechanical classifications. Results: A total of 215 patients with EoE (mean [standard deviation] age 38 [12] years; 31% female) were included. Seven PhysioMechanical classifications were identified that differed by various clinical characteristics, including symptom duration (P <.001) and Endoscopic EoE Reference Scores (EREFS) (P <.001). In particular, patients with “nonreactive fibrostenosis” (n = 14), had greater symptom duration (median [interquartile range] 20 [10–30] years) and more frequently had EREFS grade 2 or 3 ring scores (14 of 14 patients) than patients with a “normal” PhysioMechanical classification (symptom duration: 3 [1–8] years; 4 of 50 [8%] had EREFS grade 2 or 3 rings). In addition, among patients off treatment at cross-sectional evaluation (n = 46), there was a difference between PhysioMechanical classifications in future proton pump inhibitor (PPI) response rates (ie, achieving peak mucosal eosinophil count <15 per high-powered field after PPI treatment); P =.009. PPI response ranged from 87% (13 of 15 patients) with “isolated esophagogastric junction outflow obstruction” to 11% (1 of 9 patients) with “spastic-reactive fibrostenosis.” Conclusions: Classifying PhysioMechanical esophageal function in EoE based on FLIP panometry features may facilitate defining disease severity and directing management in EoE.",

keywords = "Dysphagia, Motility, Peristalsis, Stricture",

author = "Carlson, {Dustin A.} and Ikuo Hirano and Nirmala Gonsalves and Kahrilas, {Peter J.} and Araujo, {Isis K.} and Mira Yang and Tetreault, {Marie Pier} and Pandolfino, {John E.}",

note = "Publisher Copyright: {\textcopyright} 2023 AGA Institute",

year = "2023",

month = sep,

doi = "10.1053/j.gastro.2023.05.031",

language = "English (US)",

volume = "165",

pages = "552--563.e4",

journal = "Gastroenterology",

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AU - Carlson, Dustin A.

AU - Hirano, Ikuo

AU - Gonsalves, Nirmala

AU - Kahrilas, Peter J.

AU - Araujo, Isis K.

AU - Yang, Mira

AU - Tetreault, Marie Pier

AU - Pandolfino, John E.

PY - 2023/9

Y1 - 2023/9

N2 - Background & Aims: Eosinophilic esophagitis (EoE) is characterized by eosinophilic inflammation, but also heterogeneous presentations involving fibrostenotic esophageal remodeling and esophageal dysmotility. We aimed to define and evaluate phenotypes of EoE using functional lumen imaging probe (FLIP) panometry (ie, a PhysioMechanical classification of EoE). Methods: Patients with EoE who completed FLIP during endoscopy were included in a cross-sectional study. FLIP studies were analyzed for distensibility plateau and compliance of the esophageal body, maximum esophagogastric junction diameter, and contractile response pattern. These FLIP features were then applied to define PhysioMechanical classifications. Results: A total of 215 patients with EoE (mean [standard deviation] age 38 [12] years; 31% female) were included. Seven PhysioMechanical classifications were identified that differed by various clinical characteristics, including symptom duration (P <.001) and Endoscopic EoE Reference Scores (EREFS) (P <.001). In particular, patients with “nonreactive fibrostenosis” (n = 14), had greater symptom duration (median [interquartile range] 20 [10–30] years) and more frequently had EREFS grade 2 or 3 ring scores (14 of 14 patients) than patients with a “normal” PhysioMechanical classification (symptom duration: 3 [1–8] years; 4 of 50 [8%] had EREFS grade 2 or 3 rings). In addition, among patients off treatment at cross-sectional evaluation (n = 46), there was a difference between PhysioMechanical classifications in future proton pump inhibitor (PPI) response rates (ie, achieving peak mucosal eosinophil count <15 per high-powered field after PPI treatment); P =.009. PPI response ranged from 87% (13 of 15 patients) with “isolated esophagogastric junction outflow obstruction” to 11% (1 of 9 patients) with “spastic-reactive fibrostenosis.” Conclusions: Classifying PhysioMechanical esophageal function in EoE based on FLIP panometry features may facilitate defining disease severity and directing management in EoE.

AB - Background & Aims: Eosinophilic esophagitis (EoE) is characterized by eosinophilic inflammation, but also heterogeneous presentations involving fibrostenotic esophageal remodeling and esophageal dysmotility. We aimed to define and evaluate phenotypes of EoE using functional lumen imaging probe (FLIP) panometry (ie, a PhysioMechanical classification of EoE). Methods: Patients with EoE who completed FLIP during endoscopy were included in a cross-sectional study. FLIP studies were analyzed for distensibility plateau and compliance of the esophageal body, maximum esophagogastric junction diameter, and contractile response pattern. These FLIP features were then applied to define PhysioMechanical classifications. Results: A total of 215 patients with EoE (mean [standard deviation] age 38 [12] years; 31% female) were included. Seven PhysioMechanical classifications were identified that differed by various clinical characteristics, including symptom duration (P <.001) and Endoscopic EoE Reference Scores (EREFS) (P <.001). In particular, patients with “nonreactive fibrostenosis” (n = 14), had greater symptom duration (median [interquartile range] 20 [10–30] years) and more frequently had EREFS grade 2 or 3 ring scores (14 of 14 patients) than patients with a “normal” PhysioMechanical classification (symptom duration: 3 [1–8] years; 4 of 50 [8%] had EREFS grade 2 or 3 rings). In addition, among patients off treatment at cross-sectional evaluation (n = 46), there was a difference between PhysioMechanical classifications in future proton pump inhibitor (PPI) response rates (ie, achieving peak mucosal eosinophil count <15 per high-powered field after PPI treatment); P =.009. PPI response ranged from 87% (13 of 15 patients) with “isolated esophagogastric junction outflow obstruction” to 11% (1 of 9 patients) with “spastic-reactive fibrostenosis.” Conclusions: Classifying PhysioMechanical esophageal function in EoE based on FLIP panometry features may facilitate defining disease severity and directing management in EoE.

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KW - Motility

KW - Peristalsis

KW - Stricture

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A PhysioMechanical Model of Esophageal Function in Eosinophilic Esophagitis

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