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🎙 Swallowing Difficulty? Is it Eosinophilic Esophagitis? Ep 236

• Dr. Yuval Patel • Episode 236

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Ever wondered what’s behind that persistent difficulty swallowing or chest discomfort? On this episode of MedEvidence, Dr. Yuval Patel uncovers the mysteries of eosinophilic esophagitis (EOE), an often-misunderstood chronic allergic condition. We'll take you through the role of eosinophils, the specific white blood cells responsible for allergic reactions, and how their infiltration into the esophagus can lead to painful inflammation and food pipe narrowing. 

Our conversation expands to the “three Ds” of EOE treatment: drugs, diet and dilation. You'll gain a comprehensive understanding of first-line treatments while we also highlight the crucial role of dietary changes. We wrap up by discussing the vital importance of personalized treatment plans and groundbreaking clinical trials. Don’t miss this chance to understand the long-term prognosis and the vital management strategies needed to prevent complications in EOE patients. Join us for an enlightening journey through the complexities of eosinophilic esophagitis!

Talking Topics:

  • Understanding Swallowing Difficulty
  • Treatment Options for Eosinophilic Esophagitis
  • Managing and Treating Eosinophilic Esophagitis
  • Advancements in EOE Treatment

Recording Date: August 7, 2024

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Announcer:

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts.

Dr. Yuval Patel:

I'm going to get started here. My topic today is on swallowing difficulty and we're going to discuss eosinophilic esophagitis. There we go, all right, so eosinophilic esophagitis. For the rest of the talk I'm going to use the acronym EOE, but it's a disease that primarily impacts swallowing, which in clinical terms, gastroenterologists describe dysphagia or trouble swallowing.

Dr. Yuval Patel:

Eosinophilic esophagitis the first thing that would be important to define is what is an eosinophil allergic reactions, so asthma, eczema, seasonal allergies, and then also different immune system functions, such as tackling parasites. You can have a few different types of abnormal eosinophilia, which just means different levels of eosinophils that are above what a normal range would be, and that can occur both in the blood, which we call blood eosinophilia, or in the tissues, which is tissue eosinophilia, and for EOE it's a tissue eosinophilia type of disease. So what that means is the eosinophils are infiltrating the lining of the food pipe or the esophagus and they're causing inflammation there, and what does that result in? Well, it results in discomfort in the chest, issues with swelling in the food pipe and over time can cause narrowing and stricturing of the food pipe, and people experience that with swallowing difficulty. Oftentimes you ask somebody do they have trouble swallowing with EOE? And you get the answer that, especially with somebody who's had that disease for a while, that they've kind of worked around the trouble swallowing and now they don't have it. But if you really pinpoint the symptoms and drill hard, they've changed the way they're swallowed and they changed the way they eat just so that they can swallow routinely on a day-to-day basis. And that's often a little clue that there's something like continued inflammation occurring in the esophagus. So eosinophilic esophagitis this is this chronic allergic immune condition that I was talking about, and it's the eosinophils that are lining the esophageal mucosa or the superficial aspect of the food pipe there. So why does that occur? So just you know, I like to often say in clinic just how somebody with a nickel allergy, if they're wearing a belt that has nickel in it, they'll see edema and swelling and inflammation around the belt buckle and that's a clue that they have had an allergic reaction there. The same thing is happening in the food pipe. You may not realize it, but certain different types of things that you eat may cause swelling, inflammation in the food pipe that therefore you experience as trouble swallowing Often. You know different subtle clues that this disease is happening include, you know, patients starting to avoid certain types of foods with certain types of textures because they feel like they're getting stuck, and that includes meat bread. They feel difficulty swallowing all the time, sometimes, regardless of different types of textures or food groups.

Dr. Yuval Patel:

Oftentimes people are diagnosed with eosinophilic esophagitis on an index admission for a food impaction. So what does that mean? So a food impaction is when food is actually stuck in the food pipe and it's not going up or down. It's stuck there and a patient experiences this. You know they're unable to get their saliva down, they're having a lot of secretions. They go to the emergency room, get x-rays what have you? And a GI doctor is called in to go in with a scope and take the food out, and oftentimes that's the first impression that that person has eosinophilic esophagitis. But then when you really drill down with that person about their history in the past, they likely have been suffering from, you know, trouble swallowing for a while and they've just worked around it. So what do they do? They increase their chewing, they eat slower, they drink a lot of sips of liquids to support the swallowing, to get the food down. But if you're not dealing with the issue, oftentimes the esophagus strictures up enough.

Dr. Yuval Patel:

Where a food impaction occurs. Some patients suffer from abdominal pain, especially in the higher part of the abdomen, related to this disease. Other patients suffer from what seems like to be symptoms of GERD. So they're having heartburn, especially refractory heartburn. Where they're on good acid suppression, the heartburn is still continuing. And we go in there with a scope, thinking we're evaluating, you know, looking for acid damage or esophagitis or any other clues of why acid control has been hard to, you know, completely squash.

Dr. Yuval Patel:

And then we see what looks like an eosinophilic esophagitis, esophagus where we see ringed esophagus, furrows, exudates and different features and we take samples and then we often find that they actually we have the disease wrong. It's actually eosinophilic esophagitis. So sometimes people present a little bit atypically in that way and often another clue for eosinophilic esophagitis is thinking about the other medical conditions. Patients have that support more of an allergic issue in general for that person. So a lot of patients around 50% or so, or 40 to 60% depending on the studies have another type of allergy-related conditions, such as asthma, eczema or known food allergies or seasonal allergies.

Dr. Yuval Patel:

So how do we diagnose it in the clinic? So it's a combination of different things, you know. First a patient comes into the clinic telling us about their trouble swallowing, try to figure out if we see any patterns with food and liquid or association with different food items and really drill down on that part of the history and we see patients in clinic for this, obviously and really try to dig through how long this has been going on and whether further evaluation is needed for it. Often that includes allergy testing If causing the reaction of EOE. But this is not a perfect way to figure out EOE. Oftentimes allergy testing does not correlate well with what we see endoscopically and what we see by removing different other food items that don't pop up on the allergy testing Endoscopy. So, just as I said, when we do an upper scope and look in the food pipe we can see different clues that tell us that EOE is a problem. We take samples of the esophagus when we do that, both in the higher part of the esophagus and the lower part of the esophagus, and what we're doing is we're looking for the eosinophils under the microscope. So actually the pathologist will review in great detail how many eosinophils they see and if they see that eosinophilic inflammation and that kind of tells us if it's going on and this is very good for also response for eosinophilic esophagitis. So if a patient is on a therapy or eliminated a certain food culprit, we can resample and see if the eosinophils have gone down. All right.

Dr. Yuval Patel:

And so what does the data say? So who are the patients that typically have the disease? So it has more commonly been a disease in men. So it's about an 80% prevalence. So much more common in men. It's often frequently diagnosed in the younger population.

Dr. Yuval Patel:

So children and young adults, and in children in particular, they present a little bit different than adults. They have, you know, food avoidance issues, issues with caloric intake, failure to thrive, type symptoms, nausea, vomiting, so they're not necessarily saying they're having trouble swallowing, but clearly they're not getting nutrition down. But adults, as I described in the slides previously, typically it's more trouble. Swallowing is the hallmark symptom that patients have, and EOE has increased significantly over the past few decades. But we think it's in general a part of the avoidance of different types of antigen exposures. And when youth is, for children what that means is if we are avoiding different types of food items really, really young, maybe that increases the chance of developing allergies to them later in life. And we're also seeing it first in the Western world more, but now we're seeing it infiltrate other parts of the world too. So it is becoming more and more recognized and becoming more and more of an issue.

Dr. Yuval Patel:

All right, so now on to treatment. So the different types of treatment for EOE. The best way to simplify is the three Ds of treatment. So here you can see on the pictures just some different clues of what we see endoscopically. So all the way on your left is a healthy esophagus, nice pink mucosa, nothing abnormal there, just looks like a straight tube. But then when you have eosinophilic esophagitis we can see certain clues. So in the one on the left you can see subtle furrows there which look like little grooves, that going up and down the esophagus, and subtle rings that look like little circles. And then the picture to the right. You can see some exudates which are also a different clue that EOE is going on. And the one all the way to the right you can see the furrow is a little bit more ingrained. When EOE is more and more advanced the tube actually shrinks in size and becomes more of a long, thinner, smaller caliber tube where food is harder to get through and you can have stricture sort of throughout. As you blow through, add air and blow through the esophagus to try to expand. You can see these more tight rings In terms of the D's of of treatment.

Dr. Yuval Patel:

So it's a three-pronged approach. We think about drugs, we think about adjusting diet and we think about using dilation to help our patients. So in terms of drugs, the first-line treatment is the proton pump inhibitor class, which most people think of in terms of treating reflux disease and acid issues, heartburn. But we actually know that proton pump inhibitors not just not do, they just increase the pH of the stomach contents so that liquid that goes up the food pipe isn't as caustic and burning in the sense of having strong gastric acid hurting that lining. It also exerts an anti-inflammatory effect. So there is something about the PPIs that reduces the eosinophils from infiltrating the area and it's a pretty good first-line treatment. About half the patients do respond to being on these medicines.

Dr. Yuval Patel:

Other, more second-line treatments are using topical glucocorticoids. So in a similar way, if somebody has an allergic inflammatory-like rash and they get hydrocortisone cream from their primary care doctor or their dermatologist, we're doing something similarly with topical glucocorticoids. So what that means is you swallow a topical steroid. That's sort of coating the lining of the esophagus to try to reduce inflammation. Now people don't like being on steroids necessarily long-term and usually try to do short courses. But unfortunately there is some relapse with that and if you think about it you have to swallow it a certain way and then hope that the liquid is coating the esophagus. So it is a little tricky to administer for some folks In terms of approved therapy.

Dr. Yuval Patel:

So in the past we used to just order budesonide and create it into a slurry or use the fluticasone inhaler and have patients swallow that instead of pumping it into their lungs. There's now an oral suspension version called eohilia of the same type of topical steroid. But the same issue remains. It tends to be a short-term treatment but it can get people into remission. And there is dupixent, which is a biologic medication which actually more targets the antibody inflammatory response related to this disease and it doesn't have the negative effects of other types of biologics for other types of diseases, in the sense that it doesn't reduce the immune system's ability for attacking other types of infections or increasing the risk of infections, nor does it really increase the risk of malignancy or other obviously adverse events because it's very much just targeting the pathway of the eosinophils and that is an injection medicine.

Dr. Yuval Patel:

Now some patients understandablyably don't want to try medicine because they want to think about how can I just get rid of the disease by going at the core source, which is let's try to figure out what food allergy is promoting it. Right, the top six culprits are wheat, milk, eggs, nuts, soy and fish shellfish. So there's been a lot of different types of strategies on how to eliminate food to see if people get a response symptomatically to EOE, and one aggressive approach would be to eliminate all six food culprits. But now more and more research has come out that we could do more of a scale-up approach because the two most common food culprits are wheat and milk. So in my clinic I often just have patients, if they're on board for this, cut out wheat and milk first and see how their symptoms respond.

Dr. Yuval Patel:

Potentially do a scope in about six to eight weeks and see if the symptoms go down, particularly if the symptoms are better. But if not, we may expand the different you know food items here and we, from a process of elimination standpoint, we can sometimes find the diet culprit here. The most extreme version of all this would be if somebody goes on an elemental diet which we sometimes have to do for children, which is a very challenging thing to do where you're pretty much trying to remove anything that potentially could be an allergen. And then we talk through with patients especially patients that have strictures related to EOE how food textures can be impactful, so how to think through you know which different items will go through the food pipe, and sometimes it's more important to really strategize not just on chewing, but what particular items they're eating. And then, lastly, the third D is dilatation, and for you, what we sometimes need to do is, if somebody has a very tight stricture, when we go down with the scope, we can use a balloon or a different type of dilator to push open that stricture, and that often leads to a lot of you know improved symptoms. It doesn't get at the underlying issue, though, because the underlying issue is the inflammation from the allergen, but we can do that to help with response.

Dr. Yuval Patel:

I often do that in conjunction to try to get people I mean in conjunction with dietary as well as medical therapy to try to get people swallowing better, but it is something that we can offer when we do endoscopy, and so this is a good slide from the aga that kind of gives a general, thorough overview of what uh, you know how to think about treatment for EOE. So we have medical or pharmacological therapy, which includes the proton pump inhibitors, the topical corticosteroids and now dupixent, which is a biologic medication or injectable. We have dietary therapy which we can do an elimination diet, sometimes just the top two, like the wheat and the dairy, like I talked about, or we could do all six. A very strict would be the elemental diet which we typically don't really do in adults but often are used in kids. And then sometimes an allergy-directed diet, and that's why we work with our immunologist allergist. And then lastly, the dilatation, if we need to, if we see a stricture, where we do the upper scope and then we sort of revisit and look at maintenance therapy.

Dr. Yuval Patel:

Sometimes patients with EOE we have to do endoscopies multiple times, sometimes multiple times through the year to check on if their esophagus is responding correctly or if they need a repeat dilation. All right, and to end here, I just did want to once more just bring up that we do have treatments on the horizon ENCORE Research Group and it is a good resource for patients that are suffering from trouble swallowing. So again, if you notice that it's not just that, you know some patients again have worked around their trouble swallowing and actually do okay because they realize they can chew certain types of consistencies and drink liquid in a way where they can get the food down. But if you are adjusting your diet in a certain way it may be time to think about, you know, getting care for that disease.

Announcer:

My Borland-Groover doctor has me on Omeprazole. Is that safe for long-term therapy?

Dr. Yuval Patel:

That's a good question. So the way to think about the proton pump inhibitors. There's been a lot of press that's been negative against the proton pump inhibitors over the years. But if you look at the data, the only prospective study we have meaning looking forward in time actually showed that proton pump inhibitors were safe and didn't increase the risk of any adverse effects versus a control group. So some of the studies that are out there right now show that maybe proton pump inhibitors can increase risk of dementia, kidney disease, bone loss, infections. But then in the only study we have where we gave some people omeprazole and some people placebo or fake omeprazole and we looked five years out, there was no difference between any or among any of those things. Now you may say, well, five years of a medicine maybe that's not long enough. That's true. So we don't have a longer-term data to check prospectively for it.

Dr. Yuval Patel:

The data that has linked proton pump inhibitors to these different adverse events has all been retrospective. So what I mean by that is they've taken a population of patients that have dementia and they look through their med list and they see a lot more. A lot of them have proton pump inhibitors on it. Does it mean the proton pump inhibitor caused it. Not necessarily, but there is an association there and obviously we don't want to ignore an association, but the data hasn't been that strong. So the way I counsel my patients are if you have a disease that is clearly causing you a known issue, that's more important to tackle than worry about the hypothetical issue on the back end. And you know we should always try in my perspective for any medication try to get people on the lowest medication that does the job. And so sometimes in the beginning patients are on higher doses of proton pump inhibitors but then the doses do go down over time, as long as they keep the disease controlled.

Announcer:

How long does it take Dupixent to heal EOE?

Dr. Yuval Patel:

That's a tricky one. I think we've seen some patients get response even late, which can be sometimes months. So I wouldn't necessarily give up on Dupixent right away if it's not working for a given patient.

Announcer:

When you can't eat milk and wheat. What do you suggest?

Dr. Yuval Patel:

If you are considering doing a diet elimination and want to try taking out dairy and wheat. It is challenging to do that, obviously, but you need to do it for about six to eight weeks if you're really going to give it a proper shot and seeing if that is the food culprit causing it a proper shot and seeing if that is the food culprit causing it. Sometimes it's helpful to see a nutritionist to try to strategize how to you know substitute foods that you're commonly eating or that are around the dinner table, if that helps, but it unfortunately you do have to kind of think through all the ingredients of the food items to really try to eliminate things as well as possible.

Announcer:

How often is the injection given as a treatment option?

Dr. Yuval Patel:

In my personal practice for Dupixent I often don't think about it first line. I'm thinking about trying to use the proton inhibitors and food testing or food elimination more first line and oftentimes insurance companies will be thinking the same way, like they would want somebody to fail the proton pump inhibitors as treating their EOE or the proton pump inhibitors as well as failing a topical corticosteroid like the budesonide. So it usually is sort of a second or third option that we're thinking about. I particularly think about using it in my patients that feel like it would be a very good medication for my patients that need to have a comorbid condition like eczema or asthma that's challenging to control and oftentimes, like you work with a pulmonologist who's working with that patient with their asthma and we find a good, you know, a nice unifying treatment option that would help calm down the allergic response fully. Dupixent usually, if I recall, is once a month right now, but it's not. It doesn't necessarily mean the first shot. People will have a response. Sometimes you need to have a few shots.

Announcer:

What is the long-term prognosis of this disease for young people With management? Can it still get worse to the point where other interventions are needed, and would it increase the chances of esophageal cancer in the future?

Dr. Yuval Patel:

The disease. For young people it can be challenging. The younger you have it, oftentimes the reaction is more severe and it's a little bit trickier to get under control. It doesn't increase the risk of esophageal cancer. It's an inflammatory condition but it can cause issues with stricturing, making it challenging to eat over time. But it wouldn't be something, therefore, I would ignore. And definitely there's people that with management you know they have great responses, like just this past Christmas I was on call and a patient came in who was suffering from trouble swallowing with a food impaction. And this is the middle of Christmas Day and the reason why he had a food impaction is because he went to a party and he ate something he's not used to and he had an incredibly narrowed esophagus, multiple strictures and it was tricky. But now it's eight months later and he's doing great and he's only on a daily PPI and he's like a new person. So definitely you know there are medications that we can. You know that help reverse this disease and keep it under control.

Announcer:

Should I take Dupixent and Budesonide too? I'm currently taking Pantoprazole and Dupixent. I had taken Budesonide only for many years but had impaction and perforation, so the doctor prescribed Pantoprazole and Dupixent.

Dr. Yuval Patel:

I feel like that this is a very that's a complicated scenario and it's probably best to talk with your personal gastroenterologist about this, but this is it sounds like a very challenging circumstance where, needing multiple medications we sometimes do have patients on both, particularly like you can have more than one disease sometimes do have patients on both, particularly like you can have more than one disease. You can have reflux disease as well as a disease like eosinophilic esophagitis. That's separate, and so sometimes controlling the acid component that's promoting stricture formation as well as the allergic component are two different ways to think about it.

Announcer:

You mentioned, dupixent was taken typically once a month. I have been taking 300 milligrams once a week for six months. Am I taking too much?

Dr. Yuval Patel:

Sorry, I meant to say once a week. So it is, and that's a standard dose that you're on.

Announcer:

I have been on a PPI for 23 years. No problems so far. Do you know if there is a surgical treatment for hiatal hernia?

Dr. Yuval Patel:

You know that's a question to talk to your personal gastroenterologist about, but there are surgical treatments for hiatal hernia. It's a case-by-case basis on thinking if that's the right option for your reflux or if you're suffering from that with a hiatal hernia. We don't think about hiatal hernia surgery in the same sense for patients that suffer from trouble swallowing from EOE. That's not going to reduce the EOE.

Announcer:

Should a TNF-alpha blocker be controlling the inflammation caused by EOE? I take Humira already.

Dr. Yuval Patel:

It would not, because the TNF-alpha blockade. It's causing a reduction in different cytokine pathways, separate to the allergic reaction in.

Dr. Yuval Patel:

EOE

Announcer:

Could dupixent control ankylosing spondylitis.

Dr. Yuval Patel:

Dupixent wouldn't control ankylosing spondylitis. However Humira can potentially impact like a TNF-alpha can potentially impact the ankylosing spondylitis. However, humira can potentially impact like a TNF-alpha can potentially impact the ankylosing spondylitis. But dupixent can work with other allergic-type reactions or disease states like asthma or eczema or like severe eczema. It can reduce that allergic cascade. But all the injectables aren't the same. All because they're injectable. They work on different pathways. They're not all the same. So the TNF alpha would be different.

Announcer:

I don't have EOE, but I have an issue that I am aspirating some when I swallow. Is there anything that can be done to help me?

Dr. Yuval Patel:

That's a question to talk with a gastroenterologist in the clinic and to confirm no EOE. Sometimes an EGD is needed with the samples right. Like we talked about Aspirating some when I swallow, I would be more concerned about issues a little bit higher up where maybe the back of the swallowing mechanism could be impaired. But it should be something to discuss with your doctor.

Announcer:

What is your opinion on long-term therapy with budesonide? How long would you allow this therapy to continue?

Dr. Yuval Patel:

Yeah, that's a challenging question because it is a topical steroid. It's not getting a lot of systemic absorption, so it's not going to cause. If you were on prednisone, you know, for lupus or something people are worried about bone loss and systemic effects. The budesonide is still just topical. So oftentimes we do a challenge and you can try it. You could be on it for months and then try taking off and see what happens. But that again is a question to kind of chat with your personal gastroenterologist about.

Announcer:

Are all gastroenterologists familiar with EOE treatment?

Dr. Yuval Patel:

Yeah, I would say all gastrodocs should be familiar, particularly at Borland-Groover. We all have multiple patients with EOE. I take care of multiple patients with EOE, so the exciting part about EOE is there's more and more treatments that are starting to be offered that are that we're. You know we're seeing ENCORE as as well with our trial opportunities that are trying to target, you know, the underlying inflammation and give patients better options.

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