Gastroenterology

Gastroenterology

Volume 165, Issue 3, September 2023, Pages 552-563.e4
Gastroenterology

Original Research
Full Report: Esophagus
A PhysioMechanical Model of Esophageal Function in Eosinophilic Esophagitis

https://doi.org/10.1053/j.gastro.2023.05.031Get rights and content

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.

Section snippets

Subjects

Consecutive adult (age ≥18 years) patients with a diagnosis of EoE who completed FLIP during sedated endoscopy between January 2015 and December 2021 were included. Patients were prospectively evaluated and data were maintained in an esophageal motility registry. This study used a cross-sectional study design reflecting the time of endoscopy with FLIP. In addition, subsequent proton pump inhibitor (PPI) response and topical corticosteroid (TCS) response were assessed in subsets of patients who

Patient Characteristics

A total of 215 patients with EoE (mean [standard deviation] age 38 (12) years; 31% female) were included (Table 1). At the time of endoscopy with FLIP, 162 (75%) patients were on treatment, which included only PPI in 110 patients (51% of cohort), topical steroid in 24 patients (11%; 12 patients also on PPI), and elimination diet in 28 patients (13%; 13 also on PPI) (Figure 1). Among patients on treatment, 61 (38%) were in histologic remission (eosinophil density <15 eos/hpf), whereas the

Discussion

This study of 215 patients with EoE described a PhysioMechanical classification to represent a spectrum of esophageal function for EoE based on measures of esophageal distensibility and esophageal motility. Examination of clinical associations demonstrated that various measures of EoE disease severity related to both remodeling, such as endoscopic features of fibrostenosis (rings and stricture), and inflammation (eosinophilia) were also associated with more “advanced” stages of esophageal

CRediT Authorship Contributions

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).

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    • Cited by (3)

    • Pathophysiology and Clinical Impact of Esophageal Remodeling and Fibrosis in Eosinophilic Esophagitis

      2024, Immunology and Allergy Clinics of North America

    • Composite score of physiomechanical esophageal function using functional lumen imaging probe panometry in eosinophilic esophagitis

      2024, Gastrointestinal Endoscopy

    • Flipping the Script: Diagnostic Delay, Distensibility, and EoE Progression

      2024, Clinical Gastroenterology and Hepatology

    Conflicts of interest These authors disclose the following: Dustin A. Carlson: Medtronic (speaking, consulting, license), Phathom Pharmaceuticals (consulting). Ikuo Hirano: Adare/Ellodi (consulting, clinical trial support), Allakos (consulting, clinical trial support), AstraZeneca (consulting, clinical trial support), Celgene/Receptos/Bristol Meyers Squibb (consulting, clinical trial support), Sanofi/Regeneron (consulting, clinical trial support, speaking), Shire/Takeda (consulting, clinical trial support, speaking), Amgen (consulting), Arena (consulting, clinical trial support), Eli Lilly (consulting), EsoCap (consulting), Gossamer Bio (consulting), Parexel/Calyx (consulting). Nirmala Gonsalves: Allakos (consulting), Astra-Zenca (consulting), Takeda (speakers bureau), Abbvie (consulting), Sanofi-Regeneron (consulting; speaking), Nutricia (consulting), Knopp Pharma (consulting), BMS (consulting). Peter J. Kahrilas: Reckitt, Ironwood (consulting); Medtronic (license). John E. Pandolfino: Sandhill Scientific/Diversatek (consulting, speaking, grant), Takeda (speaking), Astra Zeneca (speaking), Medtronic (speaking, consulting, patent, license), Torax (speaking, consulting), Ironwood (consulting). The remaining authors disclose no conflicts.

    Funding This work was supported by P01 DK117824 from the NIH (PI: John E. Pandolfino).

    Data Availability Data including the patient functional lumen imaging probe output for each patient and interpretations are included as an Appendix. Additional data that support the findings of this study are available from the corresponding author on reasonable request and completion of necessary privacy and ethical approvals.

    Author names in bold designate shared co-first authorship.

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