Correspondence

Eosinophilic Esophagitis

N Engl J Med 2007; 357:1446-1447October 4, 2007

Article

To the Editor:

In the description of their Image in Clinical Medicine on eosinophilic esophagitis (May 17 issue),1 Hawari and Pasricha note that endoscopic dilation of the esophageal stricture near the gastroesophageal junction was performed before treatment with oral fluticasone. The safety and efficacy of esophageal dilation in patients with eosinophilic esophagitis are still controversial. Straumann et al.2 treated 11 patients with dilation and reported complete improvement in 6 patients and partial relief in 4 without relevant complications. However, Shafi et al.3 treated 10 patients with 16 endoscopic dilations, 5 of which resulted in free perforation or a deep tear. There was a significantly increased risk of esophageal perforation with dilations, especially among patients with multiple esophageal webs.3

Endoscopic dilation is helpful but must be attempted with prudence in such patients because of the risk of perforation. A trial with corticosteroids should be considered before endoscopic dilation, in order to reduce active inflammation and the rate of complications with the procedure.4

Philippe Leclercq, M.D.
Audrey Marting, M.D.
Pierrette Gast, M.D., Ph.D.
Liège University Hospital, 4000 Liège, Belgium
philleclercq@belgacom.net

4 References

1. 1

   Hawari R, Pasricha PJ. Eosinophilic esophagitis. N Engl J Med 2007.
   

2. 2

   Straumann A, Spichtin HP, Grize L, Bucher KA, Beglinger C, Simon HU. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology 2003;125:1660-1669
   CrossRef | Web of Science | Medline

3. 3

   Shafi MA, Eisien GE, Al-Kawas FH, Benjamin SB. Increased risk of esophageal perforation with dilatation in patients with multiple esophageal webs (feline esophagus): a case control study. Gastrointest Endosc 1997;45:56-56
   

4. 4

   Sgouros SN, Bergele C, Mantides A. Eosinophilic esophagitis in adults: what is the clinical significance? Endoscopy 2006;38:515-520
   CrossRef | Web of Science | Medline

Author/Editor Response

I agree that dilation in cases of suspected eosinophilic esophagitis should be carried out with caution. However, there is a difference between empirical dilation of webs in patients with chronic dysphagia and dilation of high-grade fibrotic strictures. In the case presented, the patient had a high-grade stricture at the gastroesophageal junction, with a residual lumen of less than 8 mm that appeared fibrotic. The patient also presented with impaction. Careful dilation of a predominantly fibrotic area is safe and offers an alternative means of management to restore enteral nutrition. In the abstract that Leclercq et al. cite with respect to an increased risk of perforation,1 the patients underwent multiple dilations for chronic dysphagia with the use of balloons with an average size of 15 to 18 mm or an average Savary size of 36.8 French (12.26 mm), indicating an aggressive target size for dilation. Endoscopic dilation should always be carefully performed, and the anatomy of every single stricture should always be studied before dilation is approached, regardless of the underlying pathology.

Rami Hawari, M.D.
Digestive Disease Center, Huntsville, AL 35801
rahawari@gmail.com

1 References

1. 1

   Shafi MA, Eisien GE, Al-Kawas FH, Benjamin SB. Increased risk of esophageal perforation with dilatation in patients with multiple esophageal webs (feline esophagus): a case control study. Gastrointest Endosc 1997;45:56-56
   

Citing Articles (1)

Citing Articles

1. 1

   Antoine Geagea, Christophe Cellier. (2008) Scope of drug-induced, infectious and allergic esophageal injury. Current Opinion in Gastroenterology 24:4, 496-501
   CrossRef